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Journal of Communication Disorders 42 (2009) 29–42

Predicted and observed outcomes in preschool children following

speech and language treatment: Parent and clinician perspectives
Nancy Thomas-Stonell a,b,*, Bruce Oddson c,1, Bernadette Robertson a,2,
Peter Rosenbaum d,3
a
Bloorview Research Institute, Bloorview Kids Rehab, 150 Kilgour Road, Toronto, ON, Canada M4G 1R8
b
Graduate Department of Speech-Language Pathology, University of Toronto, Canada
c
School of Human Kinetics, Laurentian University, 935 Ramsey Lake Road, Sudbury, ON, Canada P3E 2C6
d
CanChild Centre for Childhood Disability Research, McMaster University, 1400 Main Street W., Hamilton, ON, Canada L8S 1C7
Received 15 November 2006; received in revised form 8 July 2008; accepted 18 August 2008

Abstract
Parents of 210 preschool children (age 2–5.7) and their clinicians were asked to describe their expectations for therapy and the
changes they observed following treatment. Based on content analysis of the parents’ and clinicians’ responses, it was apparent that
the comments aligned with the World Health Organization’s (WHO) International Classification of Functioning, Disability and
Health—Child and Youth version (ICF-CY) framework. Parents and clinicians observed positive changes across the ICF-CY
domains of Body Functions, Activities and Participation and Personal Factors following therapy. Parents noted twice as many
changes in the Participation and Personal Factors domains as clinicians. Parents described improvements in play, socialization,
confidence and behaviour at home, school and in the community—changes not typically captured by other preschool speech and
language outcome measures. New outcome measures need to be based on actual observations of change by both parents and
clinicians to ensure that they measure a sufficiently broad-based range of skills.
Learning outcomes: The reader will better understand (1) the parents’ expectations for therapy (2) the types of changes that can
be associated with speech and language therapy and (3) the need for broad-based outcome measures that can evaluate speech and
language outcomes.
# 2008 Elsevier Inc. All rights reserved.

1. Introduction

In order for speech–language pathologists to evaluate the effect of their interventions on children’s lives, it is
essential that relevant and valid outcome measures be developed (Yorkston, Klasner, & Swanson, 2001). Outcomes

* Corresponding author at: Bloorview Research Institute, c/o Bloorview Kids Rehab, 150 Kilgour Road, Toronto, Ontario, Canada M4G 1R8.
Tel.: +1 416 425 6220x3425; fax: +1 416 425 1634.
E-mail addresses: nthomasstonell@bloorview.ca (N. Thomas-Stonell), boddson@laurentian.ca (B. Oddson), brobertson@bloorview.ca
(B. Robertson), rosenbau@mcmaster.ca (P. Rosenbaum).
1
Tel.: +1 705 675 1151x1017; fax: +1 705 675 4845.
2
Tel.: +1 416 425 6220x3425; fax: +1 416 425 1634.
3
Tel.: +1 905 525 9140x27834; fax: +1 905 522 6095.

0021-9924/$ – see front matter # 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.jcomdis.2008.08.002
30 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

research is needed to determine the impact of speech and language therapy and to inform evidence-based practice
(Hammell & Carpenter, 2000). Clinicians need outcome information to learn which children, with which kinds of
problems, will benefit most from various types of speech and language therapy (Beitchman, Nair, Clegg, & Patel,
1986). Policy makers need outcome information to help guide policy decisions regarding health and community-based
service needs (Majnemer & Mazer, 2004). The first step in these processes is to identify the changes that are associated
with speech and language therapy so that we can focus on the collection and evaluation of the most important and
relevant outcome information.
In the past 10 years, health care paradigms have shifted beyond a focus on impairments to a focus on enhancing a
person’s ability to participate in their community. In 2001, the World Health Organization (WHO) published a revised
model of Functioning, Disability and Health (ICF) to reflect this change. The new model represents a dynamic system,
which has expanded ‘points of entry’ (Rosenbaum & Stewart, 2004). This framework recognizes that interventions at
any or perhaps all levels may be important, appropriate and interlinked (Rosenbaum & Stewart, 2004). The new ICF
model now includes Contextual Factors (i.e., Environmental and Personal Factors). Environmental Factors can be
social, cultural or institutional in nature (see Fig. 1). Personal Factors include gender, upbringing, coping styles, social
background and character style (Rosenbaum & Stewart, 2004; WHO, 2001). The ICF model acknowledges that the
settings in which people live their lives play a central role in their capacity to function.
Recently, the WHO published the International Classification of Functioning, Disability and Health—Children and
Youth Version (ICF-CY). This derived classification of the ICF framework provides a common language for
documenting and measuring health and disability in children and youth (WHO, 2007, p. vii). The ICF-CY adheres to
the structure of the ICF while recognizing that child development is a dynamic process (WHO, 2007, p. xv) The
challenge is to translate this framework into practice by shifting beyond a traditional biomedical, impairment-focused
treatment model to a focus on adaptation of tasks, provision of environmental facilitators and removal of
environmental barriers that interfere with a child’s ability to communicate in their home and community (Rosenbaum
& Stewart, 2004). Several researchers have recommended that clinicians use the ICF framework to develop treatment
goals that focus on Activities and Participation (McLeod, 2004; McLeod & Bleile, 2004; Threats & Worrall, 2004). To
measure the impact of such treatment goals on children’s lives, we must have appropriate measures that allow the
profession to document and report outcomes across the entire ICF framework from physical deficits to barriers to
participation (Simmons-Mackie & Damico, 2001; Threats, 2003).
A recent literature review found only two comprehensive speech–language pathology outcome measures for
preschool children: the American-Speech-Language-Hearing Association National Outcome Measure System (Pre-K
NOMS) and the Therapy Outcome Measures (TOMs) (ASHA, 1996; Enderby, 1997). The Pre-K NOMS was
developed by a committee of content experts, peer reviewed for face validity, field-tested and then revised

Fig. 1. World Health Organization’s International Classification of Functioning, Disability and Health (WHO, 2001).
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 31

(Dobrzykowski, 1997). Although widely used across the United States and in parts of Canada, there have been no
published studies of the reliability, validity or responsiveness of this measure. A responsiveness study completed by
the authors indicated that the Pre-K NOMS significantly underestimated ‘real life’ changes associated with speech–
language therapy (Thomas-Stonell et al., 2007). The Pre-K NOMS measures change primarily at the ICF levels of
Body Function and Activities, but not at the levels of Participation, Environmental or Personal Factors. In addition, the
Pre-K NOMS evaluates communication changes only in the specific areas that correspond to the treatment goals. Both
clinicians and parents consistently observed changes in communication skills and abilities such as attention and
socialization that were not treatment goals.
Developed in England, the TOMs was based on a retrospective review of speech–language pathology charts
(Enderby, 1997). It combined a medical model with an earlier version of the WHO framework—the International
Classification of Impairment, Disability and Handicap (ICIDH) (WHO, 1980). Clients are assigned to specific
diagnostic categories (e.g., dysarthria) and then rated in 4 levels: ‘Impairment’, ‘Disability’, ‘Handicap’ and
‘Wellness/Distress’. The TOMs reflect a broader view of outcome measurement than the Pre-K NOMS by including
clinical, functional, and social issues (Roulstone, John, Hughes, & Enderby, 2004). A client receives one score in each
rating scale, which has multiple descriptors (e.g., roles/social integration/decision making). This means that measured
change cannot be attributed to specific descriptors and there is no way to know how many of the descriptors have
changed. An extensive research project was completed in Australia to adapt the measures (AusTOMs) to their health
care system, however, the AusTOMs continues to use the earlier linear ICIDH framework (Australian Institute of
Health and Welfare, 2003; Perry & Skeat, 2004). A new generation of outcome measures is needed that reflects the
revised ICF framework and permits more precise tracking of individual outcomes.
Information generated by outcome studies is only useful if the measure is clinically applicable and scientifically
sound (van der Putten, Hobart, Freeman, & Thompson, 1999). While the profession is under pressure to collect
outcome information, neither available measure is well suited for today’s healthcare paradigm. The Pre-K NOMS has
limited responsiveness and no published reliability or validity studies. The TOMs uses the outdated ICIDH framework
and provides only general descriptions of change. New outcome measures are needed that incorporate the new ICF
health-care paradigm and are based on empirical data collected from clients and families (Rosenbaum, King, &
Cadman, 1992; Trigg, Wood, & Hewer, 1999). Qualitative data are needed to provide insights into the changes
associated with treatment and to inform the development of future quantitative outcome instruments.
A literature review in Medline, CINAHL and international speech–language pathology journals revealed no studies
that described, from a holistic viewpoint such as the ICF framework, the changes associated with speech and language
treatment. Some preschool program evaluation studies measured outcomes directly related to the program goals, but
these did not investigate whether measured outcomes resulted in changes at home or in the community (Gaines &
Gaboury, 2004; Girolametto, Pearce, & Weitzman, 1996). While speech–language pathologists have heard anecdotal
comments from parents and clients about changes associated with speech and language therapy, these comments have
not been collected and examined in a systematic fashion (Simmons-Mackie & Damico, 2001).
Qualitative research methods are ideally suited for investigating details associated with treatment outcomes (Damico
& Simmons-Mackie, 2003). They allow the researcher to view children in the context of their environment and to
understand the dynamics of that environment, for it is there that the consequences of Activity Limitations and
Participation Restrictions acquire meaning (Jongbloed, 2000). Content analysis is a research method that uses a set of
procedures to make valid inferences from text (Weber, 1990). It combines attributes of both qualitative and quantitative
techniques to produce counts of key categories and is ideally suited for analyzing open-ended survey questions in health
care research (Hsieh & Shannon, 2005). In this study, content analysis was used to examine the observations of change
provided by the parents and clinicians of 210 children who received speech and language therapy.

2. Methods

Six organizations in Ontario that provide speech and language services to preschool children collaborated on this
study. These organizations were: Bloorview Kids Rehab (Toronto), Children’s Hospital of Eastern Ontario (First
Words program) (Ottawa), Ottawa’s Children’s Treatment Centre, Porcupine Health Unit (Timmins), Pathways Health
Centre for Children (formerly Sarnia and District Children’s Treatment Centre) and the York Region Preschool Speech
and Language Program (Beyond Words). Following ethical approval from all participating centres, all families who
had children between the ages of 2 and 6 years receiving speech and language therapy were invited to participate in the
32 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

study. Families were included if their child was between 3 and 6 years of age during the treatment period.
Organizations with small speech and language caseloads invited every family whose child met the age criterion to
participate. The organizations that served large numbers of preschool children selected the front-line clinicians who
typically treat preschool children with communication disorders in the absence of diagnosed medical conditions.
These clinicians were selected to increase the cross-section of the population as two of the children’s treatment centres
only treated children with associated medical conditions. These clinicians invited every family on their caseload
whose child met the age criterion to participate in the study. Written information was made available in both English
and French. Although interpreters were available if families did not speak either English or French, this service was not
requested.
This study enrolled 218 children and their families. Complete data were obtained on 210 children (96%). Eight
children were lost to follow-up (four children moved, two clinician data forms were missing due to a job change and
two parent follow-up forms were missing). Four questionnaires per child were completed (i.e., parent and clinician
start of treatment questionnaires, and parent and clinician completion of treatment questionnaires). A total of 840
questionnaires were reviewed.

3. Demographic information

In the present study, the children’s ages ranged from 2.5 to 5.7 years with a mean age of 4.1 years (S.D. = .66).
Sixty-eight percent of the children were boys. Approximately 25% of families reported that more than one language
was spoken in the home. Treatment was provided in either English (95%) or French (5%).
Medical information was collected from the health records of the participating organizations. Thirty-eight percent
of the children had associated medical diagnoses. Sixty-two percent had no medical diagnosis when entering
treatment. The most prevalent diagnoses identified were Neuromotor Disorders (e.g., cerebral palsy, muscular
dystrophy) at 14%, followed by Developmental Delay (10%). The prevalence of Autism and Related Disorders and
syndromes (e.g., Down, Prader-Willi) was 5% each. None of the children had progressive conditions.
Clinicians classified each child’s communication disorder using the International Classification of Diseases, Ninth
revision, Clinical Modification (ICD-9-CM) disorder codes (National Center for Health Statistics, n.d.) While the
children had a variety of communication disorders, the three most commonly identified were: Developmental Speech
Disorders (41%), Developmental Language Production (22%) and Developmental Language Comprehension
Disorders (16%).
The mean duration of treatment, reflecting current community-based practice in this province, was 3.3 months,
ranging from 2.1 to 6.0 months. To facilitate data collection, a maximum treatment interval of 6 months was
established. Treatment frequency ranged from one session every six weeks to five sessions a week; however, consistent
with current service delivery models in Ontario, most children (85%) received therapy once a week. The mean length
of treatment provided during the treatment block was 8.7 hours (see Fig. 2). Eighty-five percent of therapy sessions
lasted between 31 and 60 min. Individual treatment was provided 61% of the time and group treatment 32% of the

Fig. 2. Amount of treatment provided to children in the study. Note: Arrow denotes mean length of treatment.
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 33

time. In the remaining 7%, consultation was provided to community staff and/or parents who were provided with
speech and language programs.
At the start of treatment, parents and clinicians independently completed a prescribed questionnaire. They rated the
child’s skills compared to their peers in six common communication areas: articulation/intelligibility, language
comprehension, language production, pragmatics, attention/problem solving and swallowing/chewing. In addition,
parents and clinicians completed 3 open-ended questions:

1. Does your child have any other communication needs that you are concerned about? Please describe.
2. What changes are you expecting for your child as a result of therapy?
3. Do you think these changes will make a difference in your child’s ability to communicate independently in real life
situations? Yes/No. Explain
At the completion of treatment, parents and clinicians re-rated the child’s communication skills compared to
their peers using the same questionnaire. After completing these ratings, parents and clinicians were provided with
the questionnaires they had completed at the start of treatment. Comparing the ratings from the start and completion
of treatment, they then rated whether, and how much change had been observed in the 6 communication areas, using
a 0–7 rating scale where 0 = ‘got worse’, 1 = ‘no change’ and 7 = ‘excellent change’. They also responded to a yes/
no question about whether or not they had observed any ‘real life’ communication changes. This methodology is
recommended by Russell et al. (1989) to improve the reliability of judgments of change. If parents and clinicians
felt that ‘real life’ changes had occurred, they were asked to complete three additional open-ended questions:
4. Following this treatment block, I have noticed my child is now able to . . .
5. Are there any other changes that you have noted in your child that occurred during this treatment block? Please
describe.
6. In what way are these changes important to you/your child?

Content analysis examines the content of written text in order to describe phenomena, in this case the types of
change associated with speech and language treatment. Hsieh and Shannon (2005) recommend that categories be
derived from the data to avoid using preconceived categories. The categories that emerge from the message pool are
then organized into a set coding schema. Definitions for each category are developed and exemplars for each category
identified from the data. The ‘codebook’ is then used to classify text into categories through a systematic coding
process. The frequency of each code is counted so that the most recurrent categories can be identified (Hsieh &
Shannon, 2005; Neuendorf, 2002, p. 172).
Three researchers independently analyzed the questionnaires from 30 children to identify recurring categories in
the descriptive data. The researchers subsequently compared and discussed findings in an iterative process, until 100%
consensus on the categories was established. Once consensus was reached on the categories, a further 80
questionnaires were reviewed. No new categories emerged, indicating that all of the categories had been identified. A
codebook was developed to define the categories for the coding schema and ensure the reliability of the coding. The
codebook contained definitions and sample comments for each category. Once the codebook was completed, the
balance of the data was analyzed.
The reliability of the coding was assessed in two phases. First, 10% of the data were coded independently by two
researchers. One of the researchers had participated in the original coding (above). The second researcher had had no
prior experience with the data. Initial agreement for each category ranged between 60 and 100% with the majority of
differences reflecting an omission of one category. An additional 10% of the definitions were recoded. A co-
investigator reviewed the coding until consensus was achieved. The revised codebooks were applied to the overall data
by a third researcher. This procedure resulted in reliability of greater than 90%.

3.1. Coding schema

After reviewing the data, the researchers noted that the emerging categories from the start and end of treatment
questionnaires aligned with the WHO ICF-CY framework. Since many authors suggest that outcome measures should
evaluate changes across ICF/ICF-CY domains, the researchers felt that this coding system would assist them to
identify the impact of treatment changes from individual deficits to the home and community (Butler, 1995; Lollar,
Simeonsson, & Nanda, 2000; Simmons-Mackie & Damico, 2001). Each component in the ICF-CY framework can be
34 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

described in both positive and negative terms, except for the Personal Factors domain (WHO, 2007, p. 10). Since our
data clearly showed categories relating to both positive and negative Personal Factors, we also divided Personal
Factors this way.
The ICF-CY defines ‘Body Functions’ as ‘‘physiological function of body systems, including psychological
functions’’ (WHO, 2007, p. 9). Examples of categories that were coded as Body Functions include: producing speech
sounds or single words in isolation, increased tongue tip elevation, improved eye gaze and improved oral motor control.
The ICF-CY defines Activity as ‘‘the execution of a task or action by an individual’’ and Participation as
‘‘involvement in life situations’’ (WHO, 2007, p. 9). Distinguishing between these domains has been an ongoing
challenge for users of the ICF and the ICF-CY (Threats & Worrall, 2004). To help distinguish between them,
comments that did not specifically mention a transfer of skills to a societal setting were coded as ‘Activities’ rather than
‘Participation’. Items within the Activities and Participation domains were further defined using the ICF qualifiers of
Capacity and Performance. ‘Capacity’ is defined as ‘‘an individual’s optimal ability to execute a task or action in a
standard environment’’ and ‘Performance’ is defined as ‘‘what an individual does in his current environment, which
includes a societal context. (WHO, 2007, p. 13).
Categories were coded as Activities when they referred to the acquisition of specific skills in the standardized
environment of the clinical setting or when comments did not specify the use of specific skills in a ‘societal’
environment. Examples of categories that were coded as Activities/Capacity include: increased vocabulary, increased
sentence length, more frequent communication and improved communication abilities. Categories were coded as
Participation when they referred to observed changes at home, daycare and school. Examples of categories that were
coded as Participation include: socialization with peers, answering questions in circle time and communicating better
with other children.
The ICF-CY defines Personal Factors as ‘‘the particular background of an individual’s life and living’’ which
includes ‘‘features of the individual that are not part of a health condition or health states’’(WHO, 2007, p. 15).
Personal Factors include such factors as gender, race, age, other health conditions, upbringing, coping styles, social
background, past and current experience, overall behaviour patterns and character style (WHO, 2007, p. 15). Parents’
comments about their child’s frustration, shyness, anxiety and/or temper tantrums when trying to communicate were
interpreted as representing the child’s coping style and/or overall behaviour pattern (Costa & McCrae, 1989; Feifel,
Strack, & Nagy, 1987). They were coded as Personal Factors—Negative. Comments about such issues as confidence,
increased willingness to communicate, decreased shyness and improved behaviour were coded as Personal Factors—
Positive. These comments could also have been coded under the Mental Functions codes in the Body Function domain.
The Personal Factors domain was selected because these children did not have identified personality impairments and
this domain seemed more accurately to reflect the intent of the parents and clinicians who made the comments
(McLeod & McCormack, 2007). Examples of parent and clinician comments coded according to the ICF Schema are
included in Table 1.

Table 1
Examples of parent and clinician comments according to the ICF schema
Sample comments ICF domain
Increased range of movement of jaws/lips Body Functions—Positive Aspect
Is stimulable for some target sounds Body Functions—Positive Aspect
Oral motor planning problems Body Functions—Negative Aspect
Lacks ability to initiate verbalizations Body Functions—Negative Aspect
Putting sentences together much better Activities
Expressing himself better with words Activities
Cannot communicate effectively Activity Limitation
Difficulties with expressive language Activity Limitation
More social at daycare Participation
Starting to play with other children Participation
We do not understand what he is trying to tell us Participation Restriction
Cannot communicate effectively with peers without adult assistance Participation Restriction
Very shy with limited eye contact Personal Factors—Negative Aspect a
I hope to see her communicate verbally rather than frustration and physical Personal Factors—Positive Aspecta
a
The Personal Factors domain was divided into positive and negative aspects for the purposes of this study.
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 35

4. Results

The frequency of the categories mentioned by parents and clinicians for each open-ended question is presented
below, however, only those domains and categories that were cited by a minimum of 10% of the parents and clinicians
have been reported. Comments illustrate the most frequently coded category for parents and clinicians in each domain.

4.1. Start of treatment

Question #1: Does your child/client have any other communication needs that you are concerned about? (in
addition to communication concerns in: articulation/intelligibility, language comprehension, language production,
pragmatics, attention/problem solving and chewing/swallowing, which had been described previously).
Sample parent comments:
Body Function ‘‘To pronounce his words correctly’’
Activity Limitation ‘‘He cannot communicate effectively or clearly.’’
Participation Restriction ‘‘She is unable to carry on a conversation that anyone can understand.’’
Personal Factors—Negative ‘‘She tends to get frustrated and cries when she is not understood.’’

Forty percent of the parents (84/210) had additional concerns. These concerns crossed the ICF-CY domains of: Body
Functions, Activity Limitations, Participation Restrictions and Personal Factors. Parents’ comments focused predomi-
nately on their child’s difficulties in Body Functions (40%) and Activity Limitations (48%). The most frequently recurring
categories in the Activity Limitations domain included: difficulties forming sentences, using grammar, carrying on a
conversation and limited vocabulary. Recurring concerns in the Body Functions domain were the child’s difficulties
vocalizing, producing speech sounds and stuttering. Parents also mentioned concerns in the Participation Restrictions
(27%) and in the Personal Factors (25%) domains. They expressed concerns about not being able to understand their child,
other adults and children not understanding their child, and social isolation. They also were concerned that poor
communication skills were causing significant frustration and behavioural difficulties (e.g., tempers, outbursts).
Sample clinician comments:
Body Function ‘‘Has motor planning difficulties which affect expressive abilities.’’
Activity Limitation ‘‘Difficulties with expressive language.’’
Participation Restriction ‘‘He rarely engages socially with his peers.’’
Personal Factors—Negative ‘‘Worry about increasing frustration due to not being understood.’’

Thirty-five percent of clinicians (73/210) reported additional concerns, which also crossed the ICF-CY domains:
Body Functions, Activity Limitations, Participation Restrictions and Personal Factors. Most of the clinicians’
concerns related either to impairments of Body Functions (45%) or Activity Limitations (50%). Recurring concerns
related to Body Functions were difficulties with oral motor skills and fluency. Recurring concerns related to Activity
Limitations were difficulties with expressive language and difficulties communicating effectively. Clinicians’
concerns at the level of Body Functions and Activity Limitations were similar to those noted by parents, however,
clinicians were much less likely to comment on concerns in the Participation Restrictions and Personal Factors
domains. A comparison of parent and clinician concerns is provided in Table 2.
Question #2: What changes are you expecting for your child/client as a result of therapy?
Sample parent expectations:
Body Function ‘‘Will pronounce words better.’’
Activities/Capacity ‘‘Able to put sentences/stories together and be understood.’’
Participation ‘‘To communicate effectively in all situations (i.e., school, play dates, sports, birthday parties).’’
Personal Factors—Positive ‘‘His self-confidence will increase, frustration will decrease.’’

Ninety-seven percent of the parents (203/210) responded to this question. The parents predicted that speech and
language therapy would make changes across the ICF-CY levels of Body Functions (49%), Activities (63%),
Participation (29%). Parents predicted that treatment would result in improvements in their child’s ability to
36 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

Table 2
A comparison of clinicians’ and parents’ comments at the start and completion of treatment
Clinicians Parents
Start of treatment
Concerns (Q1)
Body Functions and Structures 45 40
Activity Limitations 50 48
Participation Restrictions 11 27
Personal Factors—Negative 13 25
Predicted change (Q2)
Body Functions and Structures 39 49
Activity 85 63
Participation 11 29
Personal Factors—Positive 4 16

Completion of treatment
Observed change (Q4)
Body Functions and Structures 44 38
Activity 79 74
Participation 13 28
Personal Factors—Positive 10 15
Other changes (Q5)
Body Functions and Structures 14 21
Activity 62 53
Participation 16 27
Personal Factors—Positive 47 44
Average Observed Changes (Q4 & Q5)
Body Functions and Structures 29 30
Activity 71 64
Participation 15 28
Personal Factors—Positive 29 30
Note: The values represent percentages calculated by dividing the number of comments in each domain by the total number of clinicians and parents
who responded to each question.

communicate and that it would improve their child’s relations with peers and their readiness for school. A small
percentage of parents (16%) predicted that there would also be improvements in the Personal Factors area, resulting in
greater confidence and less frustration.
Sample clinician expectations:
Body Function ‘‘Clearer speech. Produce /f/, /sh/ and /s/ blends.’’
Activities/Capacity ‘‘Have him be able to express himself in one to two word utterances.’’
Participation ‘‘To functionally communicate wants and needs with familiar listeners.’’

All clinicians (209/210) predicted that treatment would be associated with changes primarily at the ICF-CY levels
of Body Functions (39%) and Activities (85%). Clinicians’ expectations included: improved articulation/phonology,
improved expressive language skills, increased mean length of utterance, expanded vocabulary and more
communication attempts. Only 11% of clinicians expected treatment to make changes in the child’s ability to
participate in the community compared to 29% of parents. Although the clinicians noted concerns in the Personal
Factors areas, only 4% of them predicted that treatment would have a positive effect in this area.
Question #3: Do you think these changes will make a difference in your child’s ability to communicate
independently in real life situations? Explain.
Sample parent comments:
Activities/Capacity ‘‘She very much knows what it is she is wanting to say, but isn’t saying it effectively.
Our hope is that at end of therapy she’ll be able to do so.’’
Participation ‘‘So that other people can interpret her likes and dislikes when mom and dad are not around.’’
Personal Factors—Positive ‘‘Give her more confidence so not as shy around others.’’
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 37

All 210 parents responded to this question. Eighty-four percent stated that they thought that therapy would make a
‘real life’ difference. They indicated that therapy would enhance Participation (71%), Personal Factors (39%) and
Activities/Capacity (24%). Examples of predicted improvements in Participation were: being understood by extended
family and teachers, being accepted by their peers and being ready for school. Predicted improvements in Personal
Factors included: being less shy, reducing frustration and becoming more confident. Expected improvements in
Activities/Capacity were: using more complete sentences, communicating better and more often.
Sample clinician comments:
Activities/Capacity ‘‘Allow him to be a better communicator.’’
Participation ‘‘Socialization and expressive language skills from group treatment setting expected to carry over to
other environments.’’
Personal Factors—Positive: ‘‘Increased confidence to communicate verbally, less frustration when not understood.’’

Clinicians answered this question for all of the 210 participants. Eighty-seven percent indicated that therapy would
be associated with real life changes in the domains of Activities (49%), Participation (66%) and Personal Factors
(30%). All of the clinicians predicted that treatment would improve communication skills. Some thought that therapy
might also improve the child’s attention.

4.2. Completion of treatment

Question #4: Following treatment my child/client is now able to . . .

Sample parent comments:
Body Functions ‘‘Pronounce words much more clearly, specifically /f/ and the /l/ sound when prompted.’’
Activities/Capacity ‘‘Speak in simple sentences from time to time, rather than keywords and labels.’’
Participation ‘‘Play freely with others without children or adults always asking him to repeat himself
because they can’t understand what it is he is saying.’’
Personal Factors—Positive ‘‘Has developed her confidence.’’

Parents described changes for 96% (201/210) of the participants. Parents observed changes at the ICF-CY levels of
Body Functions (38%), Activities/Capacity (74%), Participation (28%) and Personal Factors—Positive (15%) (see
Table 2). Recurring comments specific to communication skills pertained to improved expressive language skills,
improved articulation/speech skills and improved language comprehension. Parents also commented on
improvements in attention, socialization, emotions and quality of life.
Sample clinician comments:
Body Functions ‘‘Good articulation at the word level.’’
Activities/Capacity ‘‘Using many spontaneous single words, some combinations in structured tasks.
With some cueing, can produce complete sentence forms.’’
Participation ‘‘Is greeting others; Is more oriented towards communication with others.’’
Personal Factors—Positive ‘‘Decreased shyness. Opened up!’’

Clinicians described changes for 98% (206/210) of the participants. They observed changes at the ICF-CY levels of
Body Functions (44%), Activities/Capacity (79%), Participation (13%) and Personal Factors—Positive (10%).
Comments pertained to improvements in expressive language skills, articulation, intelligibility and pragmatic skills.
Clinicians also observed changes in attention and socialization. Clinicians’ and parents’ observations of change were
similar, although parents were twice as likely to comment on changes at the level of Participation as the clinicians.
Question #5: Are there any other changes you have noticed in your child/client during this treatment block?
Sample parent comments:
Body Functions ‘‘Using complete words now.’’
Activities/Capacity ‘‘Trying to put words together and communicate.
Participation ‘‘His play with peers has improved in terms of sharing, turn-taking, following conversations.’’
Personal Factors—Positive ‘‘Now I feel comfortable leaving her at school and daycare and not worrying as much,
I’m glad people can understand her now.’’
38 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

Seventy-six percent of parents (160/210) observed ‘other’ changes. These occurred at the ICF-CY levels of
Body Functions (21%), Activities/Capacity (53%), Participation (27%) and Personal Factors—Positive (44%).
Parents primarily noted positive changes in the Activities and Personal Factors—Positive domains. Parents
commented that their child was communicating better and was happier, more confident and having fewer temper
tantrums. Parents’ observations of change generally matched their expectations, although they noted fewer
changes at the ICF-CY level of Body Functions and more changes in the Personal Factors—Positive domain than
expected.
Sample clinician comments:
Body Functions ‘‘More willing to attempt words and sounds.’’
Activities/Capacity ‘‘She is also able to maintain a conversation beyond one turn.’’
Participation ‘‘This child is able to share ‘news’ and novel information from one setting/communication
partner to another, e.g. home to school and back.’’
Personal Factors—Positive ‘‘Reduced frustration and ‘acting out’ behaviours as she can now use words to express her needs better.’’

Seventy percent of the clinicians (146/210) noted ‘other’ changes. These included positive changes at the ICF-CY
level of Activities (62%), Personal Factors—Positive (47%), Participation (16%) and Body Functions (14%).
Clinicians commented primarily on improvements in speech and language areas that had not been the primary focus of
treatment. Pragmatic skills were most frequently cited by clinicians as having improved. Clinicians also commented
on improvements in the child’s confidence, attention and an increased willingness to try to communicate with others.
Clinicians observed fewer changes than expected in the Body Functions and Activities/Capacity domains. Only 4% of
clinicians predicted changes in the Personal Factors—Positive domain, however, 29% of clinicians commented on
improvements in this area (see Table 2).
Question #6: In what ways are these changes important to you/your child?
Sample parent comments:
Activities/Capacity ‘‘He is putting together sentences much better.’’
Participation ‘‘Able to express himself in play groups without parents.’’
Personal Factors—Positive ‘‘She is a happier, easier-going child. She isn’t overlooked at school
because now the teacher can understand her.’’

Eighty-six percent of the parents (181/210) responded to this question. While most of the comments (75%)
pertained to the importance of the achieved changes on their child’s life currently, some parents commented on the
importance of these changes for their child’s future. Anticipated benefits of treatment focused on improvements at the
level of Participation. Parents felt that treatment would improve their child’s quality of life. They commented that the
child would be more ready for school and have greater academic and life success.
When parents commented on the importance of the achieved changes, the majority (72%) noted the impact of
changes in Participation domain. They talked about their child’s ability to carry on conversations, socialize with their
peers and participate in school. Parents also commented on the impact of these changes in the Personal Factors—
Positive (48%) and Activities/Capacity (29%) domains. Parents commented on improvements in the child’s
confidence and quality of life (e.g., doing better in school, becoming more independent).
Sample clinician comments:
Body Functions ‘‘Client is attempting speech sounds.’’
Activities/Capacity ‘‘Communication book has given her means to further expand her expressive language
and generate novel sentences.’’
Participation ‘‘This child has begun to separate from his mom and relate to another boy in the group.
He began to smile and laugh and react in a positive manner.’’
Personal Factors—Positive ‘‘More confident communicator.’’

Eighty-two percent of clinicians (172/210) commented on the importance of the observed changes. Most comments
(77%) pertained to the impact of achieved changes on the child’s life currently. Clinicians commented on the impact of
these changes at the level of Activities/Capacity (55%) and Participation (52%). One third of the clinicians (33%)
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 39

commented on positive changes in the child’s emotions (Personal Factors—Positive). They noted that the children
were more intelligible and becoming successful communicators. Improvements were also noted in socialization and
independence.

5. Discussion

At the start of treatment, both parents and clinicians expressed concerns about the children’s Body Functions and
Activity Limitations. Fifty-two percent of parents stated that their child was experiencing Participation Restrictions or
negative Personal Factors (e.g., shyness, anxiety, frustration, behaviour problems, temper tantrums) as a result of their
communication impairments. Parents were twice as likely as clinicians to note concerns in these areas. This difference
reflects the profession’s bias towards an impairment-based model of speech and language treatment. As McLeod and
Bleile (2004) suggest, this bias likely reflects the medical and behavioural frameworks of the profession. The use of the
ICF-CY framework as a conceptual model for treatment helps ensure that clinicians consider all aspects of a child’s
life (McLeod, 2006). Clinicians need to become more aware of the impact of communication disorders on children’s
ability to ‘participate’ within their communities and on their emotional health. They should routinely obtain more
information about the child and family’s life contexts so that they are able to identify important Participation
Restrictions that are clearly obvious to parents.
Clinicians and parents differed in their expectations of treatment. Although parents expected to see some changes
across the ICF-CY domains of Body Functions, Activities/Capacity, Participation and Personal Factors, over 72% hoped
treatment would improve their child’s ability to ‘participate’ at home and in the community. Almost 40% of parents hoped
that treatment would also have a positive impact on their child’s emotions and behaviour. Clinicians expected that
treatment would primarily be associated with changes in Body Functions and Activities/Capacity and focused their
treatment goals on these domains (reflecting the traditional biomedical focus of our interventions). Although 13% of
clinicians noted concerns in the Personal Factors domains, only 4% predicted that there would be positive changes in this
domain following treatment. These findings suggest a need for greater collaboration between parents and clinicians in the
formulation of therapy goals to ensure that treatment goals address both parent and clinician concerns.
Predicted changes were compared to the changes (average of responses to Questions #4 and #5) actually observed
by both parents and clinicians. Both parents and clinicians reported that therapy had had an important positive effect on
the children’s lives. Some of the observed improvements occurred in areas predicted by parents and clinicians, but
some improvements were noted in areas not predicted by either parents or clinicians (see Table 2 for a comparison of
Predicted vs. Average Observed Changes). Both parents and clinicians observed fewer improvements in the Body
Function domain than predicted. Parents observed changes in the Personal Factors domain twice as often as predicted.
Clinicians observed changes in the Personal Factors domain seven times more often than predicted.
Parents were more aware of their child’s participation restrictions than clinicians. They noted improvements in this
area after treatment twice as often as clinicians. Clinicians need to broaden their treatment goals to include
Participation and Personal Factors. The new ICF-CY model is multi-directional, and provides clinicians the freedom
to broaden their treatment approaches. It suggests that therapy focused on improving ‘participation’ skills such as
improved play, attention and socialization may result in improved ‘communication’ skills. Spending more time
playing with their peers increases children’s exposure to positive language models and provides more opportunities for
practicing communication skills.
As predicted, improvements were observed in communication skills. Parents and clinicians noted positive changes
in expressive language, receptive language, vocabulary, pragmatics and articulation skills after treatment. In addition,
parents and clinicians consistently reported improvements in attention, socialization and the child’s emotions (i.e.,
more confidence, reduced frustration, fewer tempers). Thirty-nine percent of parents stated that therapy had had a
positive impact on their child’s quality of life. Parents reported that their child was playing more with friends and
siblings and doing better in school. They noted positive changes in school participation and in academic skills such as
reading readiness and independence. It is obviously important that speech–language pathology outcome measures for
preschool children ask questions about these important skill areas, if they are to be responsive to treatment changes.
Ma, Worrall, & Threats (2007) state that ‘‘The translation between the ICF conceptual framework and assigning
specific codes is not always straight-forward nor will it likely receive universal agreement.’’ The authors interpreted
the parents’ and clinicians’ comments regarding their child’s frustration and/or confidence in communication
situations as referring to the children’s coping styles and coded them in the Personal Factors domain (Costa & McCrae,
40 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42

1989; Feifel et al., 1987). It was felt that becoming frustrated in response to communication breakdown was an age-
appropriate coping strategy for a young child and it was possible that these children were confident in non-
communicative contexts. As McLeod and Threats (2008) point out developmental ages and stages must be considered
when applying the ICF codes to children. The parents and clinicians who commented that the children were more
confident communicators after therapy felt that speech and language therapy had removed an environmental barrier to
communication (Contextual Factor), thus diminishing the amount of stress experienced by the child. Alternatively,
these comments could be interpreted as referring to impairments of Personality and Temperament in the Mental
Functions section of the Body Function domain or as restrictions in the Activities and Participation domain (d240—
Handling stress and other psychological demands or d250—Managing ones own behaviour). As Ma et al. (2007) note,
there are grey classification areas in speech–language pathology, which are beyond the scope of this paper.
This study examined parents’ and clinicians’ perceptions of change following speech and language treatment. The
descriptive data were gathered prospectively from the parents and clinicians of 210 children who received speech and
language therapy. While there were no independent measures collected to ‘prove’ that these changes occurred, both
parents and clinicians independently described similar changes. The similarity and frequency of the comments across
such a large sample of children is compelling.
Clinicians’ and parents’ comments may reflect a bias towards improvements however it is important to note that not
all of the clinicians and parents observed improvements. Also, the types of change observed by parents and clinicians
differed from their predictions or expectations at the start of treatment. This study suggests several areas that may be
associated with the provision of speech and language treatment, but it does not prove that therapy caused these
changes. The study does, however, highlight the need for new quantitative outcome measures that can evaluate
changes across the ICF-CY framework systematically. Such outcome measures would be a valuable resource for
current clinical practice. The observations from this study can form the basis for the creation of an outcome measure,
which reflects the ICF/ICF-CY framework. Once developed, this outcome measure could be used to evaluate the
efficacy of speech and language therapy.

6. Conclusions

Parents and clinicians observed important positive changes in children following speech and language therapy. After
receiving an average of 8 hours of treatment, improvements were noted in communication skills, attention, play,
socialization, confidence and behaviour. Overall, parents’ and clinicians’ comments described changes in the same
domains, although there was somevariation in the frequency of observed changes within these domains. Parents were twice
as likely as clinicians to note the negative impact of a communication disorder on the child’s ability to participate in school/
play activities and on their emotional health (e.g., shyness, anxiety, frustration, behaviour problems, temper tantrums).
This research has implications for the development of outcome measures. It suggests that the content of outcome
measures should be based on actual observations of change collected from parents and clinicians. Outcome measures
such as the ASHA NOMS, developed using expert clinician groups to predict which areas should be measured, do not
capture a sufficiently broad-based range of skills, resulting in an instrument that cannot measure many of the positive
changes associated with speech and language treatment. This research supports the recommendation of Trigg et al.
(1999) that qualitative information be obtained prior to test development and used to generate test items. This ensures
that the items are relevant to the population concerned and ensures that the measure has high content validity
(Rosenbaum et al., 1992; Frytak, 2000).
Clinical practice is shifting from a traditional biomedical, impairment-focused treatment model to a focus on
adaptation of tasks and the removal of environmental barriers that interfere with a child’s ability to communicate in
their home and community (Rosenbaum & Stewart, 2004). Outcome measures need to be developed that reflect the
new ICF-CY framework and echo this broader approach to rehabilitation. We believe that work such as we have
described here is an important first step in this process and will be a valuable addition to our resources to evaluate
clinical practice.

Acknowledgments

The authors wish to acknowledge the financial support of Ontario Ministry of Health and Long-Term Care and
Ministry of Community, Family and Children’s Services; and The Hospital for Sick Children Foundation. The authors
 N. Thomas-Stonell et al. / Journal of Communication Disorders 42 (2009) 29–42 41

express sincere appreciation to the families who participated in this research project. We especially wish to
acknowledge the Research Coordinators and Speech-Language Pathology clinical staff at the: Children’s Hospital of
Eastern Ontario – First Words Program, Ottawa Children’s Treatment Centre, Pathways Health Centre for Children
(formerly Sarnia and District Children’s Treatment Centre), Porcupine Health Unit, York Region Preschool Speech
and Language Program (Beyond Words), and Bloorview Kids Rehab for their clinical expertise and assistance with
data collection.

Appendix A. Continuing education

(1) The International Classification of Functioning, Disability and Health is a framework for the description of health
and health-related states. True/False
(2) Outcome measures need to be valid, responsive and relevant to clinical practice. True/False
(3) Outcome measures allow the profession to measure the impact of treatment. True/False
(4) Content analysis uses attributes of both qualitative and quantitative techniques to make valid inferences from text.
True/False
(5) Outcome measures need to reflect a broader approach to rehabilitation. True/False

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