School Screening - All India Institute of Speech and Hearingaiishmysore.in/en/pdf/School_screening.pdf · ted at various levels viz., primary, secondary and tertiary prevention. According

School Screening

Distribution of Communication disorders in

School Children

Communication Disorders

Prevention

Incidence & Prevalence of Communication Disorders in India

School Screening Program

Significance of School Screening

Epidemiological Data on School Screening: Current Status

School Screening Program at AIISH

Material

Participants

Procedure

Results

Conclusion

References

AIISH, MYSURU

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru

AIISH OCCURRENCE OF COMMUNICATION DISORDERS: EPIDEMIOLOGICAL REPORT

1

AIISH, MYSURU

Communication Disorders

Communication is the essence of human life. It is also the most effective tool

to cope up with day-to-day living. Verbal communication is unique to

human beings and it is said to be the most efficient mode of communication.

Communication disorder is a broad term which covers different types of

disorders (Ruscello, Louis & Mason, 1991) which can be seen at the level of

comprehension or production of speech sounds (i.e. consonants and

vowels), words, phrases, or sentences (ASHA, 2006). The spectrum of

communication disorders include problems in speaking, hearing and

thinking such as voice disorders, phonological disorders, fluency disorders

(Stuttering & Cluttering), language disorders, delayed and/or arrested

speech and language development due to hearing impairment, mental

retardation and other problems. Details of the different communication

disorders are mentioned in table 1.

Table 1: Different types of communication disorders

Type of disorder Definition

Phonological/articulation

disorders

Atypical production of speech sounds characterized

by substitutions, omissions, additions or distortions

that may interfere with intelligibility (ASHA, 1982)

Fluency disorder An interruption in the flow of speaking characterized

by atypical rate, rhythm, and repetitions in sounds,

syllables, words, and phrases. This may be

accompanied by excessive tension, struggle

behaviour, and secondary mannerisms (ASHA,

1982)

Voice disorder Characterized by the abnormal production and/or

absences of vocal quality, pitch, loudness,

resonance, and/or duration, which is inappropriate

for an individual's age and/or sex (ASHA, 1982)

Cleft lip palate An opening or split in the upper lip, the roof of the

mouth (palate) or both (Mayo clinic, 2015).

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


2

AIISH, MYSURU

Prevention

Research has shown that prevention of any disorder is effective in reducing

incidence and prevalence. The World Health Organization (1998) defined

prevention as “the measures not only to prevent the occurrence of disease,

such as risk factor reduction, but also to arrest its progress and reduce its

consequences once established”. Communication disorders can be

prevented at various levels viz., primary, secondary and tertiary

prevention. According to American Speech and Hearing Association

Spoken language

disorder

Individuals with language difficulties has a unique

profile, based on his or her current level of language

functioning, as well as functioning in areas related

to language, including hearing, cognitive level, and

speech production skills (ASHA, 2011).

Mental Retardation A condition of arrested or incomplete development

of the mind, which is especially characterized by

impairment of skills manifested during the

developmental period, skills which contribute to the

overall level of intelligence, i.e. cognitive, language,

motor, and social abilities. Retardation can occur

with or without any other mental or physical

condition (ICD-10, 2015)

Cerebral palsy A disorder of movement, muscle tone or posture

that is caused by an insult to the immature,

developing brain, most often before birth

(Mayo clinic, 2013)

Autism Spectrum

Disorder

(A neuro-developmental disorder characterized by

deficits in social communication and social

interaction and the presence of restricted, repetitive

behaviours (ASHA, 1982)

Reading and writing

problems

Problems with age-appropriate reading, spelling,

and/or writing (ASHA, 1982)

Hearing disorders A hearing disorder is the result of impaired auditory

sensitivity of the physiological auditory system. A

hearing disorder may limit the development,

comprehension, production, and/or maintenance of

speech and/or language (ASHA, 1993)

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


3

AIISH, MYSURU

(1988), Primary prevention refers to the “elimination or inhibition of the

onset and development of communication disorder by altering

susceptibility or reducing exposure for susceptible persons. Whereas,

secondary prevention refers to the early detection and treatment of

communication disorders (ASHA, 1988). Tertiary prevention is defined as

the reduction of a disability by attempting to restore effective functioning

(ASHA, 1988).

Incidence and prevalence of

communication disorders in India

Communication disorders may affect social and emotional well-being,

cognition, and behaviour (Felsenfeld, McGue, & Broen, 1995; Lewis,

Freebairn, & Taylor, 2000). Prevalence is defined as the number of people

with a disease or condition in a given population at a specific time, either a

point in time or over a period of time. The prevalence of a disorder is

essential to assess the need for health services and to evaluate the problem

of disease in a population. It helps to compare the prevalence of disease in

different populations and to examine trends in disease prevalence or

severity over time. As per the country wide sample survey conducted by

Government of India in 2011, census listed hearing impairment (18.9%) as

the second leading disability and speech impairment (7.5%) as the fifth

highest disability. Males outnumbered the females in both hearing (Males-

52.8%, Females-47.2%) and speech impairment (Males-56.25%, Females-

43.8%).

In India, Sreeraj, Suma, Jayaram, Sandeep, Mahima and Shreyank (2013)

conducted a survey in rural population of India and found out that the

prevalence of individuals at risk of communication disorders was 6.07%.

Among those at risk, the prevalence of audiological and or otological

disorder was found to be 90.58% and that of speech and language disorder

was 9.42%. Among those at risk of speech and language disorder, 22.9%

were found to be at risk of mental retardation.

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


4

AIISH, MYSURU

School screening program

Screening refers to the process of identifying the presence of a problem.

There are several screening procedures, which include use of high-risk

registers, checklists, questionnaires, screening tests, etc. Through preschool

and school screening, it is feasible to identify children at risk for any speech,

language, hearing or academic problems and also detect communication

disorders in children. It is a part of secondary prevention where in the

condition is identified for any risk and then a detailed evaluation will

confirm the diagnosis in order to carry out intervention as early as possible.

Thus, preventing the deterioration or worsening of the condition. Routine

school screening programs will provide an estimate of the prevalence of

communication disorders in school aged population. The incidence and

prevalence of any disorder estimated through surveys or school screening

programs helps to evaluate the problem of a disorder in a population and

also facilitates need for appropriate clinical services to these children.

Significance of school screening

In preschool and school age children, the prevalence of communication

disorders can be high but go undetected as the population are not screened

or identified with appropriate measures. Also many of these conditions in

children may not be identified until the age of 2–3 years of age, particularly

in the absence of any medical risks or cognitive disabilities (Wetherby &

Prizant, 1996). According to an epidemiological data of World Health

Organization, the burden of hearing impairment ranges between 0.5% and

5% of every born infant (WHO, 2010). Newborn hearing screening aims on

congenital or childhood deafness and ignores acquired speech language and

hearing loss seen at later stage of life in children. Universal newborn/infant

screening program is essential not only for hearing screening but also to

check for communication disorders as a whole. In universal

newborn/infant screening programs, only screening identification of

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


5

AIISH, MYSURU

children lesser than 3 years is taking place and, however, children who are

above 3 years of age are missed out.

Epidemiological data on school screening:

Current status

Earlier studies on western population reported that prevalence of Speech-

Language and hearing disorders have broad variability in the prevalence

rates. Prevalence of communication disorders was found to be between

4.19% (De Andrade, 1997), and 13.0% (McLeod & McKinnon, 2007). The

prevalence of speech disorder was 1.06% (McKinnon, McLeod & Reilly,

2007), 4.6% (Kirkpatrick & Ward, 1984), 2.3-24.6% (Law, Boyle, Harris,

Harkness & Nye, 2000). Similarly, the prevalence of language disorders was

found to be 2.02–19% (Law, Boyle, Harris, Harkness & Nye, 2000). Several

western studies reported the prevalence of communication disorders in

school going children but the incidence and prevalence rates are lacking in

the Indian scenario.

School screening program at AIISH

Screening of school children was carried out by a professional team

comprising of a Speech-Language Pathologist, Audiologist, and an ENT

specialist. Screening was conducted in a relatively noise free environment.

The following protocol was followed for pre-school and school screening

program:

Initially ear examination was done through an Otoscope. Pure tone

audiometric screening was carried out in a quiet room at 500 Hz, 1 kHz, 2

kHz and 4 kHz, through a screening audiometer air-conduction mode. In

addition, Immittance screening (Tympnaomtery & Reflexometry) was

performed to check for any abnormality in middle ear. A Pure tone

threshold of more than 20 dB HL at any one of the frequency and or the

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


6

AIISH, MYSURU

tympanaogram of ‘B’ or ‘C’ type with absent reflex at 1 kHz was considered

as ‘fail’ criteria.

Material

Speech and Language evaluation was carried out using a protocol

developed for assessing speech and language skills in children. Table 2

shows the tools used for speech and language evaluation.

Table 2: Various assessment tools used to screen/assess speech and language

skills in children.

Name of the test Author Age

(yrs) Population Domains

Linguistic Profile Test

in Kannada

Suchithra&

Karanth

(1990, 2007);

6-15

Language

delay or

disorders

Assess receptive and

expressive language

skills

Reading Acquisition

Profile – Kannada

Prema (1997) 8-12 Children with

Learning

Disability

Meta-phonological

tests, Reading and

writing test, test for

orthographic principles

and reading

comprehension.

English language Test

for Indian Children

Bhuvaneshw

ari & Shanbal

(2010)

4-6 Children with

HI, MR, CP, PD,

etc.

Assess language

abilities of the child

using following

domains: Semantic

Knowledge,

Morphological rules and

syntactic rules

including the following

subtests: Lexical

Categories, Nouns,

verbs, generative

naming, opposites,

tenses and plurals.

Assessment checklist

for speech-language

skill

Swapna,

Jayaram,

Prema &

Geetha

(2010)

0-6 Children with

communication

disorders

Includes assessment of

receptive language and

expressive language

skills

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


7

AIISH, MYSURU

Participants

The Department of Prevention of Communication Disorders (POCD) at the

All India Institute of Speech and Hearing (AIISH), Mysore is involved in

carrying out regular school screening programs in various regions. One

such school screening program was conducted in government and private

school setup of rural and urban regions in the districts of Mysore and

Mandya, in the state of Karnataka. Twenty five schools were screened for

communication disorders between the years 2012 and 2014. The data was

analysed for 2010 school going children. Out of 2010 children, 829 children

belonged to urban region and 1181 belonged to rural region. Across

grades, 1407 children were studying in lower primary grade (≤5th grade)

and 603 children (6th& 7th grade) in upper primary grade. Across gender,

1093 were boys and 917 were girls.

Test of Articulation in

Kannada

Babu,

Rathna, &

Bettagiri

(1972);

Deepa &

Savithri

(2010)

3-6

Phonological/A

rticulation

disorders

Assesses articulation

skills in children

Early Literacy

Screening Tool

Shanbal,

Goswami,

Prathima&

Chaithra

(2011)

3-6

Children at risk

for Learning

disability

Assesses auditory

discrimination, oral

language, verbal

memory, early literacy,

phonological awareness,

reading, writing,

mathematics

Dyslexia Assessment

Profile for Indian

Children (DAPIC)

Kuppuraj&

Shanbal

(2012)

6-13 Children with

Learning

disability

Checks for reading and

writing abilities at

alphabet, word and

sentence level.

Stuttering severity

Index (SSI)

Riley (1981) 3-8

years

Children with

stuttering

Checks for dysfluencies

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


8

AIISH, MYSURU

Procedure

A prior permission was taken from the respective districts of Deputy

Director of Public Instructions (DDPI) office. All the school children were

screened for speech and language disorders if any, through the Assessment

checklist for speech-language skills (Swapna, Jayaram, Prema & Geetha,

2010) to check for speech and language skills; Early Literacy Screening Tool

(Shanbal, Goswami, Chaithra & Prathima, 2011) to check for literacy skills.

Children were screened informally through general conversation and/or

story narration to check for voice, fluency and articulation. If the child failed

in screening, further referral was made to administer an appropriate

speech and language tests on identified child to confirm the deficit. Routine

detailed diagnostic evaluations were carried out by qualified Speech-

Language Pathologists and Audiologists.

Analyses

The data was analyzed to look for prevalence of communication disorders

in school going children and the effect of regions (urban & rural), grades

(Lower primary & Upper primary) and gender (Boys & Girls). Percent of

prevalence rate was calculated and Chi-square test was used to find the

significant association between prevalence of communication disorders

across regions, grades and gender.

Results

Occurrence of communication disorders in school children

Among 2010 screened children, 14.2% were found to have communication

disorders. Among the identified group, the occurrence of language

disorders was found to be highest followed by speech disorders, hearing

disorders and multiple disorders. Table 3 and figure 1 showed distribution

of overall occurrence of communication disorders in school children.

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


9

AIISH, MYSURU

Table 3: Distribution of children who had communication disorders in school

[Total screened (N) =2010]

Communication Disorders N Occurrence rate ( %)

Language disorders 138 6.9%

Speech disorders 74 3.7%

Hearing disorders 68 3.4%

Multiple disorders 6 0.3%

Total 215 75.4

Figure 1: Distribution of communication disorders in school children

Occurrence of communication disorders across region

The occurrence of communication disorders between regions revealed a

high prevalence of language disorders, speech disorders, hearing disorders

and multiple disorders in the rural region (86.2%, 64.4%, 63.2% & 100%

respectively) compared to urban region (13.8%, 35.6% 36.8% & 0%

respectively). Results of Chi- square test indicated a significant association

[χ² (3) = 20.91, p <0.01] between regions and communication disorders

(Speech, language, hearing & multiple). Table 4 and figure 2 showed

distribution of communication disorders across regions.

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


10

AIISH, MYSURU

Table 4: Distribution of children who had communication disorders across

regions [Total screened (N) =2010]

Communication disorders

Rural Urban

N % N %

Language disorders 119 86.2 19 13.8

Speech disorders 47 64.4 26 35.6

Hearing disorders 43 63.2 25 36.8

Multiple disorders 6 100.0 0 0.0

Total 215 75.4 70 24.6

Chi square- χ² (3) =20.91 Statistical Significance -p <0.01

Figure 2: Distribution of communication disorders across regions

Occurrence of communication disorders across grades

Relatively, higher occurrence of language disorders (71.7%), speech

disorders (82.2%), hearing disorders (66.2%) and multiple disorders

(83.3%) was found in the lower primary grades than in the upper primary

grades (28.3%, 17.8%, 33.8% & 16.7% respectively). However, results of

Chi-square test revealed no significant association between grades and

communication disorders [χ² (3) =5.197, p>0.05]. Table 5 and figure 3 show

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


11

AIISH, MYSURU

distribution of communication disorders in lower primary and upper

primary grades in school going children.

Table 5: Distribution of children who had communication disorders across

grades [Total screened (N) =2010]


Lower Primary Lower Primary

N % N %





Total 209 73.3 76 26.7

Chi square- χ² (3) = 5.197 Statistical Significance- p>0.05

Figure 3: Distribution of communication disorders across grades.

Occurrence of communication disorders across gender

The results revealed a high occurrence of language disorders, speech

disorders, hearing disorders and multiple disorders in boys (63.8%, 68.5%,

61.8% & 83.3% respectively) compared to girls (17.1%, 7.1%, 8% & 2.1%

respectively). Results of Chi-square test indicated no significant association

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


12

AIISH, MYSURU

between gender and communication disorders [χ² (3) = 3.22, p>0.05]. Table

6 and figure 4 showed distribution of communication disorders (Speech,

language, hearing & multiple) between boys and girls.

Table 6: Distribution of children who had communication disorders gender

[Total screened (N) =2010]


Boys Girls

N % N %





Total 185 64.9 100 35.1

Chi square- χ² (3) = 1.68 Statistical Significance- p>0.05

Figure 4: Distribution of communication disorders across gender.

Further descriptive analysis was done to estimate the distribution of

various speech and language disorders in school children. Among the total

communication disorders, 11.44% (N=230) were found to have some form

of speech and/or language and/or multiple disorders. Table 7 shows

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


13

AIISH, MYSURU

distribution of different types of speech, language and multiple disorders in

children.

Table 7: Distribution of different types of Speech, language and multiple

disorders

Communication disorders Total

n %

Language disorders

Learning disability 100 43.5

Mental retardation 25 10.9

Specific language impairment 18 7.8

Autism spectrum disorder 2 0.9

Speech disorders

Articulation/phonological

disorders 43 18.7

Fluency disorders 25 10.9

Voice disorders 5 2.2

Childhood dysarthria 4 1.7

Hypernasality with repaired Cleft

lip & Palate 3 1.3

Multiple disorders Combination of any Speech and

language disorder 5 2.2

From Table 7, it can be inferred that children with Learning disability was

more common in school children (43.5%) among the language disorders.

Among the speech disorders, children with Articulation/ Phonological

disorders were found higher (18.7%). Other disorders like Fluency

disorders (10.9%), Mental retardation (10.9%), Specific language

impairment (7.8%), Voice disorders (2.2%), Childhood dysarthria (1.7%),

Hypernasality with repaired cleft-lip & Palate (1.3%), Autism Spectrum

Disorders (0.9%) and multiple disorders (2.2%) were also prevalent in the

study.

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


14

AIISH, MYSURU

Discussion

The present study identified the occurrence of communication disorders in

school children and the comparison across regions, grades and genders.

The results of the study revealed higher occurrence of communication

disorders in school children. Among those, the estimated occurrence of

language disorders was higher followed by speech disorders, hearing

disorders and multiple disorders. There exists a significant variation in the

prevalence of communication disorders across studies in different parts of

the world. The prevalence of communication disorders was reported 1.7%

in Australian children (Keating, Turrell & Ozanne, 2001); 12.40 to 13.04%

in Australian children (McLeod, et al, 2007); 14.4% to 18.7%in Greece

children (Okalindou & Kampanaros, 2001). In contradiction to the present

study, higher occurrence of speech impairment (2.3-24.6%) was reported

followed by language impairment (2.02–19%) (Law et al., 2000). However,

the results of the present findings cannot be compared with the existing

findings due to difference in study design. The difference in prevalence rate

among the communication disorders could be due to the difference in

methodologies used in the study, age of participants, data collection

methods such as direct assessment and/or parent/teacher report,

definition of communication disorders and its sub-groupings such as

speech and language disorders (McKinnon et al., 2007).

Between regions, the present study reported that school children who are

in rural regions exhibited higher occurrence rate compared to urban areas.

This is in consonance with the prevalence reported by Singh, Chandra,

Dayal, Chandra and Bhushan (1980); Srivastava and Khan (2008); Gad-

Allaha, Abd-Elraoufa, Abou-Elsaadb and Abd-Elwahedc (2012). Incidence

of communication disorders in rural areas is relatively more as it is not

always identified and treated accordingly (Srivastava et al., 2008) at an

earlier stage due to ignorance or lack of knowledge and lack of access to

facilities for identification and treatment of communication disorders in the

rural regions. It might also be due to lack of resources and infrastructure

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


15

AIISH, MYSURU

(Yadav, Jarhyan, Gupta & Pandav, 2009); lack of health awareness due to

various socio economic factors (Kumar, 1997); poor accessibility, non-

availability, poor utilization of rehabilitation services and also its cost-

effectiveness (Kumar, Roy & Kar, 2012).

Between grades, the results of the present study revealed that there exists

no association between communication disorders. Generally, the incidences

of communication disorders in children are reported to have reduced with

age (Keating, Turrell & Ozanne, 2000; Harasty & Reed, 1994; Craig, Hancock,

Tran, Craig, & Peters, 2002). The present data showed no significant

difference for language, hearing and multiple disorders and their

association between grades. This might be due to a smaller difference in age

between the groups. The findings of the present study can be correlated

with the fact that children at this age show greater alteration in speech

during the phases of dental exchanges and reorganization of the intraoral

space required to produce speech (Rabelo, Alves, Goulart, Frinche & Lemos

et al., 2011).

With respect to gender, in the present study, no association was seen in the

occurrence of communication disorders and gender. However, earlier

studies showed a greater rate of impairment in boys than girls with male to

female ratios ranging from 1.5 to 2.4 for speech disorders, and 0.98:1 to

2.30:1 for language disorders (McKinnon et al., 2007; Tomblin, et al., 1997).

A consensus of literature reports indicate that gender differences for

communication disorders is not a significant factor amongst all

communication disorders. For e.g., in studies of children with Learning

disability (Dhanda et al., 2013; Roth, 2004), Mental retardation (Helgason,

1964; Murphy, Yeargin-Allsopp, Decoufle, & Drews, 1995), Autism

Spectrum Disorders (Werling & Geschwind, 2013) and others reported that

though occurrence was greater in boys than girls, there was no significant

difference reported within the gender. On the other hand, those studies

who report of significant gender differences in children suggest that these

variations in general could be due to a relatively lower threshold for

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


16

AIISH, MYSURU

developing certain skills in boys indicating a difference in the genetic

predisposition of brain development for boys and girls (Lewis, 1990).

Gender differences in few of the communication disorders are attributed to

susceptibility of brain injury between males and females. For e.g. studies

have reported that among children with cerebral palsy, males are at greater

susceptibility to white matter injuries and intraventricular haemorrhage

than females, especially when children born are preterm (Reiss, Kesler,

Vohr, Duncan, Katz & Pajot et al., 2004; Johnston & Hagberg, 2007).

With respect to the distribution of different types of speech, language and

multiple disorders, the present study revealed a perceptible occurrence in

school children (11.4%). Among these, distribution of learning disability

and articulation/ phonological disorders were more widespread followed

by other disorders like Fluency disorders, Mental retardation, Specific

language impairment, Voice disorders, Childhood dysarthria, Hypernasality

with repaired cleft-lip & Palate, Autism Spectrum Disorders and multiple

disorders. A greater proportion of children associated with learning

difficulties in the present study could be due to the factors such as poorer

educational opportunities in schools, poor socioeconomic status (Emerson,

Hatton, Robertson, Roberts, Baines, Evison & Glover, 2010), and poor

access to the rehabilitative services. Generally, as children grow articulation

problems could seem to fade and disappear without treatment. More

occurrence of deprived articulation might be due to poor modelling and

reinforcement in the classroom and at home.

Conclusions

The findings of the present study showed the occurrence of communication

disorders in school going children. Among the identified children with

communication disorders, language disorders were found high compared to

speech disorders, hearing disorders and multiple disorders. Occurrence of

communication disorders was higher in rural regions than urban regions.

But no significant gender effect and grades effect was seen for any form of

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


17

AIISH, MYSURU

communication disorders. Further, it was also notices that learning

disability and articulation/phonological disorders were found to be more

common in school going children compared to other speech and language

disorders. The results indicated the need and importance of screening of

communication disorders in school going children for early identification

and primary, secondary and tertiary prevention. It can be concluded that

the disordered specific identify of the children is essential and they in turn

require special attention by continuously monitoring their speech and

language skills by the professionals in the field of communication disorders

and also for planning appropriate rehabilitation. However, such studies

should be carried out in a large scale with similar protocol to estimate the

actual incidence and prevalence rates of communication disorders in school

going children.

Department of

Prevention of

Communication

Disorders,

All India Institute

of Speech &

Hearing, Mysuru


18

AIISH, MYSURU

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Department of

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All India Institute

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Hearing, Mysuru


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AIISH, MYSURU

Craig, A., Hancock, K., Tran, Y., Craig, M., & Peters, K. (2002). Epidemiology

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Documents

School Screening - All India Institute of Speech and Hearingaiishmysore.in/en/pdf/School_screening.pdf · ted at various levels viz., primary, secondary and tertiary prevention. According