Culture has a heavy overlay on the perceptions and the subsequent handling of persons with language and speech disorders. This article reviews the cultural perspectives of language and speech disorders as portrayed by persons with language and speech disorders, parents, teachers, and language and speech pathologists. The information on cultural perspectives was collected between November 2006 and August 2007 during Operation Smile, Kenya Chapter Missions. 20 persons, aged between 8 and 53 years, were interviewed. The research objective was to establish the cultural perspective that determines the interpretations of language and speech disorders and their subsequent management.

The finding of the study is that there is a notable cultural association or correlation between cultural beliefs and language and speech disorders. There is also ignorance of the causes and management procedures of language and speech disorders. We conclude that there is a need to provide assessment and treatment protocols that are culturally fair, effective, and acceptable. Such protocols include taking into account gender preferences, adhering to culturally relevant communication patterns, and using collaborative therapy.

Characteristics of Language Development

Communication is so pervasive in any community in its day-to-day activities that it is often taken for granted (Steinberg, 2001). Normal communication includes all means by which information is transmitted between the sender and the recipient. The means of communication are verbal and non-verbal; oral and written; formal and informal; or intentional and unintentional. Human beings, unlike other animals, mainly communicate using a system of symbolic communication referred to as language, which may be spoken, written, or signed.

Normal language develops over a period and it is sequential or ordered (Crystal, 1992). A child acquires vocalization, speech sounds (vowels and consonants) and then prosodies. This acquisition is in recognizable stages that entail acquisition of form, content, and use (Seymour and Nober, 1997). The form is the system of symbols that convey meaning and it is made up of the phonology, morphology, and syntax of a language. The content includes the individual words and combinations of words to produce meaning in the language. Content is made up of the semantics of a language. Use involves how we use words in contexts and is made up of the pragmatics of a language.

There is predictable cultural diversity in language acquisition due to the context of acquisition. Battle and Anderson (1997) observe that:

The acquisition of language is a dynamic and complex act. Children acquire language within the context of the family. There is a dynamic interaction among cultural beliefs, family values, expectations, experiences, and child rearing, which influences the language development of young children (213).

Cultural perceptions are at play right from the beginning of the language acquisition process. For instance, the sounds that a child first acquires are determined by the language or languages the child is exposed to in the rearing context. The expectations in terms of how much language and in what order it should be acquired are also determined by the culture in which the child is reared.

Many things could go wrong with the natural order of language acquisition and development. In every community, we encounter individuals with language and/or a speech disorders. Unfortunately, there is much ignorance as far as identifying these disorders is concerned. The ignorance more often than not leads to mishandling of the persons with language and speech disorders.

Defining Language and Speech Disorders

Language and speech are said to be disordered or impaired if they differ from what is considered the norm. As already indicated, the yardstick is embedded in the culture of each language; what may be considered disordered in one language will not necessarily be disordered in another language. There is need, therefore, to distinguish between genuine speech disorder and people's cultural tendencies or practices. For example, Kim (1985) notes that Asian Americans favour verbal hesitancy and ambiguity to avoid offence. They also avoid making spontaneous or critical remarks. One should respect such a community's culture and thus the hesitancy should not be confused with a fluency disorder.

The unique nature of the language and speech disorders is that they are not visible since mostly they are not physically manifested, except defects that affect articulation. Most disorders are not evident until a person opens her/his mouth to speak. The disorders, for the same reason, are often not considered a disability, even by the persons who have them.

Language and speech disorders may be due to factors such as physical, mental, or socialization defects (Crystal, 1988). Though language and speech disorders are classified together they are slightly different from each other.

Speech disorders

Speech is the vocal utterance of language and it is considered disordered in three underlying ways: voice, articulation, and fluency (Roseberry-McKibbin, 1995).

Voice involves the coordinated effects of the lungs, larynx, vocal chords, and nasal passage to produce recognizable sounds. Voice can thus be considered disordered if it is incorrectly phonated or if it is incorrectly resonated. In the incorrect phonation an individual could have a breathy, strained, husky, or hoarse voice. With the incorrect resonation an individual could have hyper-nasality or hypo-nasality.

Paralanguage issues, such as use of pitch, volume, and intonation, are diverse for they are culturally determined. Every sound of voice has a possible range of meanings that could be conveyed simply through the voice rather than the words we use. The features that should be considered in determining a voice disorder are:

  • Volume: how loudly or softly we speak
  • Pitch: how pleasant or unpleasant
  • Quality: the highness or lowness of ones voice
  • Rate: the speed at which one speaks

Voice disorders are due to damage to organs such as the larynx, lungs, vocal chords, and the nasal passage. The voice disorders could also be due to improper voicing habits.

Voice disorders are interpreted variously in different cultures. For instance, in many African cultures masculinity and femininity are determined by paralinguistic features. A man who speaks in a low volume, a high pitch, or a smooth and slow voice, would be frowned upon and called upon to "speak like a man."

Articulation involves the use of the tongue, lips, teeth and mouth to produce recognizable speech sounds. Articulation is disordered if sounds are added, omitted, substituted or distorted. Articulation disorders may be caused by factors such as structural abnormalities, for example, a cleft lip and/or palate, a tongue-tie, missing teeth, a heavy tongue, or a deformed mouth; faulty or incomplete learning of the sound system; or damage of the nervous system.

Physical appearance is very important as far as articulation disorders are concerned. We are judged by the way society has determined we should look. This is especially true in the cases of those with cleft lips and palates, missing teeth, or a tongue-tie. These conditions are visible and they disfigure the face. Apart from affecting articulation, the conditions, therefore, also affect the self-concept of the persons: "The importance of having a good self-concept is universally accepted. Appearance or attractiveness is regarded as a major component of self-concept…. Appearance also determines the differential treatment of children" (Leonard et al 1991: 347). Persons with cleft lip and/or palate thus often have an additional sense of low self-esteem due to the deformity. For instance, Tom lives in Githurai, a suburb of Nairobi and works as a fruit vendor. He has a cleft lip and palate that was not repaired fully during an operation at Kenyatta National Hospital. Tom could not afford further surgery. He therefore still talks with heavy nasality, despite the operation. Due to this, he is shy of the public and does not like to talk to any person that he is not vaguely familiar with. People who are not familiar with his way of speaking will not buy from him. It takes a lot of patience and familiarity to determine what he has said. This has not only affected his business but also his social life.

Fluency involves appropriate pauses and hesitations to keep speech sounds recognizable. Fluency is disordered if sounds are very rapid with extra sounds (cluttered), if sounds are repeated or blocked especially at the beginnings of words (stuttered), or if words are repeated. Fluency disorders are more prevalent in children and they are due to a combination of familial, psychological, neurological, and motoric factors.

The social nature of communication is affected when one has disfluent speech. Human beings are social and they spend much of their time together. They first learn how to communicate in a social set up — for instance, with parents, siblings, relations, or friends. Socialization is adversely affected if one has a fluency speech disorder. A person with disfluency is often mishandled at home, in school, or in public place. Often the individual becomes withdrawn.

Language disorders

Language is the rule-based use of speech sounds to communicate (Steinberg, 2000). Disordered language may be due to a receptive problem, that is, a difficulty in understanding speech sounds. It can also be due to an expressive problem, that is, a difficulty in producing the speech sounds that follow the arbitrary rules of a specific language. A language disorder can also be due to problems in both reception and expression. Language disorders, therefore, refer to the following:

  • The use of speech sounds in combinations and patterns that fail to follow the arbitrary rules of a particular language is a language disorder. For instance, the lack of communication etiquette is considered a language disorder. Talking out of turn, not talking when it is your turn, or not responding when you are expected to could be disorders if frequently observed in one's language behaviour.
  • The delay in the use of speech sounds relative to normal development in the physical, cognitive, and social areas is another language disorder. Most language disorders are often diagnosed in conjunction with other developmental delays — for instance, health, sensory, motor, mental, emotional, and behavioural development.
  • Speech and language disorders are reported to be more prevalent than any other disability in primary schools. They often go undetected and, therefore, unattended. This is especially so if the disorders are often concurrent with other disabilities such as deafness, autism, compromised mentation, traumatic brain injuries, or behavioural disorders, which are given attention at the expense of the speech and language disorder. Seymour and Valles (1997) reinforce the importance of the school setting in detecting language and speech disorders and in instituting intervention measures.

Disorders in the Contemporary Cultural Context

Data from observations and surveys provided the cultural views of language and speech disorders presented below. Personal interviews with persons who have been adversely affected by language and speech disorders provided information on the need for change in attitudes and handling of persons with language and speech disorders. The findings of the observation and survey indicate a need "to provide assessment and treatment protocols that are culturally fair and effective for language disorders" (Seymour and Valles, 1997: 89). The findings contradict the belief that people have changed attitudes and perceptions in regard to language and speech disorders due to education and/or religion. Contemporary culture still associates or correlates language and speech disorders to practices and beliefs. The larger percentage of the public is ignorant of the causes of language and speech disorders.

There is still a very heavy cultural overlay in what is considered normal language and speech. This in turn affects the way society treats those who have language and speech disorders. Many cultural stereotypes are still being used to explain language and speech disorders. In Kenya, various communities attribute the cleft lip and/or palate to phenomena found in their immediate environment or to curses. For instance, the Borana, Redile, and Samburu associate the camel with the cleft (Operation Smile, Meru Mission, April, 2007). The camel's nostril is split and the common belief amongst these communities is that a cleft occurs when a pregnant woman looks at a camel giving birth. The Ameru assign the cleft to curses for a social wrong doing, such as disobeying parents (Operation Smile, Meru Mission, April, 2007). During the Kisumu Mission (November, 2006), the Luo and Kisii also indicated that the cleft was brought about by curses. In the Nyeri Mission (August, 2007), the Agikuyu indicated that it was brought about by family planning methods such as the pill and the coil. The educated ones indicated that the condition is genetic. Such beliefs could discourage individuals with clefts in these communities from seeking professional advice.

Religion or beliefs are seen to play a key role in some communities that may determine whether those with language and speech disorders seek treatment or not and the extent of the treatment. For instance, those who believe that a cleft is a punishment from God would be offending God more by having it clinically repaired. Children whose parents have such beliefs often seek treatment too late, when the surgery may not be as effective as it would be if early intervention occurs.

Some parents believe that their children stammer when they speak in English, making it difficult for a speech therapist to treat this condition. Others such as the Agikuyu associate stammering with playing with chameleons in early childhood, while others associate the disorder with laughing at another who stammers. There is a need to make it clear that stammering is not a result of acquiring a second language or a childhood deed. To be successful in treating this fluency disorder, the speech therapist would have to start by helping the parent understand the condition through a clear explanation. Late or non-intervention is common in many other Kenyan communities where language disorders, such as stuttering, are associated with evil spirits or curses by the ancestors.

Cultural beliefs are not an African phenomenon. Severe strokes often cause severe speech problems. Yet among many Native American communities, a person who suffers stroke is thought to have been "hit by the wind" (Westby and Begay, 2002). The communities believe that this condition occurs when an individual is out of harmony with nature. This kind of belief would affect how the community describes the disorder and from whom they seek health care.

In Kenya, as in the rest of Africa, cultures are collective, a property of the society. That means great value is placed in the group and membership in the group. For this reason, explanation of certain occurrences can only be given by the concerned society. This often affects an individual's decision in the course of seeking treatment or therapeutic services.

The Interpretation of the Cultural Associations

Due to the ignorance of the causes of language and speech disorders, persons with disorders are mishandled and mismanaged. Society generally reacts to language and speech disorders negatively out of this ignorance. Persons with language and speech disorders are ignored, feared, pitied, mimicked, laughed at, considered helpless, rejected, or denied opportunities by being hidden. In rare cases are they given language and speech therapy or pathological care.

Persons with disorders are often unemployed due to prevailing attitudes that they are incapable to work. Many are unable to access suitable education due to lack of a suitable curriculum, institutions, or policy. The academic performance of the persons is affected and thus the chances of competing fairly and equally with others are also minimised. A case in point is Wainaina who would have wanted to be a teacher but became discouraged by his father — "Who would want you to teach their children?" his father wondered. "If you can't speak, how do you expect to teach others how to speak?" Therefore many persons with language and speech disorders have financial problems. Their financial status compounds their problems because treatment, where it is available, is often very expensive.

Some of the persons fear giving birth to children while their parents also fear having other children in case they share similar problems. Females are known to be sexually exploited as they move from one to relationship to another seeking social acceptance. Females with cleft lip and/or palate often consider themselves unattractive in appearance. Language disorders, as Leonard et al (1991) observe, leads adolescent girls to have a more negative self-concept than younger girls. Persons generally suffer from depression, anxiety, low self esteem/perception, and maladjusted behaviour (Millard and Richman, 2001). There is need for professional intervention in order to prevent or interrupt these negative psychosocial outcomes as well as communication challenges.

Persons with language and speech disorders suffer from the inability to communicate as effectively and efficiently as desired. The speech of the individual has impairment, ranging from mild to severe. The four language skills — listening, writing, reading, speaking — are affected depending on the disorder, leading to negative labels.


Persons who cannot listen as per the cultural norms are often dismissed as anti social, immature, or impolite. For instance, Daniel Lyimo, a young Tanzanian student, is often misconstrued to be rude because he does not answer questions in class. He has a hearing problem. Lyimo has to look at a speaker keenly so that he can combine his limited hearing with lip reading. Most African cultures consider such intense eye contact rude. The label "rude" has affected Lyimo's studies negatively.

Lyimo is also shy and reserved. According to him, making friends is an uphill task because they too consider him odd. He has to keep asking people to speak loudly or lip-read. The two practices do not endear him to many. No one wants to discuss intimate things loudly or when keenly watched. Even those who are close to him make fun of his hearing loss and often refer to him as "the hard of hearing one."

Although Lyimo uses a hearing device, his hearing loss has persisted and he has continued to gradually lose his hearing ability. This has devastated him considerably and he often wonders how he will cope with complete hearing loss. As a result, he suffers from depression and has to see a counsellor on a regular basis. The counselling sessions are an additional cost. This cost would not have been incurred if Lyimo were living in a "friendly and understanding" environment.


Lemmy Ejore is a young Kenyan man, who writes very differently from others. He turns his book upside down and writes from the right to the left. To read his written work, one has to turn the page. This has put him through a lot of trouble with teachers who want to know: "why is he being cheeky?" Ejore's problem is due to a sight defect. His world is upside down. Often he is teased by his classmates, who want to know what he sees when he looks at them.

Like Lyimo, Ejore is very reserved and he is often labelled "anti-social." His class work has also been affected because he has to keep explaining to others why he does not write "properly" — meaning like them. Ejore always chooses to sit at the front of the classroom to avoid his classmates' stares and rude remarks.


Persons with fluency disorders are at task to read the way others do. They will often desist from reading unless the situation dictates that they do so. In such situations, they get depressed and distraught. For instance, Achieng, eight years old, is still in class one at the primary level. At her age she should have been in class three. Achieng has a cleft lip that was not treated in infancy, the best time for surgery if full recovery is expected. Achieng's mother had been informed by a nurse at a health clinic in Kisumu that nothing could be done for her daughter. When she moved to work in Nairobi, a neighbour correctly informed her that not only could Achieng get surgical treatment but also language and speech therapy. Achieng's mother took her to Kenyatta National Hospital and the girl had her surgery under the Kenyan Chapter of Operation Smile, which is a Charitable Organisation. Achieng is now undergoing speech therapy. However, due to the delay in getting the surgery, Achieng cannot read the way children of her age do. Her classmates, who refer to her as "kibaby", often laugh at her. "Ki-" is a negative marker for an exceedingly big size and it carries a negative connotation. The label, though innocently used, means that Achieng' is a very big baby because she in not fluent in reading.


Speaking is the language skill most affected by language and speech disorders because we communicate orally more often than through reading or writing. Persons with speaking disorders result to using non-verbal communication where verbal communication would have been more appropriate.

Persons with speech disorders are thus very disadvantaged in every day communication. This in turn affects their socialization. The persons with language and speech disability are often recluses. They are either excluded by the general populace from socialization using language or they exclude themselves. What all this means is that the personal development of these individuals is often stunted and they are unable to achieve their goals.

Assessment and Intervention

The correlation or association of language and speech disorders with certain practices and beliefs displays much ignorance of the causes of these disorders. Practices and beliefs that display such ignorance should be done away with, for they interfere with assessment and intervention. However, people cannot operate in a vacuum, and so associations have to develop new adequate and effective structures and guidelines to replace the existing ones.

Our findings call for what Kuehn and Moller (2000) refer to as a "State-of-the-art activity." This is an activity which, according to them, demands "a look back, a look around, and more importantly, a look into the new millennium" (Kuehn and Moller 2000, 348.1) in relation to the development and progression of our knowledge base. There is need for strategies that will take into account the two approaches to management of language and speech disorders — physical management and behavioural management. The guidelines proposed in the next sub-section are thus drawn from the authors' experiences as therapists with the Kenyan Chapter of Operation Smile (2004 to date) and from researching on what has worked in other cultures. The guidelines take into account: gender preferences; adhering to culturally relevant communication patterns; use of culturally relevant materials during therapy sessions; and use of collaborative therapy sessions. These guidelines are mainly drawn from the Kenyan context, within which the authors have been working. They are also biased to the phonology of persons with language and speech disorders since that is our specialization.

Guidelines for Culturally Relevant Intervention

As Kuehn and Moller (2000) suggest, there should be some looking back that will enable the contextualization of the changes that we institute. There should also be some looking around. In a multi-cultural context, we need to look at what has worked in other cultures. There is also need to look into the new millennium. Whatever changes are instituted must be cognisant with the contemporary culture. From our findings we propose the following nine guidelines for intervention that is culturally relevant to the Kenyan context.

  1. Our findings indicate that gender preferences influence the intervention process. Statistics indicate that females are focused more on getting accepted by the community and adhering to the norms of the community than males (Operation Smile Inc. 2009). Females, therefore, go out of their way to seek treatment for cleft lips and palates and to improve their speech. The large numbers of females who turn up for post-surgery therapy attests this to gender differences as compared to males. The ratio is 1:2, yet the pre-surgery ratios are 50:50 (Operation Smile Inc. 2009). Findings also indicate that most male patients think that the corrective surgery will translate into correct language and speech, yet this is not the case. Such views need to be counteracted through the intervention process, during which the persons are presented with the right information that language and speech therapy is necessary. Males should be encouraged to attend the post-surgery therapy so that the language and speech correction complements the physical correction.
  2. Adhering to culturally relevant communication patterns creates trust and rapport between the Speech and Language Pathologists (SLPs) and the patients or clients. Women avoid admitting their speech and language challenges in public even during the screening. This is due to the shame and guilt associated with the language and speech disorders. We should try to alleviate this discomfort by using SLPs or interpreters from the same speech community as the individual with a disorder. We also do not ask direct questions — for instance, about pronunciation variations. We should use our phonological training to gauge the sounds the patients have problems with to avoid embarrassing them.
  3. Cultural communication norms are also to be observed in the post-surgery therapy. For instance, in the follow up therapy with Achieng', the father had to be present though it is the mother who explained the progress that their daughter had made. Achieng's father represented the family authority and we respected that throughout the sessions. He had to permit the mother to talk, though it was evident that she was the one who was more familiar with their daughter's speech and language progress.
  4. The age of the SLP needs to be taken into account in the assessment and intervention process because, culturally speaking, it can lead to a breakdown in communication (Ball and Bernhardt, 2008). For instance, in our assessment sessions we have noted that many of the old patients find it embarrassing and insulting to be asked to open their mouths wide or to repeat sounds after the SLP. Therefore, young therapists have to display expertise and authority, such as using their professional titles, which gets them respect even from the elderly. The young therapists also use culturally relevant codes to create rapport, for instance when greeting the elderly or calling them into the assessment room.
  5. There is also the selection of culturally sensitive materials and activities in follow up sessions after reconstructive surgery. For the school-age children, we use stuffed animals that are programmed with the sounds that the child has problems articulating. We also use a lot of role playing and games in the therapy sessions. For the adults we use cards with sounds written on them or tapes, and encourage them to practice on their own. Many of the adults do not want to practice articulation in the presence of the SLP. However, we have noted that they are willing to say the sounds that they have made progress on. We thus guide them along what they find easy to articulate.
  6. Collaborative therapy is also advocated by our findings. In therapy guidelines, the assessment information the SLP gathers is often viewed in conjunction with the results of investigations carried out by other professionals, such as psychologists and counsellors (Operation Smile 1999; Pena and Quinn, 2003; Bauer et al, 2009). The intervention process also incorporates "interested others," which includes teachers, parents, the extended family, and peers. The family unit, core and extended, is important in Kenya as in the rest of Africa. Disorders affect the family socially, psychologically, and financially in the pre- and post corrective stages. Intervention processes that protect the self esteem and the face of the family are more productive than those than do not do so. As SLPs, we thus consider the family perceptions of the individual's communication abilities and how they impact on the family. The family is involved in the therapy and we always ensure that they are present for the sessions and that they keep a record of the progress made by the individual with the disorder.
  7. Information about speech disorders should be presented in an understandable language to the person with the disorder, the family, and other professionals. The information should be accurate. Incorrect cultural associations should be reviewed and corrected. For instance, a person who stammers should not be blamed for the condition. He/she should also not be misinformed that she/he cannot be assisted. In our therapy we have been counselling those who have suffered because of their stammers and training them how to improve their speech through pacing utterances.
  8. Speech pathologists and other health care providers should understand the client's culture in order to offer effective assessment and treatment. Instead of dismissing cultural explanations as being wrong or inadequate, correct information should be provided. Persons with disorders should be given advice so that they can seek the appropriate physical or behavioural management. Pamphlets have been prepared that highlight the speech-language disorders that we have identified during the Operation Smile, Kenya Chapter Missions. Though we do not give therapy for all the disorders, we direct the persons to those who can assist them.
  9. Advocacy and sensitization forums that specifically address speech and language disorders could be organized by the Ministry of Health and other concerned organizations. Other disorders are often given prominence on Disability Day at the expense of language and speech disorders. The public should be made aware of the advantages of early recognition of children with possible speech disorders. Yoshinaga-Itano and Apuzzo (1995) emphasize the need for timely intervention. Most language and speech disorders can be alleviated considerably if management is provided in time — for example, cleft repair for individuals with cleft lip and palate should ideally take place before the person starts her/his speech therapy.


Our conclusion is that since communication is integral to all aspects of human development, the cultural beliefs of a community should not make it difficult for individuals with speech disorders to communicate. Individuals with speech disorders should continue to seek positive views as active individuals in a society to enable them overcome the cultural prejudices that have regarded them as helpless individuals who are to be pitied, feared, or ignored.

Though people are familiar with some speech disorders, the general knowledge concerning most disorders is limited. There is thus a growing need for public awareness of the difference between cultural beliefs and speech disorders. Parents have an important role in helping to monitor the health and language development of their children. If their children have any speech or language disorder, the information provided by the parents is crucial for an adequate assessment by a speech pathologist. Some parents and pathologists may include cultural beliefs and thus affect the assessment of the disorders. Therefore, an informed distinction should be made between a typical cultural belief and a speech disorder. The need for correct assessment and intervention in order to avoid errors in judgement cannot be overemphasised. Errors in judgement could lead to negative effects on the person's self-worth, language, and communication potential.

The training of the general public to enable them to understand what truly constitutes disorders would help them approach these disorders with an open mind. The informed would put aside the culture-based attitudes that do not necessarily explain or that often conceal the actual cause of the disorder. Knowledge would help in reducing the stigma attached to speech disorders. Negative perceptions and reactions to the disorders or to modes of treatment would then become part of the culture that we will look back to. These would belong to the past.

Works Cited

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