Development Delays

signs & symptoms


SIGNS & SYMPTOMS
:

Most children develop typically within a standard timeframe.  When a child experiences a delay in development, the explanation may be a naturally slower pace in reaching a developmental milestone or an indication that a more serious cause may be at hand.  The term developmental delay can mean when an otherwise typically developing child has a slower rate of standard progress reaching one or more developmental milestones than is expected of a similarly aged child.  Developmentally delayed can also be used to describe a child who is experiencing delays in development due to an underlying factor, like a medical condition, that prevents typical, age-appropriate development.

Generally, when difficulties related to motor coordination and planning, language, speech, sensory processing, corresponding socialization, and associated muscle tone significantly interfere with social communication, academic or occupational achievement, or result in substantially lower performance in daily activities given the individual's age and intelligence, they are referred to as disorders.  But even a minor impairment in functioning in one of these areas can require prompt attention and on-going remedial action.

For children impacted by challenges in motor coordination and planning, language, speech, sensory processing, corresponding socialization, or associated low muscle tone, the symptoms may be slight or subtle for some children while the impact on others is severe and pervasive.  Not all children with Developmental Coordination Disorder have the same motor coordination challenges or symptoms and degree of difficulty in performing motor tasks.  In addition, some children may outgrow their motor coordination difficulties, and for others, it is a lifelong condition.

Children with Developmental Coordination Disorder may have difficulty with planning a sequence of coordinated movements (ideation) and executing a plan, even when it is known (ideomotor).  Children with Developmental Coordination Disorder may have problems synthesizing information from the sensory systems (vision, balance, depth perception, auditory, touch, and general body awareness) to produce coordinated movements due to deficits in sensory information integration.  Thus, Developmental Coordination Disorder is also commonly referred to as sensory processing or integration disorder.            

Ultimately, children develop at their own pace.  Personality traits vary widely as children have their own interests and preferences and are products of their upbringing, childhood environments, and genetic make-up.  Some infants with Developmental Coordination Disorder are reported to be very colicky while others are the most pleasant of babies and did not have atypical bouts of fussiness.  Children impacted by Developmental Coordination Disorder can suffer from shyness or attention deficits in addition to facing challenges with processing sensory input, such as reacting more strongly to sounds, lights, and noises, for example.  Yet, others with Developmental Coordination Disorder, like Harry Potter actor Daniel Radcliffe, can be extremely outgoing in various settings. 

Natural differences in personality, though, may have little connection to the underlying motor coordination, language, and speech disorders because children without Developmental Coordination Disorder, Mixed Expressive and Receptive Language Disorder, Phonological Disorder, and related Hypotonia, also share personality commonalities with their typically developing peers.  However, having these motor coordination, language and speech disorders and associated low muscle tone can certainly amplify feelings of insecurity, shyness, self doubt, shame, being a failure, anger, and contribute to low self-esteem, social withdrawal, depression, and isolation. 

Physical therapy can improve fine motor control and overall body strength.  Occupational and speech-language therapy can help breathing, speech, and swallowing difficulties.  Therapy for infants and young children may also include sensory stimulation programs.  In some cases as the children reach school age, psychological or psychiatric services may be sought.  

Dispelling the Myths:

            Children with Developmental Coordination Disorder, Mixed Expressive and Receptive Language Disorder, Phonological Disorder, and associated Hypotonia may be able to be, do, and greatly enjoy any of the following:
    
            ·         puzzles, legos, building blocks

·         math and other analytical tasks

·         master one or more sports

·         read early and ahead of age and grade level

·         write proficiently or well

·         social butterflies and outgoing

            ·         be quick learners, self-taught and self-starter, and highly     
                      motivated 

            ·         interacting fully and richly and have meaningful relationships 
                      with peers, family, 
caretakers, friends, and all others in their
                      lives

·         have rich, imaginative play and strong creativity 

·         focus on a task for extremely long periods of time  
 

            ·         master electronics and computers

·                     have above-average intelligence or be gifted 

·         reach the typical range in all skills by adulthood

·         enjoy a typical (or better) life!    

About Developmental Coordination Disorder, Mixed Expressive and Receptive Language Disorder, Phonological Disorder and Hypotonia.

Developmental Coordination Disorder:
       

Also referred to as: the hidden disorder; dyspraxia or dyspraxia syndrome; overall or global dyspraxia; developmental dyspraxia; the clumsy child or clumsiness syndrome; overall limb apraxia;
specific developmental disorder of motor function; motor dyspraxia or apraxia; overall, global, or truncal Developmental Coordination Disorder; specific motor development disorder; overall apraxia; developmental apraxia; neuromotor abnormality; impaired motor function; motor coordination dysfunction; motor skill delays; gross motor skill impairment; fine motor skill impairment; dysgraphia; sensory processing disorder; sensory integration dysfunction; motor coordination or planning difficulties.

Developmental Coordination Disorder impacts up to 6% of children, but some estimates reach as high as 20%.  
    

 Associated Conditions:  Expressive Language Disorder.  Mixed Expressive and Receptive Language Disorder.  Phonological Disorder.  Recurrent Otitis Media with Effusion (ear fluid).  Recurrent Ear and Sinus Infections.  Hypotonia.  Learning Disorders.  Social Isolation.       

Differential Diagnosis:  Cerebral palsy.  Gross or Fine Motor Skills Delays.  Intellectual Disability.  Autism.       

Developmental Coordination Disorder and autism are mutually exclusive and do not co-occur.1 

        Developmental Coordination Disorder is also referred to as the hidden disorder because children can be become quite adept at working around their motor coordination inabilities and can look and move seemingly indistinguishably from their peers in most settings.  Children impacted by this disorder can generally move their entire bodies in every which direction but cannot move their bodies the way they want to when they want to, and thus, this disorder can be very difficult to detect.  Often, children impacted by this disorder feel that they are different from their peers but do not understand how.
 

            Developmental Coordination Disorder can impact children of varying intellectual abilities from the extremely gifted to the most severely intellectually disabled.  Children with Developmental Coordination Disorder frequently experience developmental delays in other nonmotor milestones.  Outcomes for children with Developmental Coordination Disorder vary.  Some children may outgrow their motor coordination difficulties, and for others, it is a lifelong condition.

There are 3 basic steps in movement: 1) forming the idea to make the movement, 2) planning the movement, and 3) carrying out the movement.  These three steps necessary for movement can be referred to as ideation, planning, and execution.  Children with Developmental Coordination Disorder may have difficulty with planning a sequence of coordinated movements (ideation) and executing a plan, even when it is known (ideomotor).  In addition,  motor coordination involves more than just planning and executing movements but also the brain and body systems must be able to process and integrate internal and external information to function properly.  Children with Developmental Coordination Disorder may have problems synthesizing information from the sensory systems (vision, balance, depth perception, touch, auditory, and general body awareness) to produce coordinated movements due to deficits in sensory information integration. Thus, Developmental Coordination Disorder is also commonly referred to sensory processing or integration disorder.      

There is currently no known cause of Developmental Coordination Disorder.  Children with Developmental Coordination Disorder do not have any clinical neurological abnormality to explain their condition, nor is there a known brain insult or injury, a distinguishing factor from cerebral palsy.  Some research suggests that the motor skill impairment is due to immature neuron development or myelination or a disroption in the neurons that transmit signals from the brain to the rest of the body.  Structural maturation of the neurons is essential for cognitive, sensory, and motor development.  Most agree, however, that regardless of cause, the signals from the brain are not being transmitted properly to the rest of the body for successful movement. 

Developmental Coordination Disorder is generally defined as substantially low performance in daily activities that require motor coordination or academic achievement given the individual's age and intelligence and can lead to severe educational, occupational, and social problems.  There may be significant delays in achieving motor milestones (for example, rolling, crawling, standing, walking, sitting), potty training, dressing oneself, personal care skills (brushing teeth or combing hair), clumsiness, drops things, difficulties with handwriting, poor performance in sports or awkward movements. 

Developmental Expressive Language Disorder:

Also referred to as: specific language impairment; verbal language impairment; language processing disorder; developmental aphasia; speech delay. 

Developmental Expressive Language Disorder impacts 10-15% of children under 3 years of age and between 3-7% of school-aged children. 

Associated Conditions:  Developmental Coordination Disorder.  Receptive Language Disorder.  Phonological Disorder.  Recurrent Otitis Media with Effusion (ear fluid).  Recurrent Ear and Sinus Infections.  Hypotonia.  Learning Disorders.  Social Isolation.  EEG or Neuroimaging Abnormalities.  Apraxic or Dysarthric Traits.       

Differential Diagnosis
:  Language or Speech Delay.  Mixed Expressive and Receptive Language Disorder.  Landau-Kleffner Syndrome.  Intellectual Disability.  Autism.       

Expressive Language Disorder and autism are mutually exclusive and do not co-occur.1 

Expressive Language Disorder is considered a specific language impairment.  Please see below for further information about Developmental Mixed Expressive and Receptive Language Disorder.     

Expressive Language Disorder is an impairment in expressive language development and may involve difficulties with both verbal language and sign language.  The resulting language difficulties interfere with social communication or with successful performance of daily activities at school or work.  There is currently no known cause of Expressive Language Disorder.  Children with Expressive Language Disorder do not have any clinical neurological abnormality to explain their condition, nor is there a known brain insult or injury.  Often children with Expressive Language Disorder can experience EEG or other neuroimaging abnormalities, such as epileptiform activity, but it is not considered nor tied to epilepsy or Landau-Kleffner Syndrome.       

Children with Expressive Language Disorder frequently begin speaking late and generally make slower progress through various stages of expressive language development.  Children with this disorder may fully understand language but cannot linguistically express themselves when and how they want. Children with Expressive Language Disorder find ways to communicate within their means, be it with echolalia (using known phrases or words just previously heard or at some time in the past to express thoughts or needs), spontaneous utterances, or nonconventional language tactics (for example, repeating known words), signs or gestures, facial expressions, body language, behavior, and other forms of nonverbal communication.    

Expressive Language Disorder may present as one or more of the following: a limited range of vocabulary and amount of speech; difficulty in acquiring new words, recalling words, or vocabulary errors; shortened sentences; simple grammar construction; limited use of grammatical structures (like verb forms); few varieties of sentence types (such as imperatives or questions); use of unusual word order; and omissions of important linguistic pieces in sentences.  While the linguistic impact of Expressive Language Disorder can vary greatly among children depending on its severity and the age of the child affected, most children ultimately acquire more or less typical language abilities by late adolescence, although minor challenges may continue to exist.      

Developmental Mixed Expressive and Receptive Language Disorder:

Also referred to as: auditory processing disorder; specific language impairment; receptive language impairment; language processing disorder; language delay or speech delay; developmental aphasia.  

Receptive Language Disorder is generally only seen with Expressive Language Disorder.  

Developmental Mixed Expressive and Receptive Language Disorder impacts up to 5% of children and 3% of school-aged children. 

Associated Conditions:  Developmental Coordination Disorder.  Phonological Disorder.  Recurrent Otitis Media with Effusion (ear fluid).  Recurrent Ear and Sinus Infections.  Hypotonia.  Learning Disorders.  Social Isolation.  EEG or Neuroimaging Abnormalities.  Apraxic or Dysarthric Traits.          

Differential Diagnosis
:  Expressive Language Disorder.  Language or Speech Delay.  Landau-Kleffner Syndrome.  Intellectual Disability.  Autism.   

Mixed Expressive and Receptive Language Disorder and autism are mutually exclusive and do not co-occur.1  
            
            Mixed Expressive and Receptive Language Disorder is considered a specific language impairment.  Please see above for information about the expressive language aspects of this disorder.   
 

            Mixed Receptive and Expressive Language Disorder is an impairment in both expressive and receptive language development and may involve difficulties with both verbal language and sign language.  The resulting language difficulties interfere with social communication or with successful performance of daily activities at school or work.  There is currently no known cause of Mixed Expressive and Receptive Language Disorder.  Children with Mixed Expressive and Receptive Language Disorder do not have any clinical neurological abnormality to explain their condition, nor is there a known brain insult or injury.   

Mixed Expressive and Receptive Language Disorder is diagnosed when a child has problems expressing thoughts using language and also has problems understanding what people say.  Receptive Language Disorder may present as one or more of the following: difficulty understanding basic words or simple sentences to age-appropriate vocabulary, statements (for example, “if-then” clauses), or specific types of words (like spatial terms); may appear intermittently not to hear, be confused, or not paying attention when spoken to; may follow commands incorrectly or not at all; may have low joint attention; may have delay in reasoning or “thinking” skills; may have delayed social skills; and may be nonresponsive when answering questions or answer inappropriately or tangentially.  A child can also have deficits in various aspects of auditory or sensory information processing, such as poor attention to or discrimination of sounds, association of sounds and symbols, sequence of sounds and memory (storage), and recall.  If the recall ability is severely impaired, it is sometimes referred to as developmental anomia.       

While the linguistic impact of Mixed Expressive and Receptive Language Disorder can vary greatly among children depending on its severity and the age of the child affected, most children ultimately acquire more or less typical language abilities by late adolescence, although minor challenges may continue to exist, and the prognosis is better for those who do not also have expressive language difficulties.       

Developmental Phonological Disorder:

Also referred to as: verbal or oral dyspraxia; developmental verbal dyspraxia; verbal or oral apraxia; childhood apraxia of speech; oral or speech Developmental Coordination Disorder; articulatory apraxia; developmental apraxia; verbal dyspraxia; speech delay, speech or oral motor impairment; developmental dyspraxia of speech; oral or speech motor planning difficulties.

Phonological Disorder can be moderate to severe in 2% of children at the ages of 6-7 but impacts a much larger percentage of children in its milder forms.  At least 3% percent of preschool children present with Phonological Disorder, but this number drops to 0.5% by age 17 years.  Developmental Dyspraxia of Speech is considered a form of Phonological Disorder. 

Associated Conditions

Developmental Coordination Disorder.  Expressive Language Disorder.  Mixed Expressive and Receptive Language Disorder.  Recurrent Otitis Media with Effusion (ear fluid).  Recurrent Ear and Sinus Infections.  Hypotonia.  Learning Disorders.  Social Isolation.    

Differential Diagnosis
Oral Hypotonia (developmental dysarthria).

Phonological Disorder is defined as a failure to use expected speech sounds that are developmentally appropriate for the child’s age and dialect.  The resulting sound production difficulties interfere with social communication or with successful performance of daily activities at school or work.  Sometimes the cause of Phonological Disorder is clear, like a hearing impairment resulting from chronic ear fluid.  For others, there is no known cause, such as a clinical neurological abnormality, to explain the condition.  Children with Developmental Coordination Disorder and associated Hypotonia may have a higher likelihood of apraxic (oral motor planning and coordination difficulties) and dysarthric (oral muscle weakness) traits.  There may be problems synthesizing information from the speech organs (lips, teeth, tongue, etc.) to produce coordinated speech movements due to deficits in sensory integration for some children with Phonological Disorder.        

Phonological Disorder may present as one or more of the following: may have errors in sound production, use, representation, or organization, like substitutions of one sound for another (/d/ for /g/ - velar consonants) or omissions of sounds (in the middle or end of a word, for example); may have difficulties with phonological production or articulation that involve the failure to form speech sounds correctly; may find it challenging to sort out the difference in meaning between various sounds; the severest form manifests in having no intelligible speech; may have problems ordering sounds within syllables and words (pasghetti for spaghetti).

Children with this disorder may know how they want to sound but are unable to control the oral muscles and speech organs to move how and when they want correctly and consistently.  Developmental Dyspraxia of Speech or Apraxia of Speech involves inconsistent errors, difficulty sequencing sounds in connected speech, and vowel distortions.  Problems solely with speech rhythm and sound are not considered to be part of Phonological Disorder.  Mild to moderate Phonological Disorder resolves in most children (roughly 75%) by 6 years of age, and approximately ½ percent of children will have lingering difficulties into adulthood.       

Hypotonia:

Hypotonia is a medical term used to describe decreased muscle tone, or the amount of resistance to movement in a muscle.  It is not the same as muscle weakness, although the two conditions can co-exist.  Children with Developmental Coordination Disorder will most likely have Hypotonia.  Infants with Hypotonia have a floppy quality or “rag doll” appearance because their arms and legs hang by their sides and they have little or no head control.  Other symptoms of Hypotonia include problems with mobility and posture, breathing and speech difficulties, lethargy, ligament and joint laxity, and poor reflexes.  Hypotonia does not affect intellect.  However, depending on the underlying condition, some children with Hypotonia may take longer to develop social, language, and reasoning skills.  Hypotonia can be a life-long condition.  In some cases, however, muscle tone will improve over time.   

Oral Hypotonia (developmental dysarthria) is a motor speech disorder existing at birth that refers to weakness, slowness, or no movement of the muscles of the mouth, face, and respiratory system.  Swallowing problems (developmental dysphagia) can be related to neuromotor speech disorders. 

Ears (Fluid & Wax), Nose (Adenoids) & Throat (Tonsils):

              Physical reactions to environmental irritants, like cigarette smoke and dust, seasonal colds, allergies, and the flu, and certain diseases and conditions can result in ear fluid, ear infections, sinusitis (sinus infection), large or enlarged adenoids, ear wax (cerumen), tonsillitis (throat infection), opacification of the sinuses or mastoid, mastoid disease or infection (mastoid air cells disease or mastoiditis), all of which could cause a disruption in hearing, auditory processing, language processing, speech, motor function, socialization, sensory processing, balance, sleep, behavior, and development. 

              Ear infections occur more frequently in boys than girls, in children whose families have a history of ear infections, during the winter seasons when upper respiratory tract infections and colds are common, and when allergies cause chronic nasal congestion.     

                Children with excess ear wax (cerumen) or ear wax impaction can experience a significant impairment in hearing (conductive hearing loss) until the ear wax is removed because excessive ear wax can impede the passage of sound in the ear canal.  Excess ear wax may also disrupt Eustachian tube (a tube that links the back of the nose to the middle ear) function and prevent fluid from draining from the middle ear.  Movement of the jaw helps the ears' natural cleaning process, and when children are late to talk, have poor oral motor coordination, or dysarthria (low muscle tone in the oral organs), there is very little jaw activity, which can cause ear wax to build up.  In addition, the narrow and short shape of the ear canal may be an impediment to the ears’ natural cleaning process, and anxiety and stress, like from having an acute ear infection, can cause an increase in ear wax production.  Sometimes excess ear wax is hereditary.  A high fat diet may also create ear wax excess. 

             Enlarged adenoids or adenoid hypertrophy (refers to swollen lymphatic tissue that is found in the airway between your nose and the back of your throat) caused by nasal congestion and infection (sinus infection or sinusitis) or naturally large adenoids can keep fluid and mucus from properly draining from the ears, even if the child has had ear tubes inserted surgically, and cause chronic inflammation, congestion, and infection in the adenoidal and surrounding tissue, including tonsils  and ears.  Conversely, an infection in the throat or tonsils (strep throat or tonsillitis) can spread to cause infection in the adenoids and ears.  In addition, large adenoids can significantly impair socialization, hearing, auditory processing, language, speech, gross motor development, articulation, balance, and even affect facial growth characteristics if there is chronic nasal airway obstruction (long face syndrome).            

            Whether adenoids and tonsils are naturally large or enlarged due to chronic congestion and infection, sleep apnea can result in children.  Sleep apnea is defined as frequent stoppage of breathing caused by relaxed tissues in the throat during sleep.  Sleep apnea has been linked to depression, obesity, high blood pressure and stroke, mood swings, personality changes, inability to concentrate, heart disease, reduction in intellectual ability, and so forth, and most often goes undetected.  In addition to loud snoring, other symptoms of obstructive sleep apnea in children include: failure to thrive (weight loss or poor weight gain), mouth breathing, problems sleeping and restless sleep, excessive daytime sleepiness, impaired reflexes, and daytime cognitive and behavior problems, including problems paying attention, aggressive behavior and hyperactivity, and poor performance in school.            

1 According to the DSM-IV, Developmental Coordination Disorder, Expressive Language Disorder, and Mixed Expressive and Receptive Language Disorder do not co-occur with autism.  However, given the expansive application of the autism criteria used today by special educators, medical professionals, and others in the public health fields to identify children wtih developmental delays as early as possible, a preexisting classification of autism should not preclude an evaluation for Developmental Coordination Disorder, Expressive Language Disorder, or Mixed Expressive Language Disorder.  

Indicators            The indicators listed below focus whenever possible on abilities and resulting characteristics that would be unique to the underlying motor, language, and speech disorders and associated muscle tone condition experienced by these children regardless of expected differences in personality traits or intelligence.             Children with Developmental Coordination Disorder, Mixed Expressive and Receptive Language Disorder, Phonological Disorder, and associated Hypotonia may experience one or more, and likely several to many, of the following during various stages of development and may experience earlier than listed below.    Infancy (Birth to 12 Months)   

Motor Planning, Coordination, & Execution

·         Inactive in the womb, little to no kicking and movement, noticeably less movement and kicking compared to prior or later pregnancies ·         May notice a tendency for middle finger or other finger(s) to point downward toward palm across environments or an unnatural hand position at rest·         Movements may seem awkward or clumsy or be limited·         May be late to roll, sit up or sit up unassisted·         May be late to crawl, stand, cruise, or walk·         May struggle to lift sippy or drinking cups to mouth with wrists·         May not kick or struggles to kick infant toys designed to promote kicking or may not use arms or struggles to use arms to play with toys designed to promote hand and arm use ·         May have difficulty coordinating feeding, swallowing, and breathing movements and struggle with these activities

·         May have difficulties holding or using a utensil, especially to get food in the mouth  

 ·         May not take pictures well; if smiles, laughter, and eye contact are not reflexive (has to think about movement), can be difficult to get baby to look at the camera and smile or laugh at the same time or on command·         May not reach out for toys, to touch caretakers, other reasons due to inability to move arms as desired but may not have difficulty when spontaneous movement·         May struggle to move eyes when and how desired (tracking) when not reflexive (has to think about movement) Language·         May seem that baby does not respond to language or sounds at times or consistently·         May not be able to distinguish instructions, family names, or other familiar termsOral/speech·         Defective suck at birth; may not latch on or have difficulties latching on or sucking when nursing or fed a bottle even though typical strength of suck  ·         Has noticeable or excessive reflux or spit-up or a lot of milk comes up soon after feeding throughout infancy·         Experiences difficulty swallowing ·         Drools excessively ·         Milk that wasn’t swallowed falls out of the mouth after nursing or feeding from the bottle ·         May be a messy eater·         When introduced to baby foods, inadvertently forces food out of mouth with tongue or has difficulty getting or keeping food in the mouth due to labored or uncoordinated tongue movements ·          May gag noticeably when introduced to solids ·         May not coo or babble; emerging sounds may be random; may make a sound or word once and not again for a long time; sounds may be more like singing·         Attempt to make sounds may be delayed Hypotonia

      · 
     Has little to no neck control at birth that is beyond the poor neck control 
            typically expected in newborns; if not supported, the head will fall
            completely back, to the side, or forward·         May roll into a ball when put in car seat or similar position ·         Has significant rings of fat collected around the upper thighs or possibly arms noticeable at birth even though birth weight is average (imagine a Michelin baby)  ·         Cheeks may be extremely round or full looking·         Body and limbs may be excessively flexible and bendy·         Has low muscle tone while body is at rest but has typical strength for age when using the muscles; may seem tired quickly after exerting muscles or need to rest a lot after activity  ·         May position legs in the supine frog-leg position with knees apart in a relaxed state, like sitting or sleeping  Ears, Nose & Throat·         May have reoccurrence of allergies, environment irritants (cigarette smoke, dust) colds, ear fluid, ear infections, sinusitis, large or enlarged adenoids, ear wax (cerumen), tonsillitis (infection in the throat), all of which could cause a disruption in hearing, auditory processing, language processing, speech, motor function, socialization, sensory processing, balance, sleep, behavior, and development·         Chronic congestion can lead to perpetual infections, viral and bacterial, in the ears (otitis media or vestibular nerve inflammation), nose (sinusitis), and throat (tonsillitis or strep throat) ·         While ear fluid can often be present without symptoms, here are a few signs:o   Recent acute ear infection, sinusitis (sinus infection), or tonsillitis (throat infection)o   Chronic nasal congestion causing adenoid inflammation; frequent runny nose o   Difficulty balancing; feels dizzy, unsteady, or nausea; experiences vertigo symptomso   Seems inattentive or unable to focuso   Doesn’t respond to being called, sounds, or language consistentlyo   Excessive drooling or excessive reflux or spit-upo   Is bottle-fedo   Feeds from the bottle or nurses  while lying flato   Has Sleep Apneao   Increased irritabilityo   Has trouble sleeping or restingo   Tugs on or swats at earsToddler (12 Months to Three) & Preschool (Three to Five)  May continue to have difficulties with any of the skills listed above for younger children and may notice generally:·         May seem immature socially, sense of humor or interests may be simpler or more common for a younger child·         Discovery of chronic ear fluid, ear infections, chronic nasal congestion or sinus infections causing enlarged adenoids ·         May have significantly lower achievement than expected for intelligence level ·         May get frustrated or emotional with inability to do things how and when wanted·         May act out behaviorally due to not having the necessary skills to move, play, socialize, and communicate age appropriately and with peers ·         May be one to three years behind in overall development or specifically in motor coordination, language, speech, socialization, theory of mind and reasoning skills development·         May have high insecurity, depression, have little to no friends

·         May have low self-esteem; children as young as four years old are aware that they cannot perform tasks or process information on the same level as their peers   

·         A delay in language can cause a delay in cognitive functions and motor development
Motor Planning, Coordination,& Execution  

      ·         May be late to walk·         May walk like the feet are heavy·         May not be able to lift feet up and down to walk in place (like Flashdance feet movement)·         May seem slow in movements to sit, stand, climb on rider toys, walk, run·         May be very late to wave hello or goodbye; waving may be large arm movements where the hand flops back and forth like a dish rag or very awkward wrist movements ·         May have difficulty pointing or not be able to point with arms outstretched but may be able to point to a page in a book, for example, if arm is in a resting position ·         May holds things, like drinking containers, with the arm against the chest or body because of difficulty coordinating movement and lack of muscle tone needed to hold or carry items let alone move while holding the items·         May not be able to shake head yes or no; shaking head yes may involve entire torso; shaking head no may be very short movements or very wide movements and arms may flail back and forth simultaneously·         May appear to drag one leg (steppage gait) when running or skipping or have appearance of abnormal gait; may run by making skipping movements, especially with one leg lagging·         May be very late to potty train or continue having difficulties with toileting skills, such as wiping into school age·         May have difficulty pedaling or riding a bike or moving toy car with feet·         May sit on a tricycle or other foot-motored car or toy but may not be able to use pedals or  or feet to move the toy vehicle·         May have difficulty throwing, catching, and kicking a ball or other objects; may turn away when an object is being thrown to catch ·         May have difficulty imitating or mirroring the movements of others (for example, in a toddler’s tumble class) ·         May run awkwardly and use whole arms when running

·         Movements may seem awkward or clumsy 

·         May be slow to learn how to hop, jump, and go up and down stairs·         May have difficulty jumping up and down·         May have difficulty climbing up and down stairs one leg alternating with the other or walking in straight line·         May have difficulty hopping forward, especially with 2 feet together·         May have difficulty balancing on one leg or walking on a balance beam·         May shy away from playground equipment or play areas at water parks if feeling rushed or pressured to hurry in line when climbing up ladder stairs, using slides or other equipment·         May not be able to lift arms to give a hug or “squeeze” with arms, hands, or legs

·         Movements may be limited or seem restricted ·        May have difficulty isolating parts of the body to move them when they want how they want but can move all parts of the body when not thinking about it (reflexive movement)  ·         May lay on a swing with the belly to swing back and forth using feet to see the ground and keep balance versus sitting on the swing due to inability to keep steady or feel safe

·         May not be able to coordinate leg movements to swing oneself while sitting on a swing

·         May have difficulty turning door knobs or opening doors·         May have little awareness of body movements and position or kinesthesia (the sense that detects bodily position, weight, or movement of the muscles, tendons, and joints)·         May have difficulty maintaining balance or have poor balance; balance may be impacted more than other children with an inner ear disturbances such as ear infections ·         May struggle to move eyes when and how desired (tracking) but may not have a problem when not thinking about it (reflexive eye movement) ·         May not be able to move torso up and down with legs or side to side, move hips, shoulders, back, or arms to dance like other children the same age·         Dancing may be twirling in circle, walking, skipping or running back and forth or in a circle, lifting one leg to the side at a time, jumping up and down, or asking to be picked up by caretaker while caretaker dances because of difficulty isolating body areas to move to the music more naturally  ·         May have problems with spatial awareness, perception of distance, or proprioception (the unconscious perception of movement and spatial orientation arising from stimuli within the body itself)·         May find learning songs that require simultaneous body movements challenging (If You Are Happy and You Know It, Clap Your Hands; Hokey Pokey) ·         May have poor timing or sense of timing·         May have difficulty combining movements into a controlled sequence or remembering the next movement in a sequence·         May have difficulty demonstrating imaginative, creative, or symbolic play because of impaired ability to manipulate objects and use gestures·         May be challenging to learn or practice new motor skills·         May be clumsy or can't seem to keep from spilling or tripping ·         May have difficulty with getting dressed or undressed·         May not take pictures well; may have extreme difficulty coordinating eyes, smile, face, head, and body to “pose” at once

·         May have difficulty doing two things at once or more than one thing at a time (multi-tasking)

·         May have problems synthesizing information from the sensory systems (vision, balance, depth perception, auditory, etc.) to produce coordinated movements·         May struggle to learn jumping jacks because of simultaneous movements of legs, arm and body ·         May have difficulty learning to swim because of simultaneous movements of holding the breath underwater and using legs, arm, and body to swim ·         May have difficulties holding or using a utensil, especially to cut own food·         May have difficulties opening containers used for food, play, or school·         If being taught signs, may notice inability to sign, poor signing, difficulty positioning fingers, signing inconsistently, awkward hand and finger movements, stiffness in fingers or awkward finger extensions·         May point with middle finger instead of index finger (forefinger)·         Struggles with using crayons, pens or pencils; may frequently break crayons while drawing with them·         May struggle to learn movement sequence for drawing or writing·         May have difficulty establishing the proper writing grasp; has a tight or awkward grip or grasp·         May position head and body awkwardly or have poor body posture when trying to write or color ·         May use whole arm and/or upper body to color with the crayon or write with pen or pencil  ·         Penmanship may be illegible·         May have difficulty typing or using electronic toys that require button pushing

·         May have difficulty using a computer mouse or similar object    

·         Tying shoe laces or other knots, buttoning, zipping, snapping clothing, buckling belts may be challenging

·         May have difficulty with self-care that requires controlled and coordinated arm and hand movements, like combing or washing hair or brushing teeth

·         May use excessive pressure when writing and complain of hand, arm, or neck soreness after coloring or writing  

 ·         May struggle to use a scissors or cut on a line·         May develop skills later than peers to draw or make pictures on a blank page, color within the lines, or to take an interest in coloring, drawing or painting 

·         May find challenging keeping organized or one’s things organized ·         May have difficulty demonstrating imaginative, creative, or symbolic play because of impaired ability to manipulate objects and use gestures

·         May experience a delay in typical motor skill functioning due to delay in language and cognitive development     

·         May find it difficult to paint or use a chalkboard or dry erase board

Language·         May have slow rate of language development and comprehension ·         Speech may be delayed·         May have limited amount of speech or range of vocabulary·         May have difficulty in expressing ideas generally·         May make few attempts at communication without prompting ·         May not be able to communicate thoughts at will or on command·         May seek to use nonverbal means to communicate and interact, such as through signs, pointing to objects or pictures, leading you to do or say something, engaging caretaker in eye contact to have a nonverbal dialogue, or other nonverbal body language ·         May be able to sign or read but not have the same verbal skills when trying to express own thoughts and ideas·         May understand language better than can be expressed·         May be able to express language better than can be understood·         May consider language development to reach plateaus at various stages ·         May wave hands or jump up and down when excited until speech is fluent          or self-awareness (theory of mind) reaches age level·         May be able to sing songs or read or recite words that are beyond speech or conversation skills ·         Conversational skills or back-and-forth verbal exchanges may be slow to emerge·         May experience a disturbance in fluency and language formulation and disruptions in language structure·         May have difficulty in acquiring new words, recalling words or word-finding, or vocabulary or tense errors·         May use shortened sentences or have difficulty producing sentences that are developmentally appropriate in length and complexity for age ·         May have difficulty putting words into sentences ·         May use simplified grammatical structures, limited varieties of grammatical structures (like verb forms), limited varieties of sentence types (such as imperatives or questions)·         May have omissions of critical parts of sentences or use of unusual word order ·         May use phrases or words just previously heard or at some time in the past to express needs and thoughts (echolalia) when language skills are still significantly delayed

·         May stick fingers in ears to signify a loud or unpleasant noise, to signal something to stop, or ears are uncomfortable, or in anticipation of a familiar, favorite, song, show, or sound if speech is delayed

·         May have to prompt child to encourage communication while language skills are delayed or emerging
·         Theory of mind, “thinking” or reasoning skills may be delayed

·         May have poor sense of self or low self-awareness and lacks awareness of how personal actions or behavior appear to others or how others may react

·         Interest or ability to play games at age level may be significantly delayed  

 ·         May have low joint attention while language comprehension and motor coordination are significantly delayed

·         Certain cognitive processes, functions, and skills reliant on language comprehension may be delayed ·         May be delayed to understand concepts, like over, under, on, above, beside·         May have difficulty identifying relationships among or grouping objects by similarities or differences while language delayed·         Interest or ability to play games (including computer and electronic games) at age level may be significantly delayed·         Socialization skills may be delayed      ·         May have difficulty following or understanding verbal instructions ·         May seem temporarily frozen or confused after being spoken to·         May seem to have hearing difficulties at times ·         May sometimes seem to not be paying attention or zoning out when spoken to·         May struggle following simple instructions or commands·         May follow commands incorrectly or not at all·         May have difficulty understanding basic words or simple sentences to age-appropriate vocabulary, statements (for example, “if-then” clauses), or specific types of words (like spatial terms)·         May answer questions nonresponsively or tangentially to the question being asked·         May have deficits in various aspects of auditory processing (temporal or central) or sensory information processing, such as giving attention to or discrimination of sounds, association of sounds and symbols, sequence of sounds and memory (storage), and recall    

·         May experience delay in processing sounds or disruption in ability to process incoming language sounds in sequence   

 ·         Language delay may cause impairment in “working memory” resulting in being able to process a little information at a time and poor recall   

·         May practice and repeat saying words and phrases

·       Communicates within means, be it with echolalia, spontaneous utterances, or nonconventional language tactics, signs or gestures, facial expressions, body language, behavior, and other forms of nonverbal communication    

·         May have delay or difficulty in demonstrating imaginative, creative, or symbolic play because of language delay ·         May be delayed in processing or reacting to information in the environment, including not responding age appropriately to emotions of others with a language delay  ·         May perform poorly on standardized social communication tests administered by a medical or educational professional due to language delay·         May perform poorly on standardized language and speech tests administered by a medical or educational professional due to language delay·         May perform poorly on standardized development tests administered by a medical or educational professional due to language delay ·   May appear to approach learning language differently, for example, rather than instinctively learning language like typically developing peers, it may seem at times that the child has to self-teach how to use language as if self-rehardwiring the brain to be able to use language
·         Social language, like please, thank you, your welcome, hello, goodbye, may be delayed

·         As language comprehension and skills emerge and improve, “typical” socialization communication and skills emerge and improve 

Oral/Speech·         Emerging sounds may be random·         Attempt to make sounds may be delayed·         Initial sounds may be more like singing·         Speech may be unintelligible as it emerges; nonfamily members may not be able to understand speech·         Speech patterns may be noticeably atypical, such as erratic speech rhythms·         May have an abnormal rate of speech·         May have difficulty controlling the speech organs·         May have difficulty with the production of voiced sounds (phonation), which are created with exhaled air stirs the vocal folds into vibration·         May have incorrect use of the varying rhythms, stresses, and inflections of speech that are used to help express meaning (prosody)·         May have difficulty sequencing sounds to form a word, especially longer words·         May make a sound or word once and not again for a long time·         May not be able to make a sound or word consistently or correctly·         May omit sounds from words, substitute one sound for another, or have sound distortions·         May have difficulty imitating speech or sound production·         May stall or pause trying to get out the right sounds in sequence or words in phrases·         May struggle with consonant and vowel sounds in general·         May make errors in sound ordering or sequencing (pasghetti for spaghetti)·         Most frequently misarticulated sounds are l, r, s, z, th, ch but may also struggle to make the w, k, g or put two sounds together such as st, sp, sm, sn, pl ·         May have problems synthesizing information from the speech organs (lips, teeth, tongue, etc.) to produce coordinated speech movements             ·         May seem to have an electrical current running through the head or body when excited or frustrated but unable to speak; may make a simultaneous sound, like saying “ooh” through clenched teeth ·         May not be able to stick out tongue or move it at will, like from side to side·         May have difficulties to blow nose, blow a candle, pinwheel, whistle·         May not be able to spit out toothpaste when brushing teeth·         May not be able to pucker for a kiss or close lips to give a kiss·         Has difficulty taking bites of food and often bites of food are too big if not precut ·         May have difficulty coordinating feeding, swallowing, and breathing movements·         May be a messy eaterHypotonia·         Weak cheek, tongue, lips, and jaw muscles (developmental dysarthria): slurred speech; speaks softly; slow rate of speech; rapid rate of speech with a "mumbling" quality; limited tongue, lip, and jaw movement; abnormal intonation (rhythm) when speaking; changes in vocal quality ("nasal" speech or sounding "stuffy"); chewing difficulty; hoarseness; breathiness; drooling or poor control of saliva·         Experiences difficulty swallowing (developmental dysphagia) ·         May have difficulty making /g/ and /k/ sounds due to weakness in tongue muscles and may substitute these sounds with /d/ and /t/, respectively·         May have weakness in sounds made·         May skip sounds of words in speech ·         Cheeks may be very round or full looking ·         Body and limbs may be extremely flexible and bendy·         May have low endurance or tire easily after physical exertion·         Has low muscle tone while body is at rest but generally has typical strength for age when using the muscles·         May seem tired quickly after exerting muscles or need to rest a lot after physical activity  ·         Has rings of fat collected around the upper thighs or possibly arms (imagine a Michelin baby) due to low muscle tone, even though average weight for size  ·         May position legs in the supine frog-leg position with knees apart in a relaxed state, like sitting or sleeping  Ears, Nose & Throat·         May have reoccurrence of allergies, environment irritants (cigarette smoke; dust) colds, ear fluid, ear infections, sinusitis (sinus infection), large or enlarged adenoids, ear wax (cerumen), tonsillitis (throat infection), opacification of the sinuses or mastoid, mastoid disease or infection (mastoid air cells disease or mastoiditis), all of which could cause a disruption in hearing, auditory processing, language processing, speech, motor function, socialization, sensory processing, balance, sleep, behavior, and development·         Chronic congestion in the nasal passages can lead to perpetual infections, viral and bacterial, in the ears (otitis media, vestibular nerve, mastoid air cells or bone), nose (sinusitis), and throat (tonsillitis or strep throat) ·         May experience a reduction in hearing (conductive hearing loss) because excessive ear wax can impede the passage of sound in the ear canal or disruption in ear tube function or balance caused by excess ear wax or ear wax impaction due to the shape of ear canals, very little jaw movement, and increase ear wax production if anxious or under stress, like from having an acute ear infection·         Signs of large or enlarged adenoids:o   Bad breath, cracked lips or dry moutho   Nasally voice or hypo-nasal speecho   Mouth breathing; snoring, especially loudlyo   Mouth open during day (more severe obstruction) or noisy breathingo   Persistent runny nose, nasal congestion, or nosebleedso   Sleep Apnea (obstructive), restlessness while sleeping, or chronic light sleeper  o   Chronic sinus (causing excessive mucus) and throat infectionso   Chronic ear infections, ear fluid, excessive ear wax, and associated hearing losso   Adenoid facies (long face syndrome) – a long, narrow face, short upper lip, oral cavity breathing, open-mouth posture, protruding upper incisor teeth, dull facial expression, and a hyperactive swallowing pattern·         Signs of Sleep Apnea:o   May be excessively tired or sleepy during daytime o   May snore loudly, squeakily, or raspilyo   Nocturnal snorting, gasping, choking (may wake self up)o   May have restless, unrefreshing, or chronic light sleepo   May be or feel chronically sleep deprivedo   May have heavy, irregular breathingo   May perspire excessively during sleepo   May struggle with severe bedwettingo   May have bad dreams (nightmares); night terrorso   May sleep with mouth open, causing a dry mouth upon awakeningo   Chest may retract during sleep in young children (chest pulls in)o   May sleep in strange positionso   May have confusion upon awakeningo   May suffer from morning headacheso   May develop high blood pressureo   May become overweight or underweighto   May have learning problemso   May have excessive irritability or become aggressiveo   May have a change in personalityo   May suffer from depressiono   May have impaired reflexeso   May have difficulty concentratingo   May have developmental or behavioral problemso   May have failure to thrive or growo   May have frequent upper respiratory infectionso   May have hyperactive behavioro   May perform poorly in school·         While ear fluid can often be present without symptoms, here are a few signs:o   Recent acute ear infections, sinus infection, or infection in the throato   Chronic nasal congestion causing adenoid inflammation or persistent runny noseo   Difficulty balancing; feels dizzy or nauseous; experiences vertigoo   Seems inattentive or has difficulty focusingo   Wants to sit closely to the TV or radioo   Asks or indicates for things to be repeated or has difficulty following verbal communicationo   Doesn’t respond to being called, sounds, or language consistently or appropriatelyo   Increased irritabilityo   Has trouble sleepingo   Complains of fullness, ringing, tenderness, or discomfort in the earo   May talk louder than usualo   Opacification in the sinuses or mastoid (seen on CT or MRI)o   Low grade fever o   Discharge or drainage from the ear or swelling behind the earo   Persistent blockage of fullness of the earo   Hearing losso   Facial weaknesso   Persistent deep ear pain or headacheo   Confusion or sleepinessSchool Age (Five to Adolescence)May continue to have difficulties with any of the skills listed above for younger children, especially if the conditions are severe, but most prominently:·         May have low self-esteem, high insecurity, depression, have little to no friends·         May seem immature socially, sense of humor or interests may be simpler or more common for a younger child·         May have lower achievement than expected for intelligence level ·         May get frustrated or emotional with inability to do things how and when wanted·         May be one to three years behind in overall development or specifically in motor coordination, language, speech, socialization and reasoning skills development ·         May act out behaviorally due to not having the necessary skills to move, play, socialize, and communicate age appropriately and with peers Motor Planning, Coordination, & Execution·         May not be good at most sports, including bicycling, but do well or enjoy swimming, horseback riding, bowling, or other sports or recreational activities
·         Penmanship may be illegible·         May struggle with writing by hand and taking notes·         May have difficulty typing or texting·         May have difficulty using a computer mouse or similar object

·         May struggle with touch screens on computers and smart phones  

·         May have difficulty driving or pedaling a bike·         May have difficulty throwing, catching, and kicking a ball or other objects·         May have body image issues·         May struggle with directional sense·         May have poor sense of body awareness, movements, and posture or kinesthesia (the sense that detects bodily position, weight, or movement of the muscles, tendons, and joints)·         May have problems with spatial awareness, perception of distance, or proprioception (the unconscious perception of movement and spatial orientation arising from stimuli within the body itself)·         May have difficulty isolating parts of the body to move them when wanted how wanted but can move all parts of the body when not thinking about it (reflexive or instinctive movement)·         May run awkwardly and make large arm movements when running ·         May have poor organizational skills·         May have difficulty doing two tasks at once or more than one thing at a time (multi-tasking)·         May have difficulty pedaling a bike, riding a scooter, or rowing a boat·         May have difficulty maintaining balance or have poor balance; balance may be impacted more than other children with an inner ear disturbance (like with ear fluid) ·         May be clumsy or can't seem to keep from spilling or tripping·         May have difficulty imitating or mirroring the movements of others (for example, in gym or physical education class) ·         May struggle with opening containers, preparing food, and using utensils

·         Penmanship may be illegible or has difficulty typing

 ·    May have difficulty playing musical instruments, like piano and violin       ·         May find it challenging to engage in electronic recreational games  
            (like Wii and Playstation)

·         May struggle with using tools and repairing, assembling, or fixing common items   

Language·         Communicates within means, be it with echolalia, spontaneous utterances, or nonconventional language tactics, signs or gestures, facial expressions, body language, behavior, and other forms of nonverbal communication·         May have limited amount of speech or range of vocabulary·         May have difficulty in expressing ideas generally·         May use shortened sentences or have difficulty producing sentences that are developmentally appropriate in length and complexity for age ·         May have difficulty putting words into sentences or getting thoughts out verbally·         May not be able to communicate thoughts on own demand or command of others·         May have difficulty expressing language or reading comprehension based on inability to verbally communicate proficiently·         May have more success at writing out thoughts than verbalizing thoughts·         May stall or pause trying to get out the right words in sequence·         May use known phrases or words to express needs and thoughts when language skills are still significantly delayed  ·         May have difficulty following or understanding verbal instructions ·         May seem temporarily frozen or confused after being spoken to·         May seem to have hearing difficulties at times ·         May sometimes seem to not be paying attention or zoning out when spoken to·         May struggle following simple instructions or commands·         May follow commands incorrectly·         May be nonresponsive when answering questions or answer inappropriately or tangentially to the question being asked·         May have deficits in various aspects of auditory processing (temporal or central) or sensory information processing, such as giving attention to or discrimination of sounds, association of sounds and symbols, sequence of sounds and memory (storage), and recall    ·         May struggle with following along in conversations, school lectures, or movies

·         May be significantly delayed in conversational fluency

·         May find challenging following multiple steps in a set of directions    

 Oral/Speech·         May have articulation difficulties·         Has difficulty taking bites of food and often bites of food are too big if not precut (also caused by weakness in oral muscles)·         May be a messy eater·         May stall or pause trying to get out the right sounds in sequence or words in phrases·         May have lingering problems synthesizing information from the speech organs (lips, teeth, tongue, etc.) to produce coordinated speech movements   ·         May have incorrect use of the varying rhythms, stresses, and inflections of speech that are used to help express meaning (prosody)·         Speech patterns may be noticeably atypical, such as erratic speech rhythms·         May have difficulty sequencing sounds to form a word, especially longer wordsHypotonia·         Weak cheek, tongue, lips, and jaw muscles (developmental dysarthria) ): slurred speech; speaks softly; slow rate of speech; rapid rate of speech with a "mumbling" quality; limited tongue, lip, and jaw movement; abnormal intonation (rhythm) when speaking; changes in vocal quality ("nasal" speech or sounding "stuffy"); chewing difficulty; hoarseness; breathiness·         May have difficulty making /g/ and /k/ sounds due to weakness in tongue muscles; may have weakness in sounds made; may skip sounds of words in speech·         Cheeks may be round or full looking ·         Experiences difficulty swallowing (developmental dysphagia)·         Body and limbs may be very flexible and bendy·         May have low endurance or tire easily after physical exertion·         Has low muscle tone while body is at rest but generally has strength when using the muscles; may seem tired quickly after exerting muscles or need to rest a lot after activity·         May position legs in the supine frog-leg position with knees apart in a relaxed state, like sitting or sleeping AdulthoodMay continue to have difficulties with any of the skills listed above for younger individuals, but most prominently: ·         May have low self-esteem, high insecurity, depression, have little to no friends·         May seem immature socially, sense of humor or interests may be simpler or more common for someone younger in ageMotor Planning, Coordination,& Execution
·         Penmanship may be illegible·         May still struggle with writing by hand·         May have difficulty typing or texting·         May have difficulty driving·         May have poor directional sense ·         May have body image issues·         May have poor organizational skills across environments (home, work)

May still struggle with using tools and repairing, assembling, or fixing common items

·         May have awkward body movements ·         May have poor body awareness (kinesthesia)·         May have problems with spatial awareness, perception of distance, or proprioception·         May be clumsy or can't seem to keep from spilling or tripping·         May not be good at most sports, including bicycling, but do well or enjoy swimming, horseback riding, bowling, or some other sports·         Fine motor tasks like opening containers, preparing food, and using utensils or tools may still be challenging·         Tying shoe laces, shaving, styling hair, knotting ties, buttoning clothing, buckling belts or other fine motor skills related to self-care may still be challenging·         May have difficulty doing two tasks at once or more than one thing at a time (multi-tasking)

·         May find it challenging to engage in electronic recreational games (like Wii and Playstation)

Language       ·         May still struggle with conversational fluency ·         May still struggle with speech or getting thoughts out verbally ·         May have more success at writing out thoughts than verbalizing thoughts·         May stall or pause trying to get out the right words in sequence·         May still struggle with language comprehension or auditory processing, like following verbal instructions or along in conversations, lectures, or movies·         May still find challenging to follow multiple steps in a set of directions

Oral/Speech   

·         May have lingering articulation difficulties ·         May stall or pause trying to get out the right sounds in sequence or words in phrases (misses the “t” sound in stop during conversational speech)·         May at times have problems synthesizing information from the speech organs (lips, teeth, tongue, etc.) to produce coordinated speech movements          Hypotonia·         May continue to have low muscle tone ·         May have lingering oral weakness, including chewing and swallowing difficulties·         Body and limbs may be very flexible and bendy

·         May have low endurance or tire easily after physical exertion

Resources:

http://www.nih.gov  U.S. National Institute of Health

http://www.ncbi.nlm.nih.gov/pubmed PubMed.gov, U.S. National Library of Medicine

http://www.guideline.gov
  U.S. National Guideline Clearinghouse

http://www.eric.ed.gov  U.S. Education Resources Information Center

http://www.cdc.gov U.S. Centers for Disease Control and Prevention

http://www.aap.org  American Academy of Pediatrics

http://www.aafp.org  American Academy of Family Physicians

http://www.entnet.org  American Academy of Otolaryngology

http://www.asha.org  American Speech-Language-Hearing Association

http://www.americankinesiology.org  American Kinesiology Association

http://www.apa.org  American Psychological Association

http://www.vestibular.org  Vestibular Disorders Association

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM), Fourth Edition, Text Revision.  Washington, DC, American Psychiatric Association, 2000.

WHO (2007). International Statistical Classification of Diseases and Related Health Problems (ICD-10) 10th Revision Version for 2007.  World Health Organization, 2010.
Web Hosting