Communication disability definition:
“Communication is fundamental for learning and development. Children and young people with a communication disability cannot express themselves, understand others or build relationships because of problems in one or more of these areas:.understanding and finding the right words.producing, ordering and discriminating between speech sounds.using rules about how words, phrases and sentences are formed to convey meaning..using and understanding language in different social contexts. One in ten children and young people struggle with this invisible disability. Without the right help, at the right time, they will be left out and left behind.“
For more information visit www.ican.org.uk
- Most children have immaturities in the way they speak, such as ‘aminal’ for animal’, but these sort themselves out with practice and experience.
- Many children have delayed speech due to a hearing difficulty, such as glue ear. So always check hearing first.
- However, some children lack the ability to make certain sounds, or cannot co-ordinate the sounds in the required sentence. These children are sometimes described as having ‘dyspraxic’, ‘dysarthric’ or ‘articulation’ difficulties.
- For other children language remains rather like a telegram because they do not naturally acquire the grammar and ‘order’ that language follows.
- Sometimes this is because the children’s language development is ‘delayed’ but nevertheless progressing along normal lines. It may be the case that these children are delayed in other areas of their development as well, and the language delay is just one part of this immaturity.
- For other children there is a specific language ‘disorder’ or ‘difficulty’ because, although the child’s language is disordered or delayed, their general intelligence and ability may be average or even high for their age.
- For these children, their understanding of language (their receptive language) is usually affected as well as their use of language (their expressive language).
- Quite often, children who have specific language difficulties also have difficulties in understanding social situations, in seeing the other point of view, in using their imaginations and in handling conversations. Sometimes these children are described as having pragmatic difficulties.
- Other children may opt not to speak at all in your setting (selective mutism) or stammer and stutter.
- Observe your child’s interactions, note down extracts of their language and understanding and make tape recordings.
- Speech and language therapists provide specialist assessment of all aspects of children’s speech, language and communication and can work with families and settings on the best ways to help. Speak to a health visitor if you feel that a specialist assessment may be needed.
An extract from “Supporting speech and language difficulties”, Dr Hannah Mortimer, Nursery Education, September 2003,
SLCN – Speech, Language and Communication Needs
Kamini Gadhok CEO RCSLT
What are “SLCN”?
- Problems with forming sounds and words
- Problems with formulating sentences and expressing ideas
- Problems with understanding speech and language
- Problems using language socially
- Delays and disorders in the development of speech and language skills
Who have SLCN?
- 7% of five year olds entering school in England – nearly 40,000 children in 2007 – have significant difficulties with speech and/or language
- 1% of five year olds entering school in England – more than 5,500 children in 2007 – have the most severe and complex SLCN
- 50% of CYP in some socio-economically disadvantaged populations have speech and language skills that are significantly lower than their peers
When are SLCN apparent in children and young people?
- The majority of SLCN are identifiable from the second year of life
- Some children have problems that are specifically about speech and language
- Some children have problems related to other conditions that affect speech and language
- If a child’s speech and language production appears to be delayed or disordered in any way when compared to other children their age, this is called an expressive language difficulty.
- You may find that a child speaks normally, but sounds like a much younger child. Perhaps they are only using one or two words together or perhaps they are speaking in short telegrams, rather than fluent sentences when compared to the others.
- You may notice that some children speak unclearly, cannot co-ordinate their speech sounds correctly, consistently swap sounds or seem unable to ‘get their tongues around’ certain sounds.
- Some children appear to speak nonsense and may even have developed their own bank of words for certain things – we call this ‘jargon’.
- Others may stammer or stutter.
- What you can do
- If you are concerned, keep a note of the speech sounds a child can make. It is useful to tape record these, taking a sample both in the setting and at home where the child will be more relaxed.
- If a child says a word that is not clear, do not ask them to say it correctly. Instead, repeat the word clearly to them so that they can hear the correct version.
- Use puppet play and telephone play to encourage vocalisations.
- Play together in small groups so that the child has a better chance to listen carefully and reply to you.
- Practise making clear mouth and tongue movements and speech sounds in front of a mirror together.
- Make sure that hearing checks are up-to-date. Speak with a health visitor if you are concerned.
When to seek help
- At first, toddlers may repeat the first syllable of a word, perhaps saying ‘bobo’ for ‘boat’. They may also repeat a consonant in different positions by saying ‘gog’ for ‘dog’. Seek help if this does not disappear by the time a child is nearly three.
- Two-year-olds still tend to miss off final consonants, such as ‘ca’ for cat, or shorten words, such as ‘boo’ for ‘blue’. Seek help if a four-year-old does this a lot.
- All children start with single words, move on to double words and then try short phrases followed by longer sentences. It is normal for them to sounds like little telegrams at first, but seek help if this persist to age four.
- Typically, ‘m’, ‘p’, ‘b’ and ‘w’ sounds develop first, soon followed by ‘n’, ‘t’ and ‘d’ when the child is one-to-two-years-old. The two-year-old begins to use ‘k’, ‘g’, ‘h’ and ‘f’ sounds, followed by ‘y’ and ‘I’ when they are about three. It is very common for three-year-olds to say ‘lellow’ for ‘yellow’ or to find it hard to say ‘th’ or ‘sh’ – these are simply immaturities that generally clear up by school age.
- If you are concerned that help may be needed, enquire about a referral to speech and language therapy.
An extract from “Supporting speech and language difficulties”, Dr Hannah Mortimer, Nursery Education, October 2003, p. 8.
- If a child’s language ‘reception’ or ‘comprehension’ appears to be delayed or disordered in any way, when compared to other children their age, they are likely to have difficulties in understanding words, sentence structures or concepts.
- A child may be speaking normally, but only seems to understand part of what you say.
- It may be that a child responds only to one or two key words in what you have said – bringing you a pencil when you have asked them to bring you the box with the pencils in.
- Perhaps a child does not understand abstract concepts, such as ‘big’ or ‘more’. Abstract words refer to things that you cannot actually point to.
- A child may not understand how the words within a sentence affect the meaning – what a question word means, such as ‘why’ or ‘when’, or that ‘bus stop’ has a different meaning to ‘stop bus’.
- Noticing that a child has receptive language difficulties can be hard to do – the child may be making use of all the other clues in the surroundings and in your non-verbal signals. So you may think that they can understand everything when in fact they cannot follow the words when they are used on their own.
What you can do
- Make sure that the child’s hearing has been checked.
- If you are concerned, try giving simple instructions that are out of context, such as ‘Please get you coat’ when it is not home time. This will help you to assess whether the child can understand your words.
- Provide plenty of opportunities for the child to experience concrete examples of concepts, such as ’empty’, ‘lots’ and ‘long’. This will enable them to make links in their thinking and learn to generalise the word to new situations.
- Time can be a particularly hard concept for a child with receptive language difficulties. Use visual clues such as timetables, and concrete examples from their own experiences, such as ‘When you have had your drink, then you can play outside.’
- Keep your language simple and clear, emphasising key words and showing the child what to do as you tell them.
- Try not to overload the child with language. They can become quickly frustrated and may ‘switch off’ from what you are saying.
When to seek help
- If you suspect that a child’s comprehension is delayed, set up a play session to gather more information. For example, ‘Pass me the little one’, ‘Show me your nose’ and ‘Where are you shoes?’
- Try teaching any words that the child cannot understand by using them in different situations.
- If you have tried these methods and a three-year-old child still cannot point to several body parts, point to a named picture or pass you a ‘big’ or ‘little’ object, then seek help from a speech and language therapist. Referrals can be made through a health visitor, school doctor or GP.
From “Supporting speech and language difficulties”, Dr Hannah Mortimer, Nursery Education, November 2003.
Stammering, or stuttering, is much more common in young children than people think. Five percent of pre-school children stammer, which means that, at any one time, 188,000 children aged under-five in the UK are affected. For the majority, stammering will be a phase they grow out of, but about a quarter to a third are at risk of developing a stammer in adult life unless they receive speech and language therapy in their early years.
Stammering commonly begins between the ages of two and five. Nobody knows what causes it. Children and adults vary in the fluency of their speech, from those who chatter away 19 to the dozen, to those who speak slowly with lots of ‘ums’ and ‘ers’, so stammering may simply be one end of this spectrum. There is a genetic component, as children of stammerers are more likely to develop a stammer themselves, and also many more boys than girls are affected – 80 percent of stammerers are male.
Stammering can take several forms. It may consist of repeated sounds (s-s-s-school) or prolonged sounds (sssschool). Sometimes children stammer over one consonant or syllable. Some have speech that sounds forced, tense or jerky. Others become so blocked that they may tense up their faces and clench their fists while trying to get any sound out at all.
Stammering is not simply a speech difficulty, but a serious communication problem. It can undermine a child’s confidence and self-esteem, affect their interaction with others and hamper their education. Children who stammer may become so self-conscious that they try to avoid speaking altogether and avoid situations in which they know they will be expected to speak. Being questioned by an adult can be a torment, and other children may tease the child, ignore them, or exclude them from their games.
Sometimes nursery workers may miss a stammering child because the child is quiet and doesn’t engage in conversation. He may be a child who works discreetly in a corner, never asks for anything and never draws attention to himself.
It can be hard for adults to spot when stammering becomes a problem. Many children have some degree of dysfluency when they are learning to talk, repeating words and sounds, and stopping and starting again. This is especially common when a child is excited or agitated. Children may have episodes of dysfluency during the years of rapid language development between two and five years of age, and at other times speak quite normally.
However, if these episodes occur often, it may cause tension and distress in both speaker and the listener. Adults can put demands on a child to speak fluently, making them self-conscious, especially if they are sensitive to failure. Adults who talk too fast, don’t listen to the child and interrupt will make things worse, and some children tune in to their parent’s anxiety about speech, which can also make the problem worse.
As it is impossible to know which children will pass through a stage of stammering into fluent speech and which will not, it is important to seek help from a speech and language therapist as soon as possible. The younger the child when treatment is given, the more effective it will be. If a doctor or health visitor will not refer a child, it is possible for the parent to do so directly.
Early intervention by a speech and language therapist can prevent persistent stammering. Research has shown that the duration of treatment for children is much shorter than for adults, lasting from eight weeks to a year. Treatments for preschool children are highly effective, usually giving complete remission and little relapse in 95 percent of those treated.
It is argued that while some of these children would have stopped stammering anyway, the treatment has done them no harm, so it is better to treat unnecessarily than to miss children who would otherwise develop a serious problem. The therapist will involve the parents in the treatment and assessment, and may look at other aspects of the child’s communication development, such as the way he or she talks and plays with others, and his general understanding and development of language.
There are two main approaches, sometimes called indirect and direct therapy. The first, Parent-Child Interaction Therapy, aims to help parents to identify factors in the communication styles within the family that help the child to regain more fluency.
A more direct approach is called the Lidcombe Programme, which was pioneered successfully in Australia. Speech therapist Mary Kingston from the Child Development Unit in Norwich went to Australia to see how it worked and is now training other speech therapists in the UK. The method relies on parents spending ten to fifteen minutes correcting their child’s speech every day. The child is encouraged to talk using books and pictures. Every time the child stammers, the parents ask him to say the word again without the ‘bump.’ When he does this, he gets a small reward. The therapy seems to work best with children between the ages of three and five.
What you can do to make speaking easier for a child
- Look at the child and get your face on the same physical level.
- Try not to use very adult language – keep it at a child’s level.
- Slow down your rate of talking to enable the child to speak back more slowly.
- Talk about the present and things that can be seen.
- Reduce the number of questions you ask and allow the child plenty of time to answer.
- Allow the child to choose when to tell you things.
- Give the child time, and show that you are interested and listening.
- Never be tempted to complete the child’s sentences for him or fill in what you think he is trying to say.
- Praise the child for things he has done well to increase his confidence.
- Rhymes and singing may help a child to achieve fluency – many children do not stammer when they sing.
- Never force a child with a stammer to read aloud in front of others. Finding time to do entertaining activities with the child that do not require a great deal of speech will help him or her to relax. Spontaneous, easy talking may then emerge.
From “Tough talking” written by Maggie Jones for Nursery World.
Children with Selective Mutism (SM), a condition caused by paralysing anxiety, are often passed over as being merely shy or withdrawn. Many of us, including teachers and health professionals, would find it very difficult to distinguish between an exceptionally shy child a a child with SM. At first these two types of children may appear the same, both preferring to stay with their mothers rather than joining in with other children, and not responding if others are trying to interact with them.
However, after a while, a shy child will usually gain confidence and, although being quieter than the others, will start to interact with some children and adults. But a child with SM will remain silent and not acknowledge any attempts at interaction. They may even appear to be frozen.
As stated in The Selective Mutism Resource Manual (Johnson and Wintgens, 2001), ‘It is the persistence over time and the intensity of the silence, that distinguishes children who are slectively mute.’
Selective Mutism is a rare condition found in children who speak fluently with intimates in the privacy of their home but remain silent when spoken to by strangers in an unfamilar setting. They talk neither at school, nor to members of the family they rarely see, and they may be equally reticent with both children and adults.
This may be a passing phase in young children, but in some cases it can persist right through a child’s life. Recent research indicates that, unless there are other identifiable causes, such children’s inability to communicate in an age-appropriate manner is usually caused by overwhelming anxiety. There may also be an inherited predisposition and psychological and social factors influencing their development. But no single cause has been established.
In the past it was thoguht that these children were being manipulative or even angry. But recent findings suggest a strong association with social anxiety.This may lead to other behaviours such as limited eye contact and facial expressions, physical rigidity, nervous fidgeting and withdrawal.
In view of the rarity of the condition – equating to around two to five per 10,000 children between the ages of six and seven – there is widespread ignorance about how such a child can be helped. In the past the condition was often described as intractable.
In 2002, Rosemary Sage, assistant director of the Centre for Innovation in Raising Educational Achievement at the University of Leicester, and myself were given a grant by the DfES to make a teaching video in order to highlight some of the successful strategies adopted by resourceful early years practitioners, teachers and parents. Young adults who had been selectively mute as children were involved in the making of the video, along with Maggie Johnson, an expert speech and language therapist and joint author of The Selective Mutism Resource Manual. The treatment approach favoured by Maggie Johnson and others experienced in this field is a step-by-step approach known as ‘fading and shaping’, derived from the treatment of phobics by psychologists. There is now general agreement that treatment should be started early, or else the child’s inappropraite behaviour is likely to become entrenched over time.
The video emphasises that any practitioner involved with a SM child has a crucial role to play in helping both the child and the parents. Recognising that SM is an anxiety response in the child should help to reduce the frustration adults often feel when dealing with this condition.
No pressure should be placed on the child, but they should be given plenty of encouragement to interact with their peers. It is importnat to create an accepting and rewarding atmosphere in which the child feels comfortable, whether or not they talk. Every achievement by the child should be praised and rewarded in order to help enhance self-esteem.
Any form of non-verbal communication from the child should be accepted and encouraged, as this helps to build the positive relationships which are so vital in overcoming this problem. Obtaining a tape recording or a video recording of the child speaking at home will enable practitioners to make an assessment of their speech and language skills.
In the case of four-year-old Eve, a home visit proved very revealing. Eve had not spoken at her creche for more than a year. She was clinging and tearful when separated from her mother, who found Eve’s behaviour very distressing. The family then moved and Eve was due to start school in a new town. Having been told the problem, the new teacher paid a home visit. Eve showed her her bedroom and they inspected favourite toys together. Eve was able to talk to the teacher on her home ground. Mother and child were then invited to visit the new school after other children had gone home. This was repeated several times before Eve started school. Six months later she was going from strength to strength, able to leave her mother and talking and socialising with her peers.
This case illustrates the importance of early intervention. Such a pupil is more likely to make a trusting relationship with an unknown adult if school entry is a gradual process, with parent and child given time and attention.
Other examples of early intervention techniques are outlined in the book Silent Children: Approaches to Selective Mutism, edited by myself and Rosemary Sage. The chapters provide an account of the use of social learning theory, psychotherapy and cognitive therapy techniques in case examples, which demonstrate their success. Brushing aside the whole question of what causes SM behaviour, they aim to concentrate efforts on helping to make a child’s responses more acceptable and to illustrate the need for flexible, multiple approaches because of the very different needs of individual children.
Identifying a child with SM
Children with Selective Mutism:
- Find it difficult to make eye contact when they are anxious. They may turn their heads away and ignore you. One might assume they are being unfriendly, but they are fearful and just do not know how to respond.
- Look blank or expressionless when anxious. In nursery or school they will be feeling fearful most of the time, which is why it is hard for them to smile, laugh or show true feelings, even when they have a wicked sense of humour.
- Move stiffly or awkwardly when anxious, or if they think they are being watched.
- Find it difficult to answer the register or say hello, goodbye or thank you. This can seem rude or hurful but is not intentional.
- Can be slow to respond to a question.
- Worry more than other people.
- Can be very sensitive to noise, touch or crowds.
- Can be intelligent, perceptive and inquisitive.
- If the child does not answer the register verbally, allow them to acknowledge their presence in other ways, such as a smile, a nod, a look or raising a hand. A teacher in an infants class encouraged all children at registration to make an animal noise instead of responding verbally, and this proved successful.
- Encourage self-expression through creative, imaginative and artisitic activities.
- Sometimes sit the child at the front of the group for a story, to encourage attention and involvement.
- In discussion and circle times, give the child the opportunity to speak and be patient when awaiting a response.
- If the child is socially isolated, link them with other quiet, shy children, singly or in small groups. Play games involving interaction between pairs or the group, such as rolling a ball, pulling on quoits, rowing boats, ring games and rhymes.
- Try non-verbal activities which require expelling air and using the mouth, for example blowing out candles, blowing bubbles, blowing ping pong balls with a straw.
- Make noises for toy vehicles and animals in play situations or as sound effects for a story.
- Introduce play with puppets, because the child may ‘speak’ through the puppet, especially from behind a screen. Masks may be helpful.
- Encoruage participation in noisy games and rhymes with predictable language such as ‘What’s the time, Mr Wolf?’
- Use activities that focus on the senses to develop the child’s self-awareness
This article was written by Alice Sluckin, Chair of the Selective Mutism Information and Research Association (SMIRA) and a former senior psychiatric social worker, for Nursery World, 17 February 2005. The Selective Mutism Information and Research Association can be contacted at 13 Humberstone Drive, Leicester LE5 0RE. Telephone: 0116 212 7411 (Tues, Wed & Fri, 4-7pm). Email: firstname.lastname@example.org
I CAN, the charity that helps children with speech and language difficulties (SLDS) in the UK, has developed a unique national training cascade called Learning Together: Working Together, with support from the Department of Health.
The training course enables educators and speech and language therapists to learn together, facilitating and enhancing collaborative practice to support children with SLDs.
The training includes:
- Information on SLD and impact for children
- Developing ways of supporting and promoting language development, using effective strategies and Foundation Stage activities
- Sharing terminology, demystifying and unravelling jargon that can impede understanding each other
- Roles and responsibilities – sharing expertise and identifying tasks and responsibilities to meet the needs of children with SLDs
- Creating language-friendly environments beneficial for all children
- SLD and early learning goals
- Joint target setting
For further information on Learning Together: Working Together, see www.ican.org.uk
From “Pass It On” by Lisa Morgan, Nursery World, 25 September 2003, pp. 22-23.
- Make sure you face the child when speaking. This is particularly important as the child needs to see your face while you’re speaking so they can glean as much information as they can about what you’re saying, from the other clues such as your non-verbal behaviour, gestures, facial expressions and so on.
- Attract the child’s attention by gently touching their shoulder and saying their name before giving instructions or information. For children with language difficulty, catching their attention before you speak is crucial. Do it whether you’re in a one-to-one situation, a small group or whole class. However, be careful if the child dosen’t like to be touched – in that case, don’t do it. Also be sensitive to child protection issues with respect to your own position – only do it if you’re comfortable with it.
- Don’t turn away your face until you’ve finished speaking. It’s very easy to do this without realising it, because you’re moving your head back and forth to include everybody in what you’re saying. But if you turn away with only half a sentence spoken, the child may well miss out on the rest of your message.
- Give instructions in small ‘bite size’ amounts, if necessary one bit at a time. Children with language difficulties may retain only the first or last part of an instruction and can become extremely confused about what they’re supposed to do – so give only as much instruction as they can handle in one go.
- Establish a positive and mutually supportive relationship with the child’s parents and carers. This is a requirement of the SEN Code of Practice, but you would do this anyway, because parents are your most precious resource in many ways and a sound working partnership can only be for the child’s good.
- Learn to use equipment, communication systems or other special facilities that the child may have. This could be a loop hearing system, a voice software programme, Braille, the communication system Blissymbolics or a signing system such as Makaton, which has symbols as well as text. Many children find this system helpful, and the other children in the setting quickly pick it up and become enthusiastic users too. Have books which incorporate these communication systems or finger spelling, if possible. Learning the child’s method of communication is well worth the effort.
- Make sure that important places, equipment and displays are clearly marked with pictures or symbols as well as lables. This includes your timeline or timetable. Pictures and symbols help the child to make sense of language, so giving them this ‘added extra’ gives them the opportunity to explore language through another medium. It also gives them the security they need in knowing what happens in the daily routine, or where things are kept in the setting.
- If the child has a stammer, it’s important not to make an issue of it. When they’re speaking, give them time to finish their sentece. Avoid finishing it for them or urging them to hurry up. They have the right to that time. If they make a mistake, leave it – do not correct them. You can model the correct way afterwards as part of the conversation you’re having with the child.
- Make sure your facial expression is relaxed and warm. The child will be sensitive to the slightest sign of impatience and irritation on your part and that will guarantee a worsening of the stammer.
- Some children’s speech can be almost inarticulate for a variety of medical reasons, such as dyspraxia, or emotional reasons. Try to ‘tune into’ what the child is saying and avoid correcting them or attempting to make them enunciate properly. Respond to their comments by modelling the correct pronunciation. For example, if they say, ‘Da car e-o’, reply, ‘Yes, I know. I saw Daddy’s car today and it is yellow.’
- Children with articulation problems may need to develop the muscles in their lips, tongue, cheeks and throat. Ask the speech and language therapist for advice, as they’ll be able to suggest games and activities that can help.
- If the child has chosen not to speak (elective/selective mutism), there’s usually a reason, often emotional, behind this. Take time to find out whether there are any social or emotional problems at home, or within the setting, that could have given rise to the difficulty. It’s essential you liaise closely with the family to support the child.
- Watch to see if the child joins in with communal singing or rhyme reciting, when they think they’re not being observed. If they are joining in, try to see how clear their articulation is. This will give a clue as to whether they actually can speak and are choosing not to. If the problem persists, get advice from a speech and language therapist or other appropriate professional.
- Check whether the child’s hearing is sound – sometimes poor speech or lack of speech is caused by an unidentified hearing difficulty. Ask the paediatric nurse or health visitor to organise an initial screening test, to see whether further investigation is necessary.
Autistic spectrum disorders
- Check whether anything in the setting sparks difficult behaviours. For example, some children with autism are overwhelmed by the colours, displays and general ‘busyness’ of an early years environment and they just react in the only way they know. Try to have an area of the room that’s more bland and less likely to upset the child.
- Keep to the daily routine as much as possible. This ensures security and stability which is essential for children with an autistic spectrum disorder. If there’s to be a change, warn them ahead of time.
- Always have a quiet area avaialble. Children with autistic spectrum disorders can benefit from somewhere pleasant to go, to be calm and quiet, particularly after a confrontation or a misunderstanding.
- Having defined spaces for activities is really useful – these can be labelled: the puzzle table, the home corner – and also supported with symbols or pictures to reinforce the area and activity.
- Using signing gives children an extra visual support. This can be a formal system like Makaton or based on natural gestures. We can sign choices of activities, stories, rhymes and songs to support vocabulary or instruction.
- Using symbols and pictures can help in a child’s confidence with their space. We can use them to label equipment, areas and activities, enabling children to find what they need and supporting the associated language.
- Using photographs of the child, their family and significant people can help to support conversations. If children find it hard to say people’s names, they can show the photographs and provide a context for the conversation.
- Using routine and structure: giving the nursery session defined times with labels is also useful. Juice time, tidy-up time or listening time again provides more security. Children often need help in learning the nursery routines, but knowing these routines will then provide a good deal more security. It is helpful to lead children through routines like ‘coats on and off’ or ‘what happens at snack time’, demonstrating and using simple language to describe what is happening.
- Using visual support to represent the nursery activities can be an excellent additional support for children with SLDs.
CLINIC FOR CHILDREN
JL Taman Bendungan Asahan 5 Jakarta Indonesia 102010
phone : 62(021) 70081995 – 5703646
Clinical and Editor in Chief :
DR WIDODO JUDARWANTO
email : email@example.com
Information on this web site is provided for informational purposes only and is not a substitute for professional medical advice. You should not use the information on this web site for diagnosing or treating a medical or health condition. You should carefully read all product packaging. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.
Copyright © 2009, Clinic For Children Information Education Network. All rights reserved.