www.rpped.com.br
REVISTA
PAULISTA
DE
PEDIATRIA
ORIGINAL
ARTICLE
Speech
and
language
disorders
in
children
from
public
schools
in
Belo
Horizonte
Alessandra
Terra
Vasconcelos
Rabelo
∗,
Fernanda
Rodrigues
Campos,
Clarice
Passos
Friche,
Bárbara
Suelen
Vasconcelos
da
Silva,
Amélia
Augusta
de
Lima
Friche,
Claudia
Regina
Lindgren
Alves,
Lúcia
Maria
Horta
de
Figueiredo
Goulart
UniversidadeFederaldeMinasGerais(UFMG),BeloHorizonte,MG,Brazil
Received17August2014;accepted8February2015 Availableonline28August2015
KEYWORDS
Speech,languageand hearingsciences; Schoolhealth; Speech;
Languagedisorders
Abstract
Objective: Toinvestigatetheprevalenceoforallanguage,orofacialmotorskillandauditory processingdisordersinchildrenaged4---10yearsandverifytheirassociationwithageandgender.
Methods: Cross-sectional study with stratified, random sample consisting of 539 students. Theevaluationconsistedofthreeprotocols:orofacialmotorskillprotocol,adaptedfromthe MyofunctionalEvaluationGuidelines;theChildLanguageTestABFW---Phonology;anda sim-plified auditory processing evaluation. Descriptiveand associative statistical analyses were performedusingEpiInfosoftware,release6.04.Chi-squaretestwasappliedtocompare pro-portionofeventsandanalysisofvariancewasusedtocomparemeanvalues.Significancewas setatp≤0.05.
Results: Ofthestudiedsubjects,50.1%hadatleastoneoftheassesseddisorders;ofthose, 33.6%hadorallanguagedisorder,17.1%hadorofacialmotorskillimpairment,and27.3%had auditoryprocessingdisorder.Thereweresignificantassociationsbetweenauditoryprocessing skills’ impairment,orallanguageimpairmentandage,suggestingadecreaseinthenumber ofdisorderswithincreasing age.Similarly, thevariable‘‘oneormorespeech,languageand hearingdisorders’’wasalsoassociatedwithage.
Conclusions: Theprevalenceofspeech,languageandhearingdisordersinchildrenwashigh, indicatingtheneedforresearchandpublichealtheffortstocopewiththisproblem.
©2015SociedadedePediatriadeS˜aoPaulo.PublishedbyElsevierEditoraLtda.Thisisanopen accessarticleundertheCCBY-license(https://creativecommons.org/licenses/by/4.0/).
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.rpped.2015.02.004
∗Correspondingauthor.
E-mail:alessandratvr@gmail.com(A.T.V.Rabelo).
PALAVRAS-CHAVE
Fonoaudiologia; Saúdeescolar; Fala;
Transtornosda linguagem
Alterac¸õesfonoaudiológicasemcrianc¸asdeescolaspúblicasemBeloHorizonte
Resumo
Objetivo: Investigar aprevalência dealterac¸õesdelinguagem oral,motricidadeorofaciale processamentoauditivoemcrianc¸asde4---10anoseverificarasuaassociac¸ãocomaidadeeo gênero.
Métodos: Estudotransversalcomamostraaleatóriaeestratificada,compostapor539crianc¸as. Foramutilizadosparaavaliac¸ãoprotocolodemotricidadeorofacial,adaptadodoRoteiropara Avaliac¸ãoMiofuncional;provadeFonologiadoTestedeLinguagemInfantilABFW;eavaliac¸ão simplificadado processamento auditivo.Foramrealizadas análises estatísticas descritivase deassociac¸ãoutilizando osoftwareEpiInfo, versão6.04. Paracompararas proporc¸ões foi empregadooqui-quadradoe,paracompararmédias,foiempregadaaanálisedevariância.Foi consideradosignificantep≤0,05.
Resultados: Dascrianc¸asavaliadas,50,1%apresentarampelomenosumadasalterac¸ões estu-dadas,sendoque33,6%mostraramalterac¸ãodelinguagemoral,17,1%demotricidadeorofacial e 27,3% do processamento auditivo. Observou-se associac¸ão significativa entre alterac¸ões fonoaudiológicas de processamento auditivo, linguagem oral e a faixa etária, sugerindo diminuic¸ãodonúmerodecrianc¸ascomalterac¸õesfonoaudiológicascomoaumentodaidade. Avariável‘‘umaoumaisalterac¸õesfonoaudiológicas’’tambémseassociouàfaixaetária,de maneirasimilaràacimadescrita.
Conclusões: Aprevalênciadealterac¸õesfonoaudiológicasnapopulac¸ãoestudadafoi consider-adaalta,evidenciandoanecessidadedepesquisaseac¸õesemsaúdeparaoenfrentamentodo problema.
©2015SociedadedePediatriadeS˜aoPaulo.PublicadoporElsevierEditoraLtda.Esteéumartigo OpenAccesssobalicençaCCBY(https://creativecommons.org/licenses/by/4.0/deed.pt).
Introduction
Theneedtocommunicateisinherenttohumanbeingsandis essentialfortheintegraldevelopment,knowledge acquisi-tionandlearning.Languagedevelopmentinvolvesphysical, neurological, behavioral, cognitive, social and emotional aspects.
The adequacy of the auditory processing,which is the transformation of the acoustic signal into a meaningful message,1 is essential in language acquisition. Another importantaspectisrelatedtotheorofacialmotricity,which isassociatedwithstructuralandfunctionalaspectsofthe orofacial and cervical regions, including the functions of sucking,swallowing,chewing,breathingandarticulation.2 Fortheorallanguagetooccur,thesoundsproducedinthe vocalfoldsaremodeledandarticulatedduringtheirpassage throughthelarynx,pharynx,andoralandnasalcavities.Itis necessaryforthephysicalmovementsinvolvedinthe emis-sionofsounds(phoneticaspects)tobeproducedadequately, whilerespectingtheorganizationalaspectsofthelanguage soundsystem(phonoaudiologicalaspects).3
Some delaysmayoccur, duringchild developmentthat willhave an adverse impact onchildren’slives. Phonoau-diologicalalterationsmayberesponsiblefor thesedelays, leading to social maladjustments, learning and interper-sonalskills’difficulties,withnegativeeffectsontheoverall development.4 Additionally, during the process of acquir-ing literacy, children transfer errors from the oral signs’ systemtothewritten language,5withlearningdifficulties beingoneofthemainimpactsoforallanguagealterations. Earlyrecognitionofthesedisorders,followedbyappropriate
interventions, can reduce the impactof these alterations onthelivesof theaffectedchildren,allowingtheir social developmentandimprovingtheirqualityoflife.
The impact of communication disorders and evidence that the prevalence is high inschoolchildren3,4,6---11 justify furtherstudiesonthesubject.Basedonthesedata,itmay bepossibletodevelop effectiveactionsforhealth promo-tion,speechtherapyandpediatricinterventions,whichwill helptopreventlearning,emotionalandsocialdisorders.
Thisstudyaimstoassesstheprevalenceoforallanguage, orofacial motricity and auditory processing alterations in childrenaged4---10yearsfrompublicschoolslocatedinthe areaofahealthcarecenterinBeloHorizonte,aswellasto verifytheirassociationwithageandgender.
Method
Thisisacross-sectionalstudy,approvedbytheInstitutional ReviewBoardoftheFederalUniversityofMinasGerais(ETIC notice 263/08), with a representative random sample of 1853 children aged 4---10 years enrolled in the six public schoolsfromtheareaservedbytheHealthCareCenterin thenortheastregionofBeloHorizonte.Thishealthcare cen-terisateaching,researchandcontinuingeducationfacility for students ofthe UniversidadeFederal deMinas Gerais, anditwasusedasareferencesupportfacilityforthe refer-raloftheassessedchildren.
losses, resulting in 545 children, stratified by school and age range.Exclusion criteriawere the presence of physi-calorcognitivelimitations thatprevented theteststobe performed, refusal toparticipatein the studyand failure toobtaintheInformedConsentformsignedbyaparentor child’slegalguardian.Atotalof539childrenwereassessed, with1.1%oflosses.
Eachchildwasassessedbyoneofthe3speechtherapists speciallytrainedontheevaluationcriteria.Datacollection wasperformedinthreesteps:orofacialmotricity(OM) eval-uation, oral language assessment and simplified auditory processingevaluation.
Toassessorofacialmotricity,aprotocoldevelopedbythe researcherswasused toassess themyofunctional aspects ofthestomatognathicsystem,adaptedfromthe Myofunc-tionalAssessmentProtocol.2Theprotocoldoesnotsuggest rigidstandardsofnormality,andalterationsaredefinedona case-by-casebasisthroughobservationbythespeech ther-apist, based onhis/her clinical experience. In this study, the criteria for any disorder were defined prior to the assessment by consensus of four speech therapists, con-sidering morphological alterations, decreased tension and alterationsinthemovementoforofacialstructures,and pos-siblefunctionalimplications.Themorphologicalaspectsof theface,lips,tongue, andcheeks,andocclusion,tension andmobilityofthelips,tongueandcheekswereevaluated byclinicalobservation;counter-resistancetestswith dispos-abletonguedepressorandglovedfinger forverificationof tension;puckering-smilemovements,inflationand contrac-tionofcheeks,protrusionandretractionofthetongueand movementofthetonguetowardthefourcardinalpointsto assessmobility.
The assessment of oral language was performed using the Child Language Test ABFW --- Phonology,12 which con-sistsin naming andimitation, inwhich the child’sspeech isrecordedthroughphonetictranscriptiondoneduringtest applicationforfurtheranalysis.Thetestconsiderstheage ofsevenasamarkerfortheendoftheacquisitionof pho-neticandphonoaudiologicalaspectsoflanguage,inaddition todefiningwhatisexpectedforeachagegroup.
We chose to use the term oral language when the following aspects were treated jointly: phonetic devia-tions, expressed by alterations in sound articulation, and phonologicaldisorders,definedaslanguagedisorders cha-racterized by the presence of productive asynchronous phonoaudiological processes (at an older range age than thatwhenthissameprocessisovercomebymostchildren), and/orthepresenceofunusualphonoaudiologicalprocesses (which are not observed in the normal acquisition of the phonoaudiologicalsystem)inthechild’sspeech.
The simplified evaluation of auditory processing1,13 involved the sequential memory to non-verbal sounds (SMNV),thesequentialmemorytoverbalsounds(SMV)and the sound location test (SLT). Given the impossibility to assesspuretonethresholdsthroughpuretoneaudiometry, we chose to assess the Cochleo-palpebral reflex (CPR) to excludechildrenwithmoderateorseverehearingloss.The criteriaoftestapplicationandanalysisofresultscomplied withtherulesdefinedbythetest.1,13
Evaluations lasted approximately30min and were car-ried out in the school environment. The results were classified as normal or altered, being considered altered
Table 1 Characteristics of the study population in the 2009/2010period,BeloHorizonte(n=539).
Characteristics n %
Agerange
<5years 67 12.4 5to<7years 185 34.3 7to≤11years 287 53.3 Gender
Male 287 53.2 Female 252 46.8
School
School1 84 15.6 School2 98 18.2 School3 114 21.1 School4 36 6.7 School5 21 3.9 School6 186 34.5
Total 539 100.0
whenthe children had insufficient resultsin one or more tests,andnormalwhentheyachievedtherequirementsof thethreetests.Childrenwithalteredtestswerereferredto speechtherapyandpediatriccare.
An electronicdatabase wascreated, andEpiInfo soft-ware,release3.5.3,wasused.Theanalysisofthefrequency distributionofcategoricalvariableswasperformed.The chi-squaretestwasusedtostudytheassociationbetweenthe presence of phonoaudiological alterations and gender. To verifytheassociationbetweenthepresenceof phonoaudi-ologicalalterationsandage, thechi-squaretest forlinear trend,thecalculationofoddsratioandconfidenceintervals at95%wereused.Ap value≤0.05wasconsidered statisti-callysignificant.
It is noteworthy that two other articles have already beenpublishedusingthesamesampleofthepresentstudy, whichhavespeech(phonetic andphonoaudiological disor-ders)asthemainobject,withonestudybeingcarriedout inschoolchildren14andoneinpreschoolchildren.15This arti-clediffersfromthepreviousonesnotonlyduetothelarger sample size and broader age range, but also due to the objective,typeofanalysisandresultsshown. Itshouldbe notedthatpopulation-basedstudiesthataddressthe preva-lenceof phonoaudiological disordersare relatively scarce inthe Brazilian literature,andthe initiative towritethis articlealsointendedtofillthisgap.
Results
The distributionof the children according to age, gender andschoolisshown inTable1.Oftheevaluatedchildren, 50.1%hadatleastoneofthestudiedalterations.Oral lan-guage alterations were observed in 33.6% of the sample, followedby auditory processing(AP) disorderswith27.3% andorofacialmotricityalterationsin17.1%(Table2).
Table 2 Prevalence of phonoaudiological disorders (n=539).
Phonoaudiologicaldisorder n % Orallanguage 181 33.6 Phonologicaldisorder 61 11.3 Phoneticdisorder 93 17.3 Phonological+phoneticdisorder 27 5.0 Orofacialmotricity 92 17.1 Auditoryprocessinga 147 27.3 Childrenwith1ormorealterationsb 270 50.1
aThe categoriesare not mutuallyexclusive. The childmay
havemorethanonetypeofalteration.
b SixchildrenwereexcludedduetoinconclusiveAPtest.
analyzed separately andwere not considered alterations, butlinguisticvariations,becausetheyareregional charac-teristicsof speech.Childrenyoungerthan 7yearsemploy thesephonoaudiologicalprocesses, accordingtothe anal-ysis of the Child Language Test ABFW --- Phonology.12 For thisreason,inthisagegroupthesesamealterationswere notconsideredlinguistic variations,butphonoaudiological processes.
The most commonly found speech disorder was sim-plification --- the final consonant and consonant cluster simplification---whichoccurredin36.4%ofchildrenwithoral languagealteration.The mainphoneticalterationwasthe frontallisp,presentin30.4%ofchildrenwithorallanguage alteration.
The testsofsequential memorytonon-verbaland ver-balsoundswerealteredin56.9%and49.0%ofchildrenwith auditoryprocessingdisorders,respectively.Inchildrenwith altered orofacial motricity, 72.1% of these changes were relatedto the positioningof the articulatoryorgans, and in67.4%,tothetensionoftheassessedstructures.
There was an association between the children’s age groupandthepresenceofoneor moreassessed phonoau-diologicaldisorders,orallanguageandauditoryprocessing alterations(Table3).Thechanceofachildyoungerthanfive yearstohaveoneormorephonoaudiologicalalterationswas 2.49timeshigher(95%CI:1.37---4.53)thanthechanceofa childaged≥7 years.The samewasnotobserved for chil-drenaged5---7years.Similarly,youngerchildrenweretwice aslikely(OR=2.15;95%CI1.21---3.81)tohaveorallanguage alterationsthanolderones,buttherewasnodifferenceif comparedtothoseage5---7years.TheOddsRatioofchildren youngerthan7yearstohaveauditoryprocessingdisorders, whencomparedwiththoseaged>7yearswas9.72(95%CI: 5.06---18.81)forthegroupaged<5years,and1.92(95%CI: 1.21---3.05)forthoseaged5---7years.Therewasno associa-tionbetweenagerangeandorofacialmotricityalterations, orbetweengenderandtheassessedphonoaudiological dis-orders.
Discussion
Studiesontheprevalenceofphonoaudiologicalalterations, especiallythoseaddressingmorethanonetypeofalteration inasinglepopulation,arescarceintheliterature.Thisstudy showeda high prevalence of sometypes of alterations in
a population of children aged 4---10 years. Validated, yet simple andeasy-to-applytestswereused,eliminatingthe need for sophisticated equipment. Despite these advan-tages,thehighsensitivityofthesetests,carriedoutalone, mayhaveledtoapossibleoverestimationoftheprevalence ofalterations.Anotheraspecttobeconsideredisthatsome childrenmayhaveshowntransientalterationsduringtheir development.However,due tothe cross-sectional charac-teristicofthestudy,whichdidnotaimtofollowthechildren longitudinally,wechosetousethecriteriaindicatedbythe teststoclassifyalterationsatthetimeofassessment.
Theprevalence oforal languagedisordersindicated by thisstudyisbetween 21%and49%,withinthesamerange foundinstudies carriedoutinBrazil.6,8,16---20 Thisvariation is probably due to methodological differences, economic factors and age of the children included in the samples, makingitdifficulttocomparethem.Theinternational stud-ies indicate a lower prevalence of alterations.21,22 In the Cuban population,astudy found a12%prevalence oforal languagedisorders,21whereasinAustralia,2213%ofthe chil-drenshowedresultsbelowtheexpectedaverageforthisage range.
Theliteratureindicatesthattheprevalenceof phonolog-icaldisordersvariesfrom9.2%to18.6%,5,8,23valuesthatare closetothosefoundinourstudy.Theprevalenceofphonetic alterationsrangesfrom2.1%to22.5%indifferentregionsof Brazil.8,23,24Apreviousstudyfoundaprevalenceof22.5%of atypeofphoneticdeviation(lisp).24InMontesClaros(MG), thelispappearedin8.4%of404childrenwithameanage of6yearsand5months.19Inthepresentstudy,amongthe phoneticalterations,the lispwasalsothe mostprevalent disorder.Inanotherstudywithchildrenfromprivateschools, theresults showedaprevalence of18% ofphonetic alter-ations,usingadifferenttypeofassessmentthanthatusedin thisstudy.23Althoughtheresultsaresimilar,tothosefound inthisstudy,theuseofdifferenttoolsmakesitdifficultto compareitwithresultsfromotherstudies.
Regardingthelinguisticvariationfound,itwasobserved thatthespeechofindividualslivinginthecityofBelo Hor-izonte, where this research was performed, included the samevariationsthatoftenoccurinthespeechofadults.25 Thisfactmayexplaintheoccurrenceofthesame simplifica-tionsinthechildren’sspeechproduction,aschildrentend tofollow thespeechpatternoftheirsocialgroup.Astudy carriedoutinBeloHorizonteshowedthatchildrenof moth-erswhohadtheconsonantclustersimplificationtendedto repeatthesesimplificationsintheirspeech.25
Theprevalenceoffailureinthesimplifiedauditory pro-cessing evaluation described in the literature is between 24.6%and44%.10,11,26Inthisstudy,thefailuretorespondto auditoryprocessingassessmenttestisclosetothatobserved inanotherstudythatusedthesametool.11Inastudycarried outwithschoolchildren,usingsimplifiedauditoryprocessing assessment,tympanometryandacousticreflexevaluation, itwasobservedthatmostchildren(64%)whofailedthetest weretheyoungestinthesample.26Theseresultsaresimilar tothoseofthepresentstudy.
Table3 Distributionofphonoaudiologicaldisordersinrelationtoagerangeandgender(%).
Agerangeinyears(%)a Gender(%)b
<5 5to<7 7to<11 Male Female (n=67) (n=185) (n=287) (n=287) (n=252)
Oneormorealterations
Yes(n=270) 67.2 51.9 45.1 53.0 47.0 No(n=269) 32.8 48.1 54.9 53.5 46.5
pvalue 0.96
OR 2.49 1.31 1
95%CI 1.37---4.53 0.87---1.94
---Orallanguagealterations
Yes(n=181) 50.7 29.2 32.4 50.3 49.7 No(n=358) 49.3 70.8 67.6 54.7 45.3
pvalue 0.37
OR 2.15 0.86 1
95%CI 1.21---3.81 0.56---1.31
---OMalterations
Yes(n=92) 16.4 18.4 16.4 59.8 40.2 No(n=447) 83.6 81.6 83.6 51.9 48.1
pvalue 0.20
OR 1.0 1.15 1
95%CI 0.46---2.16 0.69---1.92
---APalterationsc
Yes(n=147) 67.7 29.3 17.8 51.0 49.0
No(n=386) 32.3 70.6 82.2 53.6 46.4
pvalue 0.66
OR 9.72 1.92 1
95%CI 5.06---18.81 1.21---3.05
---OR,oddsratio;OM,orofacialmotricity;AP,auditoryprocessing. a Chi-squaretestforlineartrend.
b Chi-square.
c 6childrenshowedaninconclusiveresultandwerenotincludedintheanalysis.
ofthesoundsourcedirection,whichisthelocationtest.The short-termauditorymemory,involvedintemporalordering, isanimportantskillforreadingandwriting,as,toperform thesetasks,onemuststorethecontentstogoforward.The samedifficultywasobservedintheliterature.26Amongthe simple temporal ordering skills, poorer performance was observed in the test of sequential memory to non-verbal sounds,corroboratinganotherstudy.27
When usedtogether,thethreeproceduresusedfor the simplified auditory processing assessment (sound localiza-tion, sequential memory toverbal and nonverbalsounds) haveasensitivityof80%,i.e.,theyareeffectivein identi-fyingtheauditoryprocessingdisorderamongtheoneswho haveit.Failureinoneofthetestsofthesimplifiedauditory processing assessment is indicative of inadequacy and,in thesecases,oneshouldreferthechildtocompleteauditory processingassessmenttoconfirmthediagnosis.
Thesimplifiedauditoryprocessingassessmentwas devel-opedtobecarriedoutindioticlisteningconditions,inwhich the samestimulus isoffered simultaneously toboth ears, and the medicalliterature recommends that it should be performedinaquietenvironment.1Inthisstudy,itwasnot possibletomeasurethenoiselevelusingasoundpressure leveldevice.Aimingtominimizeapossibleinterferenceby
noise,theevaluatorsperformedthetestsinaquietroom, withonlythe presenceof thechildren and theevaluator, atdifferenttimesfromthebreakintervalbetweenclasses. Nevertheless,onecannot ruleoutthe possibilityof inter-ferenceof theenvironment where thesimplified auditory processing evaluations were performed, which may have ledtooverestimationoftheresults.Thepresenceofnoise generatesloss ofconcentration andattention, whichmay increasethenumberoferrors,decreasingthequalityofthe dailytasks.Inapreviousstudyusingtheauditoryprocessing testsin diotic listening oftonal pattern offrequency and duration,it was observed that subjects withand without phonoaudiologicalalterationsshowedworseperformancein thepresenceofnoise.28
showedthatmostofthechildrenhadaninadequatedietary transition, a pacifier habit, and mastication, swallowing, breathingandocclusionalterations,whichmayhave facil-itated the occurrence of orofacial motricity disorders. Another study showed that 32.5% of the 1103 children assessedthroughphonoaudiologicalscreeningin15 munici-palelementaryschoolsofVilaVelha(ES)showedalterations inorofacialmotricity,ahigherpercentagethanthatfound inthepresentstudy.18 Inatownlocatedinthecountryside ofthestate ofParaná,77.5%of31children fromapublic schoolhadorofacialmotricityalterations.30 Inastudy car-riedoutinthestateofCeará,orofacialmotricityalterations weredividedbytheaffectedstructures,withprevalences of27%inthecheeks,18%inthelipsand7%inthetongue.20 Although somestudies6,8,19 have shown ahigher preva-lenceofphonoaudiologicalalterationsinmales,especially in relation tophonological disorders, this findingwasnot confirmedinthisstudy.
Theassociationsobservedbetweenthepresenceofone ormorephonoaudiologicaldisorders,theauditory process-ingalterationsandorallanguagealterationswithagerange canbe explainedby thegradual developmentof children during normal neuropsychomotor maturation. These asso-ciationsindicatethatyoungerchildren,especiallychildren younger than 5 years, who are still acquiring commu-nication skills, can have transient manifestations, which do not necessarily characterize phonoaudiological disor-ders.
Onthe otherhand,it isknownthatchildrendiagnosed withalterationsafter7yearsofagealreadyhadindications ofchangesintheearlystagesofdevelopment,which empha-sizes the importance of phonoaudiological assessments in younger children. Additionally, it is observed that some assessedchildrenhadmorethanonesimultaneous phonoau-diologicaldisorder. This findingreiterates the importance of detection of these disorders on a timely manner. An early diagnosis can prevent deterioration of the initial condition, as one alteration may be associated with the other.14
This studyisnot withoutlimitations, withthefirstone beingitscross-sectionalcharacteristic,withoutlongitudinal follow-upofthechildrenandnoinferencesaboutcausality. The impossibility of performing otoscopy and audiometry before the auditory processing assessment and the envi-ronmental conditions for carrying out the tests are also recognized as limitations. Nevertheless, this study con-tributes to the advancement of knowledge by addressing differentalterations ina representative sample of a pop-ulationofchildrenwithnopreviouscomplaints.
Thehighpercentageofchildrenwithorallanguage, oro-facialmotricityandauditoryprocessingalterationsfoundin thestudy population maybe indicative ofthe prevalence ofthesedisordersinotherpopulationswithsimilar charac-teristics.The resultsofthisstudy emphasizetheneed for researchandactionsincommunicationhealth tofacethis problem,andfurtherreinforcetheneedtotrainhealthand educationprofessionalsforthetimelydetectionofchildren withpossiblephonoaudiologicalalterations.Weexpectthe resultsofthisresearchmayhelpintheplanningof intersec-torialandmultidisciplinary,educationaland/or assistance actionsthat willoffer the opportunity for adequate child developmentandoverallcommunicationhealthpromotion.
Funding
Thisstudydidnotreceivefunding.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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