Prevention of Communication Disorders Tutorial

Background

Until recently, prevention in the health sciences was limited mainly to infectious disease control. Research and action related to infectious disease prevention have improved the health of Americans and most of the world's people. Primary prevention of disease has also had an impact on the nature and distribution of communication disorders that are related to infectious disease. Now that rubella is amenable to primary prevention and the last major rubella epidemic was in 1964–65 (U.S. Department of Health and Human Services, 1981), new cases of children with profound hearing impairment and multiple handicaps caused by prenatal rubella are rare. Because bulbar poliomyelitis is subject to primary prevention, new cases of the chronic voice problems that used to appear in polio survivors are almost nonexistent. In the past, acquired profound hearing losses in children resulted from measles (i.e., rubeola) (McCabe, 1963). However, as the incidence of measles has fallen, so has that of such hearing losses.

As infectious diseases have come under control, the nation's health focus has shifted to a new set of preventable causes of premature death and disability: chronic diseases in adults and the aging (e.g., heart disease, cancer, and stroke) and infant mortality and morbidity.

During the 1960s and 1970s, several federal committees, bureaus, and task forces were established and legislation was passed that was designed to prevent disease and promote health. In 1963, President Kennedy called for a preventive approach to mental retardation and mental illness, an act that led to the establishment of prevention-focused community mental health centers throughout the country. In 1977, President Carter began an initiative to achieve 90% immunization levels by the opening of the 1979 school year (McGinnis, 1984), and the U.S. government established a task force on disease prevention and health promotion. In 1979, the Office of Disease Prevention and Health Promotion in the Department of Health and Human Services was established. This was followed by the establishment of a Task Force on Smoking and Health (1979). (The famous Surgeon General's Report on Smoking and Health was first issued in 1964). In 1979, the U.S. Department of Health, Education and Welfare published Healthy People, The Surgeon General's Report on Health Promotion and Disease Prevention. This influential publication established goals for reduced death rates and health objectives by 1990.

Return to Top

---

The Future of National Prevention

Implicit in setting goals to prevent premature death was the challenge to recast the nation's basic health strategy in terms of health promotion and disease prevention (Windom & McGinnis, 1987). The U.S. Public Health Service reviewed those objectives (U.S. Department of Health and Human Services, 1986). As a result of the review, new objectives for the nation were established for the year 2000.

Future significant decreases in death and disability rates will come only after advances have been made in prevention (Farquhar & King, 1984). Mounting evidence suggests that our attention to health promotion and disease prevention is making an important difference in the lives of many Americans and that many of the goals for the nation may be accomplished by 2000 (Bowen, 1987). At the federal level, there has been financial support for research on prevention. At the state and local levels, community leaders and health professionals are joining in implementing health promotion and disease prevention programs. At the individual level, many Americans are practicing better health habits (Bowen, 1987).

Background

Little public attention has been devoted to the prevention of communication disorders. However, this fact does not indicate a lack of accomplishment. As individual professionals, speech-language pathologists and audiologists have been involved in screening programs and early intervention efforts. As an organization, the American Speech-Language-Hearing Association (ASHA) has taken action in the area of prevention. A standing committee on the prevention of speech, language, and hearing problems was created in 1971. This committee and the ASHA National Office implemented a variety of prevention activities. The first policy statement on prevention was approved by the ASHA Legislative Council in 1973 and “prevention” was added to the by-laws in 1974. In 1981, “Definitions of the Word ‘Prevention’ as It Relates to Communicative Disorders” was adopted by Legislative Council. These activities, plus numerous professional articles and presentations, led to the Legislative Council's adoption of the “Position Statement: The Prevention of Communication Disorders” in 1987. Such activities illustrate ASHA's commitment to prevention of communication disorders.

Return to Top

---

The Future of Prevention of Communication Disorders

Commitment must be accompanied by policy development based on research. A cogent plan for translating policy into specific goals and actions is equally necessary. Kavanagh (1982) stressed that speech-language pathologists and audiologists should consider time devoted to prevention as part of their professional and civic duty. To develop and promote prevention-related employment and add prevention strategies to their clinical activities, speech-language pathologists and audiologists need to (a) have a thorough understanding of specific prevention strategies, (b) accept responsibility for research in prevention, and (c) understand their role in the application of strategies to reduce the incidence and prevalence of disorders in the population.

Understand specific prevention strategies. Techniques exist for promoting optimal communication development and for maintaining communication abilities through the life span. The development and application of prevention strategies are addressed in Section II of the Position Statement and this document.

Accept responsibility for research in prevention. It must be acknowledged that the prevention of communication disorders is still in the early stages of development. The body of literature about conditions with which communication disorders are associated (e.g., low birthweight, stroke, congenital anomalies, laryngeal cancer) needs to be expanded. Studies should provide additional evidence demonstrating the effectiveness of efforts to prevent speech, language, and hearing problems. It is possible and incumbent upon our profession to take an active role in prevention and related research (Kavanagh, 1982). Research in prevention is addressed in Section III of the Position Statement and of this document.

Understand our roles. The Position Statement addresses clinicians' expanded responsibilities to include prevention:

Prevention of communication disorders requires some adjustment in the traditional focus of professional practice in speech-language pathology and audiology. In the past, the principal focus of the profession has been on identification and treatment of existing communication disorders. While treatment is still an important function for speech-language pathologists and audiologists, professional roles can be expanded to include the different focus of attention and energy demanded by prevention. Prevention requires increased efforts to eliminate the onset of communication disorders and their causes and to promote the development and maintenance of optimal communication. Alternative professional roles and strategies must be developed, and the information and skills to adopt and practice them must be acquired. (p. 90)

I. Utilize Consistent Terminology Related to Prevention

This section of ASHA's position statement presents a glossary of selected prevention terminology. The glossary is not meant to be exhaustive, but only to clarify language used in the position statement and to establish a common vocabulary for our profession. The terms come from a number of sources (Beukelman, 1986; Davis & Sancho, 1988; Gerber, 1990; Healey, Ackerman, Chappell, Perrin, & Stroumer, 1981; Kavanagh, 1982; Last, 1983; Lilienfeld & Lilienfeld, 1980; Lubker & Moscicki, 1985; MacMahon & Pugh, 1970; Marge, 1984; Mausner & Bahn, 1974; O'Donnell, 1986; Tjossem, 1976; World Health Organization, 1980).

• Primary Prevention—the elimination or inhibition of the onset and development of a communication disorder by altering susceptibility or reducing exposure for susceptible persons.

  An exposure means presence of a risk factor. Immunization to prevent infectious disease is probably the best known example of primary prevention. Other examples are using ear protectors in noisy environments to prevent noise-induced hearing loss and wearing seat belts to prevent head injury.

• Secondary Prevention—the early detection and treatment of communication disorders. Early detection and treatment may lead to the elimination of the disorder or the retardation of the disorder's progress, thereby preventing further complications.

  Screening is an example of secondary prevention. A specific example would be the high-risk register for the detection of congenital or early onset deafness (Joint Committee on Infant Hearing, 1982) (see Section II.G.). If hearing loss is identified and treated early, the handicap may be reduced or eliminated.

• Tertiary Prevention—the reduction of a disability by attempting to restore effective functioning. The major approach is rehabilitation of the disabled individual who has realized some residual problem as a result of the disorder.

  The history of the communication disorders professions has been one of tertiary prevention. Speech-language pathologists and audiologists have most commonly provided tertiary prevention by rehabilitating clients to maximal levels of function within the constraints of their preexisting conditions.

• At Risk—the potential to develop a disorder based on specific biological, environmental, or behavioral factors. This term may apply to an asymptomatic population.

  A child with Down syndrome is not at risk for Down syndrome; the disorder is established. However, the child is at risk for secondary problems such as hearing loss, caregiver or attachment problems, and Alzheimer disease.

• Incidence—the rate of new occurrences of a condition in a population free of the disorder within a specified time period.

  This term refers to instances that had not existed before and that can contribute to the total pool of cases.

• Prevalence—the total rate or proportion of cases in a population at, or during, a specified period of time.

  This term means, therefore, the number of instances existing at a certain place and time.

• Epidemiology—an observational science which investigates distribution and determinants of disease and disorders in populations.

  Incidence and prevalence data are the subject matter of epidemiology. Such data may help us to institute prevention programs by identifying specific needs.

• Wellness—the development and maintenance of an optimal level of competence appropriate to any given stage of the life cycle.

  Self-responsibility is the key concept in wellness. Activities revolve around nutritional awareness, physical activity, stress management, and environmental sensitivity. For communication, the term denotes optimum communication abilities.

The preceding definitions are all included in the position statement. The following definitions are also useful to a discussion of prevention:

• Impairment—any loss or abnormality of psychological, physiological, or anatomical structure or function.

• Disability—reduced ability to meet the needs of daily living. The level of disability may be determined by the severity of the impairment, the person's lifestyle, or the extent to which the individual can compensate.

• Handicap—the social disadvantage that an individual experiences because of an impairment and resulting disability. The degree of handicap depends in part on the attitudes and biases of those who are in contact with the disabled individual.

• Health—a state of physical, emotional, and social well-being, not merely the absence of disease or infirmity.

• Health Promotion—the science and art of helping people change their lifestyles to move toward a state of optimal health. For speech-language pathologists and audiologists, the term means promoting the development and maintenance of optimal communication behavior. Individuals and communities can promote health so that people live in healthier ways. Some areas that should be targeted for attention are smoking, alcohol and drug use, nutrition, and stress management.

• Endemic—prevailing continually in a community or among a group of people (e.g., recurrent otitis media among native Americans, sickle cell anemia among Blacks).

• Epidemic—attacking many people in a community simultaneously; distinguished from endemic by the fact that an epidemic disease is not continuously present but has been introduced from outside.

The following terms are widely accepted as classifications for at-risk infants:

• At Established Risk—an infant whose early-appearing and aberrant development is related to diagnosed medical disorders of known etiology that have relatively well-known expectancies for developmental outcome within specified ranges of developmental delay.

• At Environmental Risk—a biologically sound infant whose life experiences are sufficiently limited that, without corrective intervention, they impart a high probability for delayed development. These life experiences may include deficient maternal and family care, inadequate healthcare, insufficient opportunities for expression of adaptive behaviors, and inappropriate patterns of physical and social stimulation.

• At Biological Risk—an infant who presents a history of preconceptional, prenatal, perinatal, neonatal, and early developmental events that are suggestive of biological insult to the developing central nervous system and that, either singly or collectively, increase the probability of later-appearing aberrant development.

• Preventive Intervention—intervention to delay or circumvent the occurrence of symptoms. The terms is often used for early intervention for atrisk infants.

Return to Top

---

II. Play a Significant Role in the Development and Application of Prevention Strategies

The position statement outlines 10 competencies that clinicians must have if they are to play a significant role in the development and application of prevention strategies.

A. Use Prevention Terminology Appropriately. The glossary above is provided as a consistent prevention terminology for speech-language pathologists and audiologists. The terminology used to describe the prevention of communication disorders has been borrowed, for the most part, from the disciplines of physiology, epidemiology, psychology, nutrition, health education, and public health. The health professions are by no means agreed on terminology. Often, these terms are used inconsistently and their meanings may not be clear. For example, health is sometimes used synonymously with wellness; on other occasions, health is defined as the absence of illness, suggesting that a person whose health deteriorates below a specific point can be considered ill (Goodstadt, Simpson, & Loranger, 1987).

It is, however, incumbent upon professionals to use prevention terminology appropriately, particularly in ASHA publications. Lilienfeld and Lilienfeld (1980) found that the words incidence and prevalence are often used incorrectly in published reports. Moscicki (1984) found similar evidence in publications on communication disorders. In a review of 46 papers that discussed the occurrence of hearing disorders between 1963 and 1983, Moscicki found that only 27 of the papers discussed incidence and prevalence correctly. Moscicki cautioned that the danger in such misuse of terminology is that incidence figures may be reported as higher than they actually are.

B. Understand Conditions That Place Individuals at Risk for Various Communication Disorders. Some communication disorders are not preventable, given present knowledge, but others unquestionably are. Etiology of communication disorders is often categorized as biological or environmental. Few disorders are purely one or the other, however. A third category, multifactorial, describes the etiology of those disorders in which environment interacts with genetic predisposition. In those disorders, an individual is genetically susceptible to environmental influences. (See “The Facts,” Appendix A, for a discussion of populations at risk.)

Biological etiology. One of the most obvious biological factors placing persons at risk for communication disorders is a genetic disorder; such disorders are termed established risk (see Section A), and a communication disorder is expected. For example, approximately 20% of all cases of hearing impairment result from autosomal recessive (single gene) inheritance (Bergstrom, Hemenway, & Down, 1971). People with Down syndrome, a chromosomal disorder, are at increased risk for hearing loss, usually conducive (Downs, 1985), as well as at risk for delayed speech and language development (Stoel-Gammon, 1981). Speech and language problems are typical in Fragile-X syndrome, another chromosomal disorder that is associated with mental retardation (Wolf-Schein et al., 1987).

As treatment of people with genetic disorders becomes more effective, it is expected that the incidence of genetic defects will rise in the general population. The more successful the treatment, the more likely the increase of the carrier population (Ajl, 1982). If an affected person reproduces, more children are born who are genetically at risk. A craniofacial disorder, such as Crouzon syndrome, is an example of a genetic disorder in which treatment (e.g., surgery and speech therapy) allows individuals to lead normal lives and increases the probability that they will pass on their genes. The incidence rates for 10 selected birth defects, including cleft palate, cleft lip, and Down syndrome, has not decreased from 1970 to the present.

Although medical science seems on the brink of preventing specific genetic disorders through gene therapy, current prevention strategies consist mainly of prevention of conception or selective termination of pregnancy. With few exceptions, current genetic knowledge does not give couples with an affected fetus other options to circumvent the effects of aberrant genes or chromosomes. Furthermore, couples who seek genetic services are underserved; and the population in general, including healthcare professionals, is unaware of avoidable genetic diseases and of the services that do exist (Sparks, 1985, 1988a). As Shaver (1984) reported, there are over 150 genetic causes of deafness, yet awareness of the importance of genetics in deafness is low in the medical community and all but nonexistent in the deaf community. Because of this lack of knowledge and their own communication barriers, deaf people have underused genetic services to a significant extent. At the present time, genetic services, including counseling based on family history, testing for carrier status in high-risk groups, and prenatal diagnosis followed by termination of pregnancy are the best available prevention strategies for most genetic disorders. Clinicians who work with children who have genetic disorders can (a) help families find genetic counseling for subsequent pregnancies (primary prevention) and (b) identify and intervene early to reduce or eliminate handicap (secondary prevention).

Premature, preterm, and low birthweight infants (i.e., < 2,500 g irrespective of gestational age) constitute another group at increased biological risk for the development of communication disorders. Conditions such as perinatal asphyxia and respiratory distress are additional risk factors. Longitudinal studies of such children have demonstrated a high incidence of language, learning, and hearing problems (Ensher & Clark), 1986; Rossetti, 1986). In fact, the incidence of hearing loss in very low birthweight babies (< 1,500 g) is 14 times higher than in the general population (Downs, 1982). Black infants are at highest risk for low birthweight. The risk of having a low birthweight infant is three times as high for women with no prenatal care as for women who began prenatal care during the first trimester (Institute of Medicine, 1985).

Unlike genetic disorders, however, complications of birth do not result in an expectation for a communication disorder or any lasting effects. Most infants do not have lasting handicaps (McCormick, 1989); and for those who show developmental and communication delays, early intervention (secondary prevention) offers the best chance of prevention. Speech-language pathologists and audiologists can (a) monitor the progress of at-risk infants carefully, (b) begin parent education and support before delay is evident, and (c) begin early intervention as soon as delay is suspected.

The aging process also places people at risk for speech, language, and hearing problems. Presbyacusis, the consistent gradual loss of auditory sensitivity, is directly related to the aging process (although environmental exposure to noise is likely to act synergistically with the aging process, thus accelerating the loss of hearing). The elderly are particularly susceptible to communicative consequences of various age-related diseases of the central nervous system, including cerebrovascular disease, movement disorders such as Parkinson disease, and dementia. Speech-language pathologists and audiologists can (a) inform physicians, especially internists, about the communicative consequences of aging, (b) counsel patients about increased risk of noise, (c) undertake secondary prevention by early use of amplification, and (d) manipulate the environment to enhance the communication of patients who have movement disorders or dementias.

Environmental etiology. Each person is subject to a multitude of interacting environments, such as intrauterine environment, language environment, and physical environment. Clearly, communication disorders associated with environmental causes offer the greatest opportunity for prevention activities.

Intrauterine Environment —Agents that cause birth defects when ingested by a pregnant woman are teratogens. Sparks (1984b) and Gerber 1990) have synthesized an important literature indicating that maternal intake of alcohol during pregnancy may have an impact on fetal development producing a pattern known as fetal alcohol syndrome or fetal alcohol effect, conditions that have communicative consequences for hearing loss, cognition, and neurological function. Today, the largest proportion of American infants born addicted to drugs are addicted to cocaine (Howard, 1989). The long-term communicative consequences of cocaine addiction at birth are unknown. Shih, Cone-Wesson, and Reddix (1988) found abnormal auditory brainstem responses in 18 neonates born to cocaine-abusing mothers, and Hadeed and Siegel (1989) found that cocaine use during pregnancy results in newborns with growth retardation and microcephaly. These findings suggest impairment or dysfunction of the nervous system. It seems that infants do recover from heroin addiction and withdrawal by about 3 years of age (Hoar, 1985) but it appears that the effects of prenatal cannabis are longer lasting: children who are congenitally addicted to marijuana seem to have attention deficits (Fried, Watkinson, Dillon, & Dulberg, 1987).

Additionally, women who smoke during pregnancy have a greater risk of bearing low birthweight or stillborn infants. The American College of Obstetrics and Gynecology advocates avoidance of smoking during pregnancy (Leibert, 1988).

Language Environment —Infants at risk for inappropriate language stimulation are at risk for language delay or disorder. The environment created by caregiver nurturing is even more important for infants at biological risk than for no-risk infants (Escalona, 1982). Furthermore, if that environment is a neonatal intensive care unit, it has high light and sound stimulation and low language stimulation. Studies of families of high-risk infants have shown that (a) families tend to overstimulate these infants, (b) parents and infants are less responsive to one another, leading to difficulty in interpreting communicative cues, and (c) high-risk infants have fewer and less positive interactive experiences than their no-risk peers (Wilcox & Campbell, 1988). Recognizing that caregiver style varies with culture, a nurturant or naturalistic style in which the adult responds to what children do is more facilitative for language development than more directive, controlling caregiver styles (Duchan & Weitzner-Lin, 1987; Mahoney, Finger, & Powell, 1985).

Physical Environment —Smoking contributes to many conditions that place people at increased risk for communication impairments. Smoking often results in chronic irritation of the larynx and is linked to the development of oral and laryngeal carcinoma (U.S. Department of Health and Human Services, 1987). People who have undergone total or partial laryngectomies are usually seen for voice rehabilitation. Speech-language pathologists and audiologists are also concerned about the relation of smoking to other voice disorders such as increased hoarseness and chronic laryngitis (Boone & McFarlane, 1988). Smoking is also linked to coronary heart disease and to increased risk of cerebrovascular disease (U.S. Department of Health and Human Services, 1983), with associated aphasia. Passive smoking (inhalation of smoke by nonsmokers sharing the smoker's environment) has been implicated in increased rates of otitis media in young children (Etzel, 1985). The use of smokeless tobacco has been linked to high rates of oral cancer, particularly among women in the southern United States, and is on the increase among young people (U.S. Department of Health and Human Services, 1988). (See “The Facts,” Appendix A.) ASHA's Legislative Council passed a resolution in 1986 opposing the use of tobacco products. Preventive measures (mandatory no-smoking areas) have been implemented in many public places.

Alcohol consumption also places people at risk for communication problems. Consumption of alcohol, often accompanied by smoking, may irritate vocal fold tissues and lead to hoarseness (Logemann, 1985) and may increase the deleterious effects of smoking on the oropharyngeal mucosa. Alcohol is considered a neurotoxic agent, especially in the elderly population (Larkins, 1985). Additionally, alcohol is a major causative factor in many of the accidents that lead to head trauma and other neurological insults (Farquhar & King, 1984).

Drugs other than alcohol present a complex prevention problem. First, there is the matter of use or abuse of prescription medicines. Valium, for example, is addictive, and people who are addicted to it do have difficulties with speech articulation. The use of barbiturates and amphetamines is widespread in some social groups. There are neurotoxic drugs that have a progressively degenerative effect on communication (Gerber, 1990). Second, there is the problem of unwanted and untoward side effects of nonaddictive medications. For example, Dilantin may produce swelling of the gingiva, which could affect articulation. Third, there is the enormous problem of illicit drugs. These also are neurotoxins, which could have effects on communication. Students are the population most at risk, on which primary prevention efforts should be focused. We should probably anticipate an increased need for secondary and tertiary prevention of drug-induced neurogenic communicative disorders.

Alcohol, smoking, and drugs not only are environmental toxins, they also involve personal choices. Some other communication disorders that are associated with personal choice include vocally abusive activities such as cheerleading, singing at extreme ranges, excessive throat clearing, and children's productions of “funny voices,” which may all result in vocal nodules or chronic edema and laryngitis (Logemann, 1985).

Certain toxins are found in the workplace and elsewhere in the environment. Notable among these are certain metals, especially lead (Needleman, 1983), which present a risk of encephalopathy and its communicative consequences (language disorders). Lead poisoning has been a recognized hazard since ancient times, yet today many children in the United States especially those living in dilapidated houses with lead-based paint—are still exposed to this toxic chemical. Due to lead screening efforts of the Public Health Service since the early 1970s, acute encephalopathy and death from lead poisoning are now rare. Recent studies, however, show that children exposed to lead at low levels—levels much below those causing acute symptoms—may have intellectual impairment and behavioral abnormalities.

Similarly, exposure to improperly used herbicides and pesticides may threaten both nervous and respiratory function. Consequences may appear as voice disorders (Finitzo & Freeman, 1989), oral and other respiratory system cancers, or neurogenic speech and language disorders (Gerber, 1990).

Multifactorial etiology. Multifactorial disorders reflect the combined effects of genetic predisposition and environmental factors. Probably the majority of congenital disorders result from the interaction of genetic susceptibility with intrauterine environmental factors. For example, genetic variables are of primary importance in the development of cleft lip and palate, conditions that place persons at risk for speech and voice problems. However, in 75% of the cases, there is no family history of clefting. Environmental causes such as rubella and teratogens are also causative, but teratogens may affect only those who are susceptible (Sparks, 1984). In another group of disorders, the language or speech problem is not a symptom secondary to a disorder but constitutes the primary disorder — for example, stuttering, dyslexia, or autism. All three fulfill some of the rules for genetic transmission: They run in families, more boys are affected than girls, and the disorder is found in identical twins. However, there is no clear single-gene pattern, and in many cases these disorders are considered to have an environmental component, either prenatal or postnatal, conducive to development.

Prevention for multifactorial disorders is not clear-cut. At this stage of knowledge, research must identify susceptible individuals so that environments may be manipulated to encourage optimum development.

C. Understand Conditions That Promote Development and Maintenance of Optimal Communication Abilities (Wellness). Healthy lives result when individuals make responsible choices about the way they live. Such choices might include a decision to manage stress, maintain a healthful diet, or wear ear protectors in noisy environments. People with chronic diseases or impairments can also make responsible choices about the way they live.

“Promotion of positive factors which facilitate the development and maintenance of healthy, age appropriate communication abilities could become the objective of a new, proactive focus for our profession” (Kilburg, 1985, p. 1). Facilitating communicative health is a primary prevention activity. There is, in addition, what Mausner and Bahn (1974) called health behavior, a form of prevention insofar as it refers to the psychologic and social factors that affect participation in preventive care. This means that many people respond to preventive care programs, such as communitywide chest x-rays, dental screens, blood pressure measurements, hearing and vision screens in schools and industries, and services offered at health fairs. People are usually willing to spend their time and money to prevent events that they view as potentially threatening. That is, they must believe that action will have meaningful consequences (Mausner & Bahn, 1974).

According to Kilburg (1985), there are five steps to implementing a communicative wellness plan.

• First, persons interested in promoting the plan formulate a goal. They identify a target group, one with the potential to develop optimal behavior, and they identify the means to change the group's behavior.

• Second, such persons must gain access to the target group through institutional contacts or people who have direct impact with the target group. Organizations and service providers with access to at-risk groups can be targets for preventive information. Bloom (1981) suggested each target population has “gatekeepers” or representatives through whom speech-language pathologists and audiologists can reach the population. These gatekeepers may be societal or institutional representatives or less formal leaders within the population itself (Kilburg, 1985). It is important that population-specific groups play a role in designing prevention programs for the groups they serve. Gatekeepers will be addressed again in the section on Dissemination of Information. Table 1 outlines target groups and pertinent prevention information to be disseminated.

• Third, a professional relationship based on genuine warmth and empathy must be established between the promoters and the target group.

• Fourth, tactics such as consultation and education are selected. Consultation may occur with natural support systems (such as the family), direct service personnel, or organizations and policymaking groups. Education may occur at two levels: (a) informing the general public about communication disorders, their treatment, and communicative wellness resources, and (b) developing competencies within normal or at-risk groups to improve their abilities to cope with communication disorders.

• Finally, outcomes must be evaluated. Green (1986) has provided a useful model for asking the appropriate questions in program evaluation.

D. Interpret the Existing Prevention Literature in Order to Apply the Information Appropriately. It is essential for professionals in communication disorders to be aware of available readings in the area of prevention and, in turn, to apply that information to research and practice in prevention. An abundance of speech pathology and audiology literature in the area of prevention may be useful, although it has not been cited as prevention-related material. References are provided throughout this document and in Appendix B.

If the existing prevention literature is to be interpreted and the concepts applied appropriately, there is a need for cross-fertilization among the literatures of speech-language pathology and audiology and other disciplines. We can implement the methods that have been found useful, benefit from their insights, adapt their models to generate and interpret research, and implement prevention programs. Rich sources for prevention literature are health promotion and disease prevention topics in public health, health education, medicine, nursing, and mental health.

E. and F. Present Primary Prevention Information to Groups Known to be at Risk for Communication Disorders and to Other Appropriate Groups; and Provide Individual-, Family-, and Community-Focused Primary Prevention Information and Services. Speech-language pathologists and audiologists must expand their clinical activity beyond the traditional one clinician/one client model to include education of groups. Furthermore, it is our responsibility to provide information to those groups concerning their risk. Access to groups was outlined in Table 1.

Whereas some programs are public information campaigns designed to increase public awareness about prevention of communication disorders, others are more complex, involving efforts to change human behavior. Such programs are based on assessment of need and are designed to meet specific behavioral objectives. They may include a combination of educational strategies, address social and environmental factors that influence the targeted behavior, and provide methods for program evaluation (Michaels & Peterson, 1984). Basic principles and specific strategies are found in Winett, King, and Altman (1989).

Primary prevention activities for at-risk groups can be large in scale and comprehensive. Marge (1984) proposed that the most effective prevention model is a community-based model because the participants are citizens from the community who are often committed to developing and implementing a prevention program. After the program leaders are chosen, efforts can be directed toward analyzing the community's prevention needs and establishing a long-range plan with specific objectives and strategies. The implementation components of the model should focus on carrying out the planned activities and evaluating the program.

Such activities may seem overwhelming to individual speech-language pathologists and audiologists. More modest individual efforts can also be effective in reaching preschool and school groups, young parents and potential parents, groups of elderly, caregivers to the elderly and handicapped, and other professionals. Many speech-language pathologists and audiologists already provide presentations to such groups (Kilburg, 1988). Prevention activities should be written into the job description of speech-language pathologists and audiologists, and time allotted to them.

G. Provide Early Identification and Early Intervention Services for Communication Disorders Occurring at Any Time During the Life Span. Activities of early identification and intervention are activities of preventive intervention or secondary prevention. That is, the [00ae]UL1 consequences of the original condition are prevented. Incidence and prevalence of communication problems vary across the life span. For example, the prevalence of hearing impairment increases with age (Punch, 1983), but the prevalence of speech impairment decreases after age 14 and remains fairly constant up to age 54, after which it again increases (Fein, 1983). Identification and intervention activities are outlined here on the life-span continuum.

Infants and young children. According to Rossetti (1986), “Anything that interferes with a child's ability to interact with the environment in a normal manner is a potential source of, or contributing factor to, the presence of developmental delay” (p. 2). Tjossem (1976) distinguished three types of risk factors, which are not mutually exclusive: established risk, environmental risk, and biological risk (see Section 1).

For children at established risk, associated secondary disorders, such as hearing loss, language delay, fluency disorders, voice disorders, and articulation disorders can often be reduced or prevented.

For children at biological risk with unknown expectations for handicap, such as severe hearing loss and cerebral palsy, early intervention may be so effective that the child has no residual handicap. In yet another group of infants, conditions of birth such as low birthweight and respiratory distress may place them at risk for associated or iatrogenic disorders of communication, but early identification and intervention may prevent any handicap by school age.

For children at environmental risk, early intervention with the family has been shown to be the most efficacious to prevent secondary disorders, primarily of a cognitive nature. White and Castro (1989) reported that such children benefit significantly from early intervention across different types of interventions, conducted in different settings, by different types of interveners.

The following examples of prevention activities for infants and young children warrant special consideration, but are not intended to be exhaustive.

1. High-risk hearing screening for two equally important target populations: infants in the intensive care unit and infants identified by a high-risk register. High-risk hearing screening of newborns is a worthwhile public health endeavor (Mahoney, 1984). If high-risk registers were universally implemented, more hearing-impaired newborns could be identified shortly after birth, gaining the advantage of early intervention during the critical language acquisition period. Early intervention with hearing-impaired infants has been shown to improve communication skills that are basic to future psychosocial, educational, and vocational development (Clark, 1980). There should be contingent implementation of early identification and early intervention programs.

Infants in intensive care units make up 6% of the total newborn population (Burdetti et al., 1981). Certainly, those infants who are at highest risk for sequelae, including hearing loss, should be screened. In 1982, the Joint Committee on Infant Hearing of the American Academy of Pediatrics (1982) recommended screening all newborns. Seven criteria were established to identify infants at risk for hearing impairment.

1. A family history of childhood hearing impairment.

2. Congenital perinatal infection (e.g., cytomegalovirus, rubella, herpes, toxoplasmosis, syphilis).

3. Anatomic malformations involving the head or neck (e.g., dysmorphic appearance including syndromal and nonsymdromal abnormalities, overt or submucous cleft palate, morphologic abnormalities of the pinna).

4. Birthweight less than 1500 g.

5. Hyperbilirubinemia at levels exceeding indications for exchange transfusion.

6. Bacterial meningitis, especially H. influenza.

7. Severe asphyxia which may include infants with APGAR scores of 0–3 who fail to institute spontaneous respiration by 10 minutes and those with hypotonia persisting to 2 hours of age.

Approximately 15% of the nation's newborn population is screened by a high-risk hearing register. Unfortunately, less than half of these at-risk infants are actually tested for hearing impairment (Mahoney & Eichwald, 1987; Committee on Infant Hearing, 1989), and the majority are not confirmed until at least 18 months of age (Mahoney, 1984).

2. Early detection and prompt treatment of otitis media. Otitis media is the second most common infectious disease affecting children under 6 years of age (Friel-Patti, Finitzo, & Hieber, 1987). Furthermore, otitis media with effusion (OME) (the presence of fluid in the middle ear space in the absence of acute infection) is often asymptomatic and, although children may experience significant hearing loss of 30–40 dB, is largely undetected.

Otitis media is most prevalent during the first 2 years of life, when children are normally acquiring language (Bordley, Brookhouser, & Tucker, 1986). If OME is identified, parents may be taught ways to compensate for their child's lack of adequate hearing.

Not all children with otitis media or OME develop language problems. It falls to the healthcare provider not only to identify the presence or absence of OME but also to recognize when any hearing impairment resulting from OME places a child at risk for language problems, as the policy statement of The American Academy of Pediatrics clearly states.

There is growing evidence demonstrating a correlation between middle ear disease with hearing impairment and delays in the development of speech, language and cognitive skills. A parent or other caretaker may be the first person to detect such early symptoms as irritability, decreased responsiveness and disturbed sleep. Middle ear disease may be so subtle that a full evaluation for this condition should combine pneumatic otoscopy, and possibly tympanometry, with a direct view of the tympanic membrane. This statement is not meant to be a recommendation for specific treatment methods. When a child has frequently recurring acute otitis media and/or middle ear effusion persisting for longer than three months, hearing should be assessed and the development of communicative skills must be monitored.

The committee feels it is important that the physician inform the parent that a child with middle ear disease may not hear normally. Although the child may withdraw socially and diminish experimentation with verbal communication, the parent should be encouraged to continue communicating by touching and seeking eye contact with the child when loudly and clearly speaking. Such measures, along with prompt restoration of hearing whenever possible, may help to diminish the likelihood that a child with middle ear disease will develop a communicative disorder. Middle ear disease can occur in the presence of sensory neural hearing loss. Any child whose parent expresses concern about whether the child hears should be considered for referral for behavioral audiometry without delay.

Not every child with two or three ear infections should be referred to the speech-language pathologist for language intervention; such blanket referrals would be unnecessary and costly (FrieI-Patti et al., 1987). However, children with delayed language milestones and those who have chronic otitis media or OME are clearly a group who should be referred for intervention. (See section on screening instruments.) A history of otitis media has been linked to phonological problems (Churchill, Hodson, Jones, & Novak, 1988). Numerous studies implicate early otitis media and OME in language problems (FrieI-Patti et al., 1987; Holm & Kunze, 1969; Zinkus, 1978), although no studies have documented lasting effects on language. Nevertheless, it is important to deal with the temporary effects. Speech-language pathologists and audiologists should inform parents, teachers, and day care providers about how to enhance communication with children who are experiencing temporary or lasting hearing loss (Flexer, Wray, & Ireland, 1989).

3. Screening programs for speech, language, and hearing beginning with the first follow-up visit by healthcare providers or at 6 months as part of screening for growth and development. The Early Language Milestones Scale (ELMS) is an example of a screening instrument developed to provide healthcare providers with a rapid and reliable way to identify speech, language, or hearing problems in children from birth to 3 years of age (Coplan, 1983). Since the ELMS is intended as a screening instrument only, children who fail the ELMS should be referred for formal speech and language testing.

4. Early intervention programs for children at high risk for communication disorder. Public Law 99-457 mandates establishment of early intervention programs beginning at birth for infants and toddlers who have developmental delay. The new legislation must be implemented by the states in 1990. Each state will determine its own definition of developmental delay to comply with the bill. In addition, it is left to the discretion of each state to include children at risk for any reason. Although this legislation is certainly a positive step, its implementation leaves possibilities open for such stringent definitions of developmental delay that only very severely affected children will qualify for service. Children with mild, moderate, and at-risk conditions may still be without the benefit of intervention.

5. Education programs for parents. Children at established and biological risk are said to be at double risk if they are in a nonnurturing environment (Escalona, 1982). In fact, all children at biological risk are at risk for problems of early interaction, no matter how willing their parents may be to nurture them. Prevention of language delay consists of individual or group counseling for parents on reading the cues and responses of their infant. For healthy infants at environmental risk, counseling may have a different focus, but the desired outcome is appropriate speech and language interaction (Klein & Briggs, 1987).

School-age children. Speech-language pathologists and audiologists employed in public schools have unique opportunities to work with students and engage in activities to speech, language, and hearing problems in children. With their extensive knowledge of language, hearing, and speech, they have a myriad of occasions to share information, troubleshoot, and work cooperatively with teachers, teaching assistants, parents, administrators, and others involved in the care of children. Flynn (1983) described opportunities for prevention in the consultant role:

The role of the speech-language pathologist as a consultant in the prevention of communication disorders is an ever-expanding, challenging, and satisfying role. The attractiveness of this role stems from the appreciation of prevention as affording a maximally positive influence on the lives of potential clients and from the knowledge that this approach facilitates the best use of precious clinical time. (p. 99)

Appendix B lists resources for use by school-based professionals. Prevention activities in schools may take any of the following forms.

1. Collaborate with the classroom and special education teachers. Speech-language pathologists and audiologists have a traditional role in identification and intervention (secondary and tertiary prevention) with school-aged children. An increasing number of speech-language pathologists have expanded that role and are working as communication specialists to serve students in an integrated model. Integrated service involves providing small-or large-group speech-language intervention in the student's educational environment (American Speech-Language-Hearing Association, 1988a). The content of the communication lessons is linked to the academic curriculum and student need (Miller, 1989; Nelson, 1989). This model promotes communication wellness for all students and authorizes support for students who may have language deficits and are at risk but are not eligible for special education services (DeSpain & Simon, 1987). An additional advantage of working in the classroom is the opportunity to expose regular or special education teachers to the practice of promoting the communicative competence of all students. Teacher sensitivity and awareness of the communicative needs of every student can be critical in a student's total educational experience. Speech-language pathologists need to develop a cooperative learning style in working with teachers by encouraging and expecting the classroom teacher's participation.

The audiologist and speech-language pathologist provide a secondary prevention service by helping classroom teachers to enhance the communication skills of hearing-impaired children in their classrooms (Flexer, Wray, & Ireland, 1989). Approximately 8 million school-age children suffer from a hearing impairment, but only 1% of the hearing-impaired children in schools are receiving the assistance necessary for success in mainstreamed classrooms (Berg, 1986).

2. Describe to teachers the validity of the language of students who are racially, culturally, and linguistically different from the majority. A language difference, or dialect, is not a language deficiency; but because many people have linguistic prejudices based on social prejudices, it is imperative to dispel misperceptions. It is the role and challenge of public education to develop effective oral communication programs for all students.

3. Provide classes for teachers, teaching assistants, and administrators. Many school districts offer classes for teachers and teaching assistants, either district wide or at individual school sites. Speech-language pathologists can teach such classes on language and learning to further enhance facilitative language skills among the educational personnel. This training has far-reaching benefits for students. Many students lack academic confidence, have poor language skills, and are locked into a failure frame. Teachers and teaching assistants who understand that language is the basis for all learning can advocate for and support these fragile learners in their struggle to develop confidence and attain academic success (Cleary, 1988).

4. Inform parents of their role in identification and prevention. Speech-language pathologists and audiologists need to include information about themselves and their programs in the packets given to parents as they enroll their children. Educational material on normal speech and language development needs to be available at each school site for parents. A “New Parent Night” could be a PTA program in which the speech-language pathologist and audiologist work with administrators and other educators to discuss effective preschool and home practices. Schools frequently sponsor parent groups to discuss issues of childrearing; speech-language pathologists and audiologists can participate in such meetings as resenters and resource people. Wearing a name tag with a speech-language pathologist or audiologist designation invites parents to approach the professional on a personal level and provides further opportunities for the professional to assist parents with information about speech, language, and hearing.

5. Inform administrators about prevention efforts and activities. It remains the role of the speech-language pathologist and audiologist to educate administrators about their work and the changes they support (e.g., integrated teaching model). Many administrators continue to view speech-language pathologists as “speech teachers” who work on [r] and cases of disfluency. Keeping administrators informed about the number of students, types of disorders, and program models assists them in understanding and supporting the program.

6. Expand school prevention programs to day care providers. Many parents work outside the home, and their children are cared for by others. It is consistent with a prevention focus that speech-language pathologists work with caregivers in day care settings. Teaching caregivers the importance of communication and how they can help children with the process of learning language has positive implications. Stressing the value of responding, making eye contact, smiling, imitating, taking turns, listening, expanding, and playing with language could make astonishing differences in the communicative competence of children.

7. Ask teachers of life choices and biology classes in junior and senior high schools for the opportunity to provide lectures and discussions in their classes on lifestyle choices that affect the students' communication and that of their offspring.

Middle years. During the middle years of adulthood, people develop habits that affect the occurrence and severity of communication disorders in old age. It may take years of noise exposure in industry, to lawn mowers, or to loud music to cause significant hearing loss. It may take years of smoking to develop cancer of the larynx. Chronic voice disorders often result from continuous and prolonged vocal abuse. Factors that contribute to stroke (e.g., smoking, high blood pressure, obesity, and stress) also accumulate during the middle years (see “The Facts,” Appendix A). Speech-language pathologists and audiologists may help prevent the development of those habits by informing those at risk directly and through community-based and clinician-based programs. Some examples of secondary prevention activities follow.

1. Refer clients who smoke to cessation programs as part of their treatment for voice disorders.

2. Refer clients who abuse alcohol to alcohol treatment centers. In addition, inform clients for whom alcohol consumption places them in a risk category (elderly, voice clients, pregnant women) of their increased risk.

3. Inform clients about the importance of protection against noise.

4. Inform clients how to eliminate vocal abuse.

The elderly. Data from Fein (1983) and Punch (1983) attest to the increased prevalence of communication disorders among the elderly. Opportunities for prevention services will increase as the numbers of the very old expand (see “The Facts”: Elderly, Appendix A).

Identification of and intervention for speech and language problems of the elderly can reduce disability associated with some problems. Prevention of the social isolation that hearing loss may produce is especially important for the elderly. Speech-language pathologists and audiologists may counsel those at risk and provide prevention services through community-based and clinician-based programs. Among their prevention activities, professionals may provide the following:

1. Screening for hearing loss (and speech and language disorders) at sites that are easily accessible for the elderly (e.g., community centers, industrial sites, retirement communities, health fairs, senior citizen centers, and shopping malls).

2. Information about the availability of hearing aids, assisstive listening devices, and telephone aids.

3. Assistance and counseling in the use of hearing aids and listening devices, in the use of remaining hearing, in speechreading, and in sign language.

4. Expedient referral of those with early warning signs of laryngeal cancer.

5. Planning with the interdisciplinary team (which includes the patient and family) to manipulate the physical and social environment.

6. Augmentative devices for communication (computer and electronically assisted speech).

7. Direct therapy to increase communication abilities for the institutionalized, those in their own homes, and those in community day care centers.

In addition, speech-language pathologists and audiologists should participate in activities such as the following:

1. Public education on the accessibility of speech-language pathologists for individuals with aphasia, dementias, or other problems associated with communication problems of aging.

2. Public education about communication disorders and skills for coping with communicative, behavioral, and emotional consequences of communication disorders.

3. Public education on the vocal symptoms that are early warning signs of laryngeal cancer and on the importance of medical assessment when symptoms appear.

H. Make Appropriate Referrals for Prevention-Related Services Not Provided by Speech-Language Pathologists and Audiologists. The multidisciplinary nature of prevention strategies requires that speech-language pathologists and audiologists be aware of the services offered by other professionals and be ready to make appropriate referrals as needed. According to Weiss and Lillywhite (1981), prevention-related services may be offered by dietitians, early childhood specialists, geneticists, neurologists, obstetricians, orthodontists, otolaryngologists, pediatricians, prosthodontists, psychiatrists, psychologists, public health nurses, special education teachers, and social workers. In addition to these professionals, Public Law 99-457 specifically states that other referral sources include occupational therapists, physical therapists, nurses, nutritionists, and speech-language pathologists and audiologists. Speech-language pathologists and audiologists should maintain a complete and readily available list of professionals from which individuals may select the appropriate specialist.

I. Disseminate Prevention Information to Various Public Sectors, Including Healthcare Professionals, Social Service Professionals, and Extended Families. Speech-language pathologists and audiologists have prevention opportunities as they work with organizations and individuals in the public sector.

Healthcare and social service professionals are both “gatekeepers” and target populations (see Table 1). Some suggestions for cooperation with coprofessionals follow.

1. Build credibility with other professionals before introducing prevention information. There are no short cuts to credibility. For example, clinicians in the neonatal intensive care unit of a hospital build credibility by adhering to nursing protocols, being available to the nurses for consultation, and demonstrating that speech-language pathology and audiology services are genuinely helpful to the unit.

2. Work with other professionals as fellow members of a team that has mutual respect to develop prevention protocols and exchange information. Announcing one's availability to “give a lecture” is not recommended. For example, a clinician who has contributed to postcrisis intervention on a case-by-case basis in a nursing home can work with the team to develop precrisis intervention protocols.

3. Be willing and available to update and edit information about communication disorders in the textbooks of other professionals. Many such texts are inadequate and often give misinformation.

Extended families. Family members can be reached through the organizations listed in Table 1 and through the media. ASHA routinely provides information about Various communication disorders to the media in the form of Media Update, brief articles that offer a wealth of information. Some speech-language pathologists and audiologists have prepared programs for their local cable television stations focusing on communication disorders and their prevention. Others write regular columns for their local newspapers. Many participate in activities for Better Hearing and Speech Month. These vehicles and others disseminate information to a variety of public sectors.

Extended family members are also part of the specific target populations who participate frequently in support groups and intervention programs for an affected family member. Particularly useful are videotapes that can be loaned to family members for viewing in their own homes (see Appendix B).

J. Understand Methods of Influencing Public Policy Related to Prevention of Communication Disorders. Health policies may be directed toward the individual or toward the physical or social environment. They may therefore attempt to promote health by steering individuals away from risk behaviors—for example, the National Cancer Society's antismoking campaign—or toward healthy alternatives—for example, state laws for automobile restraints. On the other hand, many policies are directed at environmental hazards rather than individual behaviors. For example, both the Environmental Protection Agency and the Occupational Safety and Health Administration have noise standards and rules concerning chemical hazards in the environment and in the workplace.

According to Cole and Marge (1985), there is an urgent need for a national effort to develop the resources to prevent many of the causes of speech, language, and hearing disorders through primary prevention strategies. Such a national effort must include not only individual work but efforts to influence public policy as well. The message is simple: Not only communication disorders sciences, but the system of healthcare in general has been focused on treatment. The alternative is prevention. We must use healthcare and education dollars for the prevention of communication disorders. Individuals and communities must recognize that they benefit both personally and economically from prevention activities. The cost-benefit ratio of early intervention usually makes it more economical than later intervention (California State Department of Education, 1987). (Also see U.S. Department of Health, Education and Welfare, 1979, The economic evidence on prevention, p. 439.)

Methods of influencing public policy may involve work directly focused on influencing legislation or educational outreach. Some examples of ways that clinicians may have an impact on public policy follow.

1. Join coalitions. Many of the legislative and regulatory issues that are of concern to the speech, language, and hearing sciences community are shared with other professional and consumer organizations. Forming and participating in coalitions produces several distinct advantages over single-group lobbying: Coalitions vastly increase the populations that are represented; a division of labor is possible; different professional and consumer organizations bring their own expertise to a coalition; and cooperation among various professional and consumer groups demonstrates consensus within the community (American Speech-Language-Hearing Association, 1988b).

For example, a number of separate community, state, and national organizations concerned with prevention of poor pregnancy outcome formed the Healthy Mothers, Healthy Babies Coalition. A small, but very successful, group member is the Mississippi Chapter; this group mounted and won a major campaign for state funding of prenatal care for all women in Mississippi. The chair, Jean Luckett, outlined their keys to successful advocacy (personal communication, 1983):

1. Committed people—even a few. Their group had only five.

2. Targeted efforts. Go for what is realistic and achievable.

3. Notable successes. It is important to have wins.

4. High visibility. Materials were prepared for education and for the press: brochures, fact sheets, an audiovisual presentation, ‘TV spots, newsletters, and a legislative alert. Petitions were circulated and presented to the legislature. In addition, a number of creative efforts were utilized: birthday cards, Mother's Day cards, and Labor Day cards from the coalition were sent to legislators. The members thought that a guide for their educational materials should have a twofold message that they called “head and heart”: statistical data for the “head” and personal stories and photos for the “heart.”

2. Form a prevention committee within an existing organization. Within ASHA, the Communicative Disorders Prevention and Epidemiology Study Group, open to all, is recognized as a related professional organization whose purpose is the enhancement of research and prevention efforts among speech-language pathologists and audiologists.

Each of the state associations needs to have a standing prevention committee. Among the existing committees, education efforts have included presenting an award to an industry that demonstrated prevention awareness with action; presenting an award to the “prevention program of the year”; helping members identify their efforts on behalf of other organizations as being associated with prevention of communication disorders (e.g., a march for the March of Dimes can be a march to prevent communication disorders); dispensing prevention literature to members (e.g., newsletter, electronic mail); and presenting skits to target populations such as school children. State associations should also acknowledge their members' prevention activities.

Efforts to influence social action can include forming policy statements as a focus for the state organization, forming coalitions with other organizations, and interacting with legislators to focus awareness and action in the legislature. For example, like state associations, the Association for Retarded Citizens (ARC) operates in every state in America. The ARC-California has a prevention committee whose principal activity is to influence public policy designed to prevent mental retardation and birth defects. It does this by being informed about biomedical and behavioral advances that can reduce such incidence and then incorporating this knowledge into legislation. ARC initiated screening programs for PKU and biotinidase deficiency. This committee has worked closely with the state's birth defects registry to identify and eradicate environmental toxins and teratogens, such as lead. Recently, the committee has been acquiring information about the possible toxic risks of pesticides and insecticides.

Return to Top

---

III. Expand Research Into the Causes of Communication Disorders and Variables That Influence the Development and Maintenance of Communication Abilities

The position statement suggests several methods and areas of research for prevention of communication disorders.

Prevention and Prevention-Relevant Research. According to the U.S. Public Health Service (1987), prevention research includes only research designed to yield results directly applicable to interventions to prevent occurrence of disease or disability or the progression of detectable but asymptomatic disease. Prevention research is divided into two categories: preintervention and intervention.

Preintervention research involves three things:

1. Identification of risk factors for disease or disability.

2. Development of methods for identification of disease controllable in the asymptomatic stage.

3. Refinement of methodological and statistical procedures for quantitatively assessing risk and measuring the effects of preventive interventions.

Intervention research involves the following:

1. Development of biologic interventions to prevent occurrence of disease or disability or progression of asymptomatic disease.

2. Development of environmental interventions to prevent occurrence of disease or disability or progression of asymptomatic disease.

3. Development of behavioral interventions to prevent occurrence of disease or disability or progression of asymptomatic disease.

4. Conduct of clinical and community trials and demonstrations to assess preventive interventions and to encourage their adoption.

In addition, prevention-relevant research includes research that has a high probability of yielding results that will be applicable to disease prevention. The definition acknowledges the contribution of prevention-relevant research as a separate and important category. Included are studies aimed at elucidating causation—the etiology and mechanisms of acute and chronic diseases. Such basic research efforts generate the fundamental knowledge that contributes to the development of future preventive interventions. Included would be advances in molecular biology and other forms of medical technology that increase the likelihood of identifying some diseases in their asymptomatic phase, a point at which their progression can still be altered. Research to develop a test to detect presymptomatic Huntington disease would be considered prevention research if it had potential application in counseling possible carriers about pregnancy.

Models for Prevention Research in Communication Disorders. Developing theoretical models for practical primary prevention efforts in the field of communication disorders is the next phase of our professional development.

Epidemiologic model. The research methods employed in subcategories of clinical and experimental epidemiology have immediacy for this profession while sophisticated research efforts are developed in areas of primary prevention. Past use of epidemiology in speech and hearing science has been confined to enumeration (i.e., determining the prevalence rates of a given disorder).

Lubker and Moscicki (1985) described three research models used in epidemiological studies that could be adopted in studies of communication disorders. They were case-control studies, in which a group of subjects with the disorder is compared with a control group; cohort studies, in which a group of identified subjects exposed to a risk factor is compared with a control group; and clinical trials, in which the treatment being tested is based on evidence gathered from case-control or cohort studies. In a clinical trial study, an experimental group with the disease is given treatment and is compared with a control group with the disease that is not given the treatment. Among the wide range of issues related to epidemiologic concepts, those recommended as having high priority for developing a strong foundation for the prevention of communication disorders are the development of scientifically sound causal models, utilization of accepted epidemiologic research designs and analytic methods, and identification of clinical populations and settings in which research on prevention and epidemiologic distributions may be designed. Two additional models have been used to design prevention research experiments in communication disorders.

Epigenetic model. Behavioral epigenesis is the continuous development process from fertilization through birth to death, involving proliferation, diversification, and modification of behavior patterns both in space and in time, as a result of the continuous dynamic exchange of energy between the developing organism and its environment, endogenous and exogenous (Kuo, 1967). Patterns of behavior and patterns of the environment affect each other and, thus, are constantly in a state of flux.

Transactional model. Transactional models propose a bidirectional pattern of influence in which either partner may influence the behavior of the other (Bell & Harper, 1977; McLean & Snyder-McLean, 1978). Samaroff (1975) proposed that researchers consider the presence of a continuum of caretaking causality that would interact with the risks associated with birth complications. For example, the addition of the child's characteristics (e.g., low birthweight) and the parents' characteristics (e.g., emotional maladjustment) would not be enough to assume later difficulties. Rather, the child should be viewed through a continuous assessment of the transactions between the child and the environment to determine how these transactions facilitate or hinder adaptive integration as both the child and the surroundings change and evolve.

With either an epigenetic model or a transactional model approach, speech-language pathologists and audiologists would have a framework in which to observe children and their environments so that they could design a primary prevention program for those who are potentially at risk of developing a communication disorder.

Possible Research Topics in Prevention

1. Epidemiologic studies in genetics.

2. Documentation of effects of intervention with high-risk individuals.

3. Development of field-tested prevention education materials.

4. Documentation of effects of prevention education with selected groups.

5. Elucidation and quantification of disorder-specific, known risk factors.

6. Attitudes of other professions toward expanded roles of speech-language pathologists and audiologists in prevention.

7. Clinical trials for efforts in prevention and intervention.

8. Reexamination of existing data on incidence, prevalence, and populations at increased risk for communication disorders.

9. Factors influencing individuals to change their behaviors to follow prevention guidelines or regimens,

10. Distribution and determinants of conditions to which communication disorders are secondary.

Activities to Facilitate Research

1. Utilization of existing databases in governmental or private agencies.

2. Interagency cooperation in developing databases and procedures for cross-sectional studies, cohort studies, and clinical trials.

3. Participation in long-range research projects established by public health, public education, industry, and other agencies.

4. Identification of clinical populations and settings in which research on prevention and epidemiologic distributions may be designed.

Clearly, speech-language pathologists and audiologists should follow strict ethical standards in the clinical trials surrounding prevention studies, as well as conform to established principles in the use of terminology, design, and analysis in their publications of prevention research.

Return to Top

---

IV. Educate Colleagues and the General Public About Personal Wellness Strategies as They Relate to the Prevention of Communication Disorders

As the introductory section of this document noted, prevention efforts in this area are still in their infancy. Nevertheless, there are certain practices that promote communicative health, also reviewed in this document. If ASHA advocates these practices for the general public, then it is reasonable for the Association to expect its own members to take leadership roles in adopting such practices themselves.

This document should not be construed as an attempt to dictate personal practices of ASHA members. Controversy would certainly accompany any effort on the part of the Association to suggest changes in the personal habits and practices of its members. Rather, it informs members of the leadership challenge they face in the arena of prevention and invites them to incorporate the promotion of good communicative health in their own lives.

A comprehensive listing of personal practices that promote communication health would be inappropriate. The following examples, however, illustrate some personal efforts ASHA members might consider adopting for themselves and their families.

1. Stop tobacco use and prolonged breathing of smoke-filled air.

2. Stop or greatly restrict the consumption of alcoholic beverages.

3. Do not drive while under the influence of alcohol, drugs, or medicines.

4. Use safety belts during automobile travel.

5. Obtain regular physical checkups and systematic medical care.

6. Obtain early and regular prenatal care, including prepregnancy immunizations.

7. Adopt good nutritional practices.

8. Get regular, appropriate exercise.

9. Avoid or limit exposure to loud noises,

10. Use ear protectors when exposure to loud noises is unavoidable.

11. Avoid or limit use of the voice in potentially hazardous or abusive situations.

12. Seek genetic counseling if at risk.

13. Learn new ways to deal with daily tension and environmental stress.

14. Avoid use of nonmedicinal drugs.

15. Avoid abuse of prescription drugs.

16. Adopt protocols to avoid spread of communicable disease.

It is reasonable to assume that ASHA members active in the prevention of communication disorders will be more effective if they incorporate these practices into their own lives. It is the position of the Association that members should remain informed about the effectiveness of these practices so that they can adopt them personally and in their clinical activities.