Speech Pathology and Audiology Commons^™

Instrumental Assessment Of Aero-Resistive Expiratory Muscle Strength Rehabilitation Devices, Angela M. Dietsch, Rahul Krishnamurthy, Kelsey Young, Steven M. Barlow

Department of Special Education and Communication Disorders: Faculty Publications

Purpose

Expiratory muscle strength training (EMST) is increasingly being used to treat voice, cough, and swallowing deficits in a wide range of conditions. However, a multitude of aero-resistive EMST models are commercially available, and the ab-sence of side-by-side comparative data interferes with clinicians’ ability to assess which model is best suited to a particular client’s needs. The primary aim of this research was to test and compare the pressure and flow parameters of six currently available EMST models to help inform clinical decision making.

Method

We identified and tested five devices of each of six different EMST models to generate …

Services Provided To Aging Individuals With Intellectual Disabilities: Survey Of Speech Language Pathologists, Claire H. Gatewood

College of Education and Human Sciences: Dissertations, Theses, and Student Research

Purpose: The present study explored current speech-language pathology service provision for aging individuals with intellectual disabilities in the United States, including areas and domains of services, factors restricting service provision, and reported knowledge and confidence of individuals within the field of speech-language pathology in providing services, to identify possible gaps of service and needed improvement.

Methods: Participants (n = 272) from across the United States completed an online survey to gather descriptive information about current speech-language pathology service provision for aging individuals with intellectual disabilities. Participants were recruited through state speech-language hearing associations and universities with speech-language pathology clinics …

Revisiting The Rainbow: Culturally Responsive Updates To A Standard Clinical Resource, Angela M. Dietsch, Richard Mocarski, Debra A. Hope, Nathan Woodruff, Miechelle Mckelvey

Department of Special Education and Communication Disorders: Faculty Publications

Purpose

Cultural responsivity is essential for efficacious and affirming clinical relationships. This may be especially important with historically marginalized clients, such as transgender and gender-diverse (TGD) people seeking behaviorally based affirming communication services. We recommend modifications to standard tools for diagnostics and training that otherwise might undermine our efforts to create an inclusive and affirming environment.

Method

Modifications to the Rainbow Passage, a standardized paragraph utilized for eliciting speech samples in clinical settings, focused on nongendered terminology and the elimination of content with religious connotations.

Results

The recommended edits to the Rainbow Passage maintain similar length, cadence, and phonetic balance …

Empower: An Adaptable Writing Intervention, Carly Dinnes

The Nebraska Educator: A Student-Led Journal

EmPOWER is a six-stage writing intervention designed by speech-language pathologists to improve the expository writings of school-aged children with language learning and executive function disabilities. The intervention uses scaffolded instruction to transform struggling students into independent and self-regulating writers by training the students to use a variety of supports (e.g., graphic organizers, checklists) and strategies (e.g., referring back to the writing prompt) throughout the writing process. Many key features of the EmPOWER approach to writing instruction directly support components described in cognitive models of writing, which indicates that EmPOWER is a theory-guided writing intervention that may benefit a wide range …

Taste Manipulation And Swallowing Mechanics In Trauma-Related Sensory-Based Dysphagia, Angela M. Dietsch, H. Duncan Dorris, William Pearson, Katie E. Dietrich-Burns, Nancy Pearl Solomon

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: This study explored the effects of highconcentration taste manipulation trials on swallow function in persons with sensory-based dysphagia.

Method: Dysphagia researchers partnered with clinical providers to prospectively identify traumatically injured U.S. military service members (N = 18) with sensorybased dysphagia as evidenced by delayed initiation and/or decreased awareness of residue/penetration/ aspiration. Under videofluoroscopy, participants swallowed trials of 3 custom-mixed taste stimuli: unflavored (40% weight/volume [wt/vol] barium sulfate in distilled water), sour (2.7%wt/vol citric acid in 40% wt/vol barium suspension), and sweet–sour (1.11% wt/vol citric acid plus 8% wt/vol sucrose in 40% wt/vol barium suspension). Trials were analyzed and compared …

Motor-Induced Suppression Of The N100 Event-Related Potential During Motor Imagery Control Of A Speech Synthesizer Brain–Computer Interface, Jonathan S. Brumberg, Kevin M. Pitt

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: Speech motor control relies on neural processes for generating sensory expectations using an efference copy mechanism to maintain accurate productions. The N100 auditory event-related potential (ERP) has been identified as a possible neural marker of the efference copy with a reduced amplitude during active listening while speaking when compared to passive listening. This study investigates N100 suppression while controlling a motor imagery speech synthesizer brain–computer interface (BCI) with instantaneous auditory feedback to determine whether similar mechanisms are used for monitoring BCI-based speech output that may both support BCI learning through existing speech motor networks and be used as a …

Examining Sensory Ability, Feature Matching And Assessment-Based Adaptation For A Brain–Computer Interface Using The Steady-State Visually Evoked Potential, Jonathan S. Brumberg, Anh Nguyen, Kevin M. Pitt, Sean D. Lorenz

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: We investigated how overt visual attention and oculomotor control influence successful use of a visual feedback brain-computer interface (BCI) for accessing augmentative and alternative communication (AAC) devices in a heterogeneous population of individuals with profound neuromotor impairments. BCIs are often tested within a single patient population limiting generalization of results. This study focuses on examining individual sensory abilities with an eye toward possible interface adaptations to improve device performance.

Methods: Five individuals with a range of neuromotor disorders participated in four-choice BCI control task involving the steady state visually evoked potential. The BCI graphical interface was designed to simulate …

Early Uneven Ear Input Induces Long-Lasting Differences In Left-Right Motor Function, Michelle W. Antoine, Xiaoxia Zhu, Marianne Dieterich, Thomas Brandt, Sarath Vijayakumar, Nicholas Mckeehan, Joseph C. Arezzo, R. Suzanne Zukin, David A. Borkholder, Sherri M. Jones, Robert D. Frisina, Jean M. Hébert

Department of Special Education and Communication Disorders: Faculty Publications

How asymmetries in motor behavior become established normally or atypically in mammals remains unclear. An established model for motor asymmetry that is conserved across mammals can be obtained by experimentally inducing asymmetric striatal dopamine activity. However, the factors that can cause motor asymmetries in the absence of experimental manipulations to the brain remain unknown. Here, we show that mice with inner ear dysfunction display a robust left or right rotational preference, and this motor preference reflects an atypical asymmetry in cortico-striatal neurotransmission. By unilaterally targeting striatal activity with an antagonist of extracellular signal-regulated kinase (ERK), a downstream integrator of striatal …

Saliva Production And Enjoyment Of Real-Food Flavors In People With And Without Dysphagia And/Or Xerostomia, Angela M. Dietsch, Cathy A. Pelletier, Nancy Pearl Solomon

Department of Special Education and Communication Disorders: Faculty Publications

Non-food gustatory stimulation has multiple potential therapeutic benefits for people with dysphagia and xerostomia. This study examined palatability and saliva flow associated with dissolvable flavored films. Taste strips with real-food flavors dissolved on the tongues of 21 persons with dysphagia and/or xerostomia and 21 healthy age- and sex-matched adults while sublingual gauze pads absorbed saliva over randomized 3-min trials. Participants rated taste enjoyment for each trial on a hedonic general labeled magnitude scale. Flavored strips elicited more saliva than baseline for both groups, and production was higher for controls than patients (M = 2.386 and 1.091 g, respectively; p = …

My Client Knows That He’S About To Stutter: How Can We Address Stuttering Anticipation During Therapy With Young People Who Stutter?, Eric S. Jackson, Hope Gerlach, Naomi H. Rodgers, Patricia M. Zebrowski

Department of Special Education and Communication Disorders: Faculty Publications

Stuttering anticipation is endorsed by many people who stutter as a core aspect of the stuttering experience. Anticipation is primarily a covert phenomenon and people who stutter respond to anticipation in a variety of ways. At the same time as anticipation occurs and develops internally, for many individuals the “knowing” or “feeling” that they are about to stutter is a primary contributor to the chronicity of the disorder. In this article, we offer a roadmap for both understanding the phenomenon of anticipation and its relevance to stuttering development. We introduce the Stuttering Anticipation Scale (SAS)—a 25-item clinical tool that can …

A Rapid, Handheld Device To Assess Respiratory Resistance: Clinical And Normative Evidence, Aaron B. Holley, Wesley D. Boose, Michael Perkins, Karen L. Sheikh, Nancy P. Solomon, Angela M. Dietsch, Jafar Vossoughi, Arthur T. Johnson, Jacob F. Collen

Department of Special Education and Communication Disorders: Faculty Publications

Introduction: Following reports of respiratory symptoms among service members returning from deployment to South West Asia (SWA), an expert panel recommended pre-deployment spirometry be used to assess disease burden. Unfortunately, testing with spirometry is high cost and time-consuming. The airflow perturbation device (APD) is a handheld monitor that rapidly measures respiratory resistance (APD-R_r) and has promising but limited clinical data. Its speed and portability make it ideally suited for large volume pre-deployment screening. We conducted a pilot study to assess APD performance characteristics and develop normative values. Materials and Methods: We prospectively enrolled subjects and derived reference equations …

A Preliminary Study Of A Spanish Graphic Novella Targeting Hearing Loss Prevention, Mark Guiberson, Emily Wakefield

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: This preliminary study developed a digital graphic novella targeting hearing protection beliefs of Spanish-speaking agricultural workers. Researchers used pretest–posttest interview surveys to establish if the novella had an immediate influence on the participants’ beliefs about noise-induced hearing loss and usage of hearing protection devices.

Method: Researchers developed a digital graphic novella directed to increase knowledge about noise-induced hearing loss and increase the proper use of hearing protection devices. The novella was tailored to meet the specific linguistic and literacy needs of Spanish-speaking agricultural workers. Thirty-one Spanish-speaking farmworkers of Mexican nationality participated. This study included an interview survey with specific …

Swallowing Mechanics Associated With Artificial Airways, Bolus Properties, And Penetration–Aspiration Status In Trauma Patients, Angela M. Dietsch, Christopher B. Rowley, Nancy Pearl Solomon, William G. Pearson Jr.

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: Artificial airway procedures such as intubation and tracheotomy are common in the treatment of traumatic injuries, and bolus modifications may be implemented to help manage swallowing disorders. This study assessed artificial airway status, bolus properties (volume and viscosity), and the occurrence of laryngeal penetration and/or aspiration in relation to mechanical features of swallowing.

Method: Coordinates of anatomical landmarks were extracted at minimum and maximum hyolaryngeal excursion from 228 videofluoroscopic swallowing studies representing 69 traumatically injured U.S. military service members with dysphagia. Morphometric canonical variate and regression analyses examined associations between swallowing mechanics and bolus properties based on artificial airway …

Assessment With Children Who Need Augmentative And Alternative Communication (Aac): Clinical Decisions Of Aac Specialists., Shelley Lund, Quach Wendy, Kristy S.E. Weissling, Miechelle L. Mckelvey, Aimee R. Dietz

Department of Special Education and Communication Disorders: Faculty Publications

Purpose The purpose of this study was to explore how speech-language pathologists (SLPs) who are augmentative and alternative communication (AAC) specialists approach the assessment process for 2 case studies, 1 child with cerebral palsy and 1 with autism spectrum disorder. The aim of the study was to answer the following questions: (a) How do clinicians with expertise approach the AAC assessment process for children with developmental disabilities? (b) Can any initial hypothesis be drawn about how SLPs approach the assessment of children with motor versus social interactive deficits?

Method This study used a phenomenological qualitative design. The researchers conducted 2 …

Dysphagia Management And Research In An Acute-Care Military Treatment Facility: The Role Of Applied Informatics, Nancy Pearl Solomon, Angela M. Dietsch, Katie E. Dietrich-Burns, Edda L. Styrmisdottir, Christopher S. Armao

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: This report describes the development and preliminary analysis of a database for traumatically injured military service members with dysphagia. Methods: A multidimensional database was developed to capture clinical variables related to swallowing. Data were derived from clinical records and instrumental swallow studies, and ranged from demographics, injury characteristics, swallowing biomechanics, medications, and standardized tools (e.g.. Glasgow Coma Scale, Penetration-Aspiration Scale). Bayesian Belief Network modeling was used to analyze the data at intermediate points, guide data collection, and predict outcomes. Predictive models were validated with independent data via receiver operating characteristic curves. Results: The first iteration of the model (n …

Differential Effects Of Cdh23753a On Auditory And Vestibular Functional Aging In C57bl/6j Mice, Bruce E. Mock, Sarath Vijayakumar, Jessica Pierce, Timothy A. Jones, Sherri M. Jones

Department of Special Education and Communication Disorders: Faculty Publications

The C57BL/6J (B6) mouse strain carries a cadherin 23 mutation (Cdh23^753A, also known as Ahl), which affects inner ear structures and results in age-related hearing loss. The B6.CAST strain harbors the wild type Cdh23 gene, and hence, the influence of Ahl is absent. The purpose of the present study was to characterize the effect of age and gender on gravity receptor function in B6 and B6.CAST strains and to compare functional aging between auditory and vestibular modalities. Auditory sensitivity declined at significantly faster rates than gravity receptor sensitivity for both strains. Indeed, vestibular functional aging was …

Using Visual Scene Displays As Communication Support Options For People With Chronic, Severe Aphasia: A Summary Of Aac Research And Future Research Directions, David R. Beukelman, Karen Hux, Aimee R. Dietz, Miechelle L. Mckelvey, Kristy S.E. Weissling

Department of Special Education and Communication Disorders: Faculty Publications

Research about the effectiveness of communicative supports and advances in photographic technology has prompted changes in the way speech-language pathologists design and implement interventions for people with aphasia. The purpose of this paper is to describe the use of photographic images as a basis for developing communication supports for people with chronic aphasia secondary to sudden-onset events due to cerebrovascular accidents (strokes). Topics include the evolution of AAC-based supports as they relate to people with aphasia, the development and key features of visual scene displays (VSDs), and future directions concerning the incorporation of photographs into communication supports for people with …

The Impact Of Interface Design During An Initial High-Technology Aac Experience: A Collective Case Study Of People With Aphasia, Aimee R. Dietz, Kristy S.E. Weissling, Julie Griffith, Miechelle L. Mckelvey, Devan Macke

Department of Special Education and Communication Disorders: Faculty Publications

The purpose of this collective case study was to describe the communication behaviors of five people with chronic aphasia when they retold personal narratives to an unfamiliar communication partner using four variants of a visual scene display (VSD) interface. The results revealed that spoken language comprised roughly 70% of expressive modality units; variable patterns of use for other modalities emerged. Although inconsistent across participants, several people with aphasia experienced no trouble sources during the retells using VSDs with personally relevant photographs and text boxes. Overall, participants perceived the personally relevant photographs and the text as helpful during the retells. These …

Supporting Narrative Retells For People With Aphasia Using Augmentative And Alternative Communication: Photographs Or Line Drawings? Text Or No Text?, Julie Griffith, Aimee R. Dietz, Kristy S.E. Weissling

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: The purpose of this study was to examine how the interface design of an augmentative and alternative communication (AAC) device influences the communication behaviors of people with aphasia during a narrative retell task.

Method: A case-series design was used. Four narratives were created on an AAC device with combinations of personally relevant (PR) photographs, line drawings (LDs), and text for each participant. The narrative retells were analyzed to describe the expressive modality units (EMUs) used, trouble sources experienced, and whether trouble sources were repaired. The researchers also explored the participants’ perceived helpfulness of the interface features.

Results: The participants …

Treating Myofunctional Disorders: A Multiple-Baseline Study Of A New Treatment Using Electropalatography, Alana Mantie-Kozlowski, Kevin M. Pitt

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: This study assessed the benefit of using electropalatography (EPG) in treatment aimed at habilitating individuals with nonspeech orofacial myofunctional disorders (NSOMD).

Method: The study used a multiple-baseline design across 3 female participants who were referred for an evaluation and possible treatment of their NSOMD. Treatment sessions were 30 min and provided twice weekly. Participant 1 received 8 treatments, Participant 2 received 6 treatments, and Participant 3 received 4 treatments. The patterns of sensor activation produced when participants’ tongues made contact with the electropalate during saliva swallows were compared with the patterns of age-matched peers. Individualized goals were developed on …

Personalizing Aac For People With Aphasia: The Role Of Text And Pictures, Aimee R. Dietz, Kristy S.E. Weissling, Julie Griffith, Miechelle L. Mckelvey

Department of Special Education and Communication Disorders: Faculty Publications

Over time, and with intensive instruction, people with aphasia (PWAs) can learn to use grid-based, categorically organized, high-technology AAC layouts during structured tasks (e.g., Hough & Johnson, 2009). In an effort to reduce the training intensity required to teach PWAs to use AAC; researchers developed visual scene displays (VSDs), designed to complement the residual cognitive and linguistic abilities of PWAs by tapping their intact episodic memory. VSD interfaces incorporate personally relevant (PR) photos, text, and speech output (Dietz, McKelvey, & Beukelman, 2006; Weissling & Beukelman, 2006). VSDs appear to facilitate improved communication success (e.g., McKelvey, Dietz, Hux, Weissling, & Beukelman, …

There Is A Continued Need For Empirical Data Supporting The Treatment Of People With Aphasia In The Acute Care Setting Including The Use Of Modified Melodic Intonation Therapy, Miechelle L. Mckelvey, Kristy S.E. Weissling

Department of Special Education and Communication Disorders: Faculty Publications

Abstract from & commentary on: Conkly, D., Novac, E., Boissy, A. Bethoux, F., & Chemali, K. (2012). The effects of modified melodic intonation therapy on nonfluent aphasia: A pilot study. Journal of Speech, Language, and Hearing Research, 55, 1462–1471.

Q: What are the immediate effects of Modified Melodic Intonation Therapy (MMIT) on the modified repetition and responsive subtests of the Western Aphasia Battery (WAB) in stroke patients with Broca’s aphasia?

While this study had several limitations, the basic premises—the exploration of the effectiveness of changes to traditional MIT and the exploration of treatment in very acute stages—were valuable. Further systematic …

Supporting Narrative Retells For People With Aphasia Using Aac: Photographs Or Line Drawings? Text Or No Text?, Julie Griffith, Aimee R. Dietz, Kristy S.E. Weissling

Department of Special Education and Communication Disorders: Faculty Publications

People with aphasia (PWAs) have demonstrated the ability to learn augmentative and alternative communication (AAC) devices that employ traditional grid layouts to enhance their communication; however, the process is typically lengthy and yields limited generalization (Fox & Fried-Oken, 2001; Koul & Harding, 1998). In response, researchers have begun to investigate the use of visual scene displays (VSDs) to support the communication interactions of PWAs by capitalizing on their relatively intact episodic memory (Beukelman, Dietz, McKelvey, Hux, & Weissling, in press; Dietz, Beukelman, & McKelvey, 2006a; Dietz, McKelvey, Beukelman, Weissling, & Hux, 2006b; McKelvey, Dietz, Hux, Weissling, & Beukelman, 2007). High-technology …

Electropalatography As An Adjunct To Nonspeech Orofacial Myofunctional Disorder Assessments: A Feasibility Study, Alana Mantie-Kozlowski, Kevin M. Pitt

Department of Special Education and Communication Disorders: Faculty Publications

The purpose of this study was to determine if electropalatography (EPG) would be a useful adjunct and feasible option for those conducting clinical assessments of individuals with suspected nonspeech orofacial myofunctional disorders (NSOMD). Three females (two adults, one child) were referred by their orthodontist for assessment of suspected NSOMD. Three adults and one child without NSOMD were recruited for the purpose of evaluating methodological construct, and to provide comparisons for participants with NSOMD. Using EPG, lingual-palatal timing and contact patterns of 105 saliva swallows (45 with NSOMD, 60 without NSOMD) were analyzed by compartmentalizing the sensor display and tracking the …

Spatiotemporal Coupling Of The Tongue In Amyotrophic Lateral Sclerosis, Mili S. Kuruvilla, Jordan R. Green, Yana Yunusova, Kathy Hanford

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: The primary aim of the investigation was to identify deficits in spatiotemporal coupling between tongue regions in amyotrophic lateral sclerosis (ALS). The relations between disease-related changes in tongue movement patterns and speech intelligibility were also determined.

Methods: The authors recorded word productions from 11 individuals with ALS with mild, moderate, and severe dysarthria using an x-ray microbeam during word productions. A coupling index based on sliding window covariance was used to determine disease-related changes in the coupling between the tongue regions across each word.

Results: The results indicated decreased spatiotemporal coupling of mid-posterior tongue regions and reduced tongue speed …

Endoscopic And Stroboscopic Presentation Of The Larynx In Male-To-Female Transsexual Persons, Derek Palmer, Angela M. Dietsch, Jeff Searl

Department of Special Education and Communication Disorders: Faculty Publications

Background. Male-to-female transsexual (MFT) persons often attempt to produce a female-sounding voice as part of the transition process. Endoscopic and stroboscopic data about how they accomplish this with an anatomically male larynx are lacking.

Objectives. To describe vocal fold activity in MFT persons producing their feminine voice and identify signs of vocal misuse or hyperfunction in MFT speakers, if any.

Study Design. Prospective, nonrandomized, descriptive study of a convenience sample of MFT persons.

Methods. All MFT persons had endoscopic and stroboscopic procedures completed. Images were rated on a range of parameters by two experienced voice therapists to derive the descriptions. …

Augmented Input: The Effect Of Visuographic Supports On The Auditory Comprehension Of People With Chronic Aphasia, Sarah E. Wallace, Aimee R. Dietz, Karen Hux, Kristy S.E. Weissling

Department of Special Education and Communication Disorders: Faculty Publications

Background: Augmented input (AI), or the use of visuographic images and linguistic supports, is a strategy for facilitating the auditory comprehension of people with chronic aphasia. To date, researchers have not systematically evaluated the effects of various types of AI strategies on auditory comprehension.

Aims: The purpose of the study was to perform an initial evaluation of the changes in auditory comprehension accuracy experienced by people with aphasia when they received one type of AI. Specifically, the authors examined the effect four types of non-personalized visuographic image conditions on the comprehension of people with aphasia when listening to narratives.

Methods …

Feasibility Of Group Voice Therapy For Individuals With Parkinson’S Disease, Jeff Searl, Kristel Wilson, Karen Haring, Angela M. Dietsch, Kelly E. Lyons, Rajesh Pahwa

Department of Special Education and Communication Disorders: Faculty Publications

Purpose: The primary purpose was to demonstrate the feasibility of executing treatment tasks focused on increasing loudness in a group format for individuals with Parkinson’s disease (PD). A second purpose was to report preliminary pre-to-post treatment outcomes for individuals with PD immediately after they complete the group program. Methods: The group intervention is described. Fifteen adults with PD who participated in the group and three clinicians leading the group provided feedback about the execution of the intervention. The participants also provided voice samples and self-ratings of voice handicap once before completing the 8-week voice group and once immediately after completing …

Age Effect On The Gaze Stabilization Test, Julie A. Honaker

Department of Special Education and Communication Disorders: Faculty Publications

Impairments of the vestibular-ocular reflex (VOR) lead to a decline in visual acuity during head movements. Dynamic visual acuity (DVA) testing is a sensitive assessment tool for detecting VOR impairments. DVA evaluates accuracy of visual acuity during fixed velocity head movements. In contrast, the Gaze Stabilization test (GST) is a new functional evaluation of the VOR that identifies a person’s maximum head velocity (in degrees per second) a person can maintain with stable vision of a target (i.e. optotype). The objective of this study was to evaluate the effect of age on the GST in participants without vestibular disease. The …

Chronic Subjective Dizziness (Csd) Vs. Conversion Disorder: Discussion Of Clinical Findings And Rehabilitation., Julie A. Honaker, Jane M. Gilbert, Jeffrey P. Staab

Department of Special Education and Communication Disorders: Faculty Publications

PURPOSE: Audiologists frequently encounter patients who complain of chronic dizziness or imbalance, in the absence of active vestibular or neurological deficits. Knowledge about conditions that cause this clinical presentation will allow audiologists to make important contributions to accurate diagnosis and effective management of these patients. This article reviews two such conditions, chronic subjective dizziness (CSD) and conversion disorder. METHOD: A case of CSD and another of conversion disorder are presented with a literature review of their clinical presentations, key diagnostic features, and treatment strategies. The role of the audiologist in assessing patients with these conditions and facilitating appropriate treatment referrals …