Morphosyntactic Deficits in Malayalam-Speaking

Morphosyntactic Deficits in Malayalam-Speaking Broca’s Aphasics Venkataraja Aithal U., M.Sc. Veena K. D., M.Sc. Associate Professor Department of Speech and Hearing, Manipal College of Allied Health Sciences, Manipal University, Manipal, India

Gilu James, MASLP Speech Language Pathologist Dubai

Rajashekhar B., Ph.D. Dean, Professor, and Head Department of Speech and Hearing, Manipal College of Allied Health Sciences, Manipal University, Manipal, India

Broca’s aphasia is the most classic form of nonfluent aphasia resulting in the reduction of linguistic proficiency termed as agrammatism. Syntactic

Asia Pacific Journal of Speech, Language, and Hearing Volume 12, Number 4, pp. 303–314 Copyright © 2009 Plural Publishing, Inc.

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deficit in Broca’s aphasics has been investigated in various languages. The present study attempted to investigate morphosyntactic deficits in Malayalam-speaking Broca’s aphasics. Eleven Broca’s aphasics with etiology of cerebrovascular accident served as subjects. Comprehension and expression of different morphosyntactic categories were investigated. Picture cards were used to elicit responses for syntactic comprehension and expression. A hierarchical order of difficulty in syntax evolved for both comprehension and expression. Future tense was the most difficult category to comprehend and participle construction and comparatives were the most difficult categories to express. A statistically significant difference existed between comprehension and expression performance in all the categories included excepting the present tense, past tense, and negatives. Findings of the morphosyntactic structures observed in Malayalamspeaking Broca’s aphasia are discussed. Key Words: Broca’s aphasia, agrammatism, morphosyntactic deficit, comprehension, expression

Introduction Syntax, a component of language, is the architecture of phrases, clauses, and sentences. The form or structure of a sentence is governed by the rules of the syntax. These rules specify word order, sentence organization and relationship between words, word classes, and other sentence elements. Neuroimaging studies support that Broca’s area is the site hosting the network for syntax, thought to be responsible for language planning, sequencing and production (Grodzinsky, 2000). Any large lesion in this area can produce a most classic form of nonfluent aphasia known as Broca’s aphasia. The main feature of Broca’s aphasia is the reduction of linguistic proficiency, particularly at the syntactic level, resulting in agrammatism (Pick, 1913). Agrammatism is a form of speech production, often associated with Broca’s aphasia, in which grammar appears relatively inaccessible. Several investigations of the language processing abilities of Broca’s aphasics have produced results that are incompatible with the classical view that Broca’s aphasia affects only the expressive aspects of language

(Damasio, 1992; Goodglass, Christiansen, & Gallagher, 1993; Grodzinsky, 1990, Zurif, 1995). Later, it was shown that Broca’s aphasics exhibit a comprehension disadvantage that is qualitatively distinct from the comprehension disorder suffered by Wernicke’s aphasics (Damasio & Damasio, 1992; Goodglass & Kaplan, 1983; Zurif, 1995). Attempts are ongoing to find out the syntactic expression deficits in this group of patients. The deficits are studied under various syntactic categories and also in different languages. Spontaneous speech in agrammatic patients traditionally has been characterized by lack of function words like auxiliaries, pronoun, predominant use of nonfunctional lexical categories such as nouns and verbs, systematic use of noun finite constructions like participles, lack of inflectional morphemes, telegraphic style, and overuse of stereotypes. Production of verbs has been shown to be more problematic than nouns in agrammatic aphasic individuals �� (Miceli, Silveri, Villa, & Caramazza, 1984; Saffran, Berndt, & Schwartz, 1989; Thompson, Shapiro, & Schendel, 1994; Zingeser & Berndt, 1990). Aphasics �� exhibit problems with use of negations; however, there is little difficulty in comprehending

Morphosyntactic Deficits in Malayalam-Speaking Broca’s Aphasics 305

negative markers with affirmative intent (Wilcox, Davis, & Leonard, 1978). Chengappa and Bhat (2000) studied syntactic deficits in Kannada-speaking aphasics in terms of comprehension and expression. They studied seven subjects (5 males and 2 females, of whom 5 were Broca’s apahsics, one each of anomic, and transcortical aphasic). They reported that Broca’s aphasics showed more errors in comprehension of syntactic structures. Errors were seen on morphophonemic structures, tenses, PNG markers, sentence types, case markers, conjuctions, comparitives, quotatives, conditional and participle clauses. Among the plural forms, usual plural form “galu” is correctly identified. But they were not able to comprehend the mass nouns and accepted the forms like “nirugalu” (waters) as correct. In tenses, future and past tenses were difficult to recognize. This is because generally irregular future tense markers are seen in Kannada, which are more difficult to access. In PNG markers, Broca’s aphasics had difficulty judging the agreement between person, number, and gender. They showed more problems in comprehending singular masculine markers. Causatives were more difficult to comprehend, for example, “maguvannu malagisu” (put the child to sleep). In sentence types, “yes-no” questions were comparatively more easy to comprehend than affirmative and negative sentence types. In predicates, pronominal constructions like “pustaka nannadu” (this book is mine) were more difficult to comprehend than adjectival constructions like “avara naji doddadu” (their dog is bigger). Quotatives and comparatives were more difficult than conjuctions. In conditional clauses, complex conditional clause and modals were difficult to comprehend. In participle clause, negative relative and relative participles were difficult to comprehend. It has been concluded that agrammatic listeners are unable to make full use of the function words present in a sentence, to enable comprehension. Broca’s aphasics violate the unity between noun and verb phrases. They are not able to utilize information provided by different

grammatical markers and use key words in a sentence to understand, which at times leads to the wrong interpretation. In spontaneous speech, Broca’s aphasics showed abundance of nouns in their utterances with reduction of other syntactic structures. In spite of reduced complexity, the authors also reported that use of intonation to express emotion was preserved in Broca’s aphasics. Analysis of correlation between syntactic comprehension and production revealed that Broca’s aphasics who produced syntactically complex utterances could better comprehend complex structures. Among two Kannada-speakers with agrammatism and matched controls, it was found that for the number of inflections produced to root words (correctly or incorrectly), the agrammatic patients had a lower inflection/root ratio for the nouns but not for the verbs, as compared to the controls. The verbs for all four participants showed approximately a 1:1 ratio of inflections: root. However, when examined for production of accurate inflections to root, the patterns for verbs and nouns were comparable for the agrammatic patients. As the number of inflections to root for nouns produced appeared low for the agrammatic versus the control participants, both with and without accuracy accounted for, it is evident that a large part of the error was omission or zero-marker substitution. For verbs, however, the inflections/root ratio was lower only when accuracy was accounted for, thus confirming that agrammatic Kannada-speaking patients are indeed able to take advantage of the optionality of the nominative case-marker and produce legal noun-roots with no apparent case-endings, albeit often in instances where nonnominative forms were required. In contrast, verbs’ obligatory affixation in Kannada restricts omission of inflections, leading these patients to produce nearly half of their multimorphemic verbs with inappropriate inflectional substitutions (Datta, Karthikeyan, Obler, Karanth, & Karpur, 2007). In other highly inflected languages such as Finnish (Niemi, Laine, & Hanninen, 1990) or Hindi (Bhatnagar, 1990), Menn and Obler


(1990a, 1990b) argued, unbound functors’ roles are served by obligatory inflections or bound functors. In agrammatism, they are retained, but the wrong one may be selected from the paradigm. Optional items, they hypothesized, moreover, generally tend to be omitted by agrammatics. Malayalam is an Indian language spoken by nearly 26 million people primarily in the state of Kerala (Geetha Kumari, 2002). It belongs to the Dravidian family of languages and is one of the four major languages (Kannada, Telugu, Malayalam, and Tamil) of this family with a rich literary tradition. This language follows the word order of Subject-Object-Verb (Mohanan, 1982). A very noticable feature of Dravidian syntax is that sentences very often end with a string of verbs which can be lengthened to any extent depending only on one’s ingenuity and patience. Only the last verb is finite, that is, marked for tense. Malayalam has no subject-verb agreement, but other Draviadian languages do. In these languages, only the last verb is marked for tense and agreement (Jayaseelan, 2004). Illa (No) in Malayalam would seem to be quite different from the corresponding affirmative sentences only by the presence of illa (No). In Kannada, it is the occurrence of the matrix gerund (nominalized clauses) or infinitive with illa that prompts the analysis of illa (No) as a finite element. In the corresponding Malayalam sentences of “avan varunn (u) illa” (He does not come) and “avan van-n(u) illa” (He has not come) there appears to be a similar need to say that illa is finite, as finiteness seems to reside in the tensed verbs. Furthermore, the main clause negation in Malayalam does not provide as salient an argument against tense as Kannada does: there are no matrix gerunds or infinitives. However, negation in nontensed complement clauses in Malayalam exhibits the same asymmetry as in Kannada: the negative element licensed here is not illa but the -a- infix that occurs in nonfinite forms. The -uka suffix “avan var-uka-(y)ee” (he need not come at all) is the bare infinitive. The -uvaan suffix of infinitives illustrated in “avan niintuvaan nooki” (he tried to swim) and “avan niint-aa-t-e irikk-uvaan nooki” (he tried not

to swim) corresponds to the dative-casemarked infinitive form of Kannada and the “for-to” infinitive of English. As in Kannada and English, the complement of the modal in Malayalam does not allow dative case marking (Amritavalli & Jayaseelan, 2005). In Hindi, an Indian national language and Malayalam declarative sentences show similar structure. With respect to interrogative sentences, yes/no questions in Malayalam the suffix-o: is suffixed to the finite verb form whereas in Hindi, the interrogative pronoun “kya” is used at the beginning or end of the sentence. Conjunctions are added at the beginning of clauses in Hindi, and compared to Hindi compound sentence patterning, are less in Malayalam. Compound sentences are formed by combining two or more main clauses by conjunctives or disjunctives or relative pronouns or relative adverbs. The conjunctive marker is “um” and in Hindi “r/va/tatha/evam;” of these, “r” is commonly used in Hindi. In Malayalam, conjoining the predicates of two sentences with identical subjects it is possible to delete the subject in the second sentence and to add “uka+yum” with each of the verbal bases. An action verb “cey” also occurs obligatory after the coordinated verbal predicate (Geetha Kumari, 2002). Considering these differences in various morphosyntactic structures among different Indian languages, it is essential to study such notions. The present study aims to explore the varying syntactic error patterns in Malayalam-speaking Broca’s aphasics. The objectives of the present study were to analyze the various morphosyntactic deficits in Malayalam speaking Broca’s aphasics with respect to comprehension and expression and to further explore the differences between them.

Methods Subjects Eleven native speakers of Malayalam in the age range of 25 to 55 years (Mean age of


40 years) participated in the study. All the subjects were right-handers having no language deficits premorbidly with a specific history suggestive of single left hemisphere cerebrovascular accident. Neurologic findings were indicative of cortical lesion in the left inferior frontal region. Subjects were diagnosed as Broca’s aphasia based on a test of Aphasia in Malayalam (Philip, 1992, adapted version of Western Aphasia Battery [WAB], Kertesz, 1972). Only subjects with fluency score of 4 in spontaneous speech were considered. They were mentally stable, well oriented, and having normal hearing and vision.

cues for the second time, the next item was presented. The clinician noted the verbatim of the responses of the client.

Scoring The responses collected from the subjects were then scored. A score of one for each correct response was given with or without cues. A score of zero was given for incorrect/no response.

Analysis Materials Used List of sentences and picture cards of simple black and white line drawings of different morphosyntactic structures with increasing grammatical relation were used for eliciting the responses (adapted from the Linguistic Profile Test in With a little bit of help. Early Language Training Manual by Karanth, Manjula, Geetha, & Prema, 1999). The different morphosyntactic structures included: plurals, tenses, comparatives, conjunctions, participle construction, verb transitives, verb intransitives, negatives, and case makers (accusative, dative, genitive, sociative, instrumental, and ablative). Fiftynine items were included in the test material for eliciting comprehension and expression responses.

Procedure Similar picture cards were used to elicit both comprehension and expression. To determine comprehension responses, picture cards depicting each of the morphosyntactic categories were shown to the subject one by one asking them to point to the appropriate picture. Similarly, verbal expression was elicited by asking the subject to describe the pictures shown. If the subject was unable to give the correct response, verbal cues were provided. In case of no response even after

The following morphosyntactic structures were analyzed viz: plurals, tenses, comparatives, conjunctions, participle construction, verb transitives, verb intransitives, negatives, and case makers (accusative, dative, genitive, sociative, instrumental, and ablative).

Statistical Analysis The collected data were subjected to statistical analysis. The percentages of correct responses were calculated for setting the hierarchy of most difficult to least difficult category for both comprehension and expression. A nonparametric test, Wilcoxon’s signed-rank test, using SPSS version 10 was used to find out the difference between the performance on comprehension and expression skills. Categories having “p” value less than 0.05 were considered as significant different. Based on the analysis, appropriate inferences were drawn.

Results Table 1 depicts the morphosyntactic categories in the hierarchical order from most difficult to least difficult in comprehension and expression tasks.


Table 1. Data Showing the Percentage Score for Different Morphosyntactic Categories in Comprehension and Expression

Category

Percentage of correct response in comprehension (%)

Category

Percentage of correct response in expression (%)

Future tense

66.66

Participle construction

3


78.7

Comparatives

3.03

Comparatives

87.8

Ablative

4.54

Conjunction

90.9

Conjunction

9.09

Past tense

90.9

Plurals

21.2

Present tense

90.9

Sociative

27.2

Sociative

95.4

Instrumental

27.2

Ablative

100

Future tense

33.3

Plurals

100

Accusatives

36.3

Instrumentals

100

Datives

50

Accusatives

100

Intransitives

54.5

Datives

100

Genitive

63.6

Intransitives

100

Past tense

75.7

Genitives

100

Transitives

78.7

Transitives

100

Present tense

93.9

Negatives

100

Negatives

Syntactic Comprehension Percentage of correct responses were calculated for comprehension tasks (see Table 1) based on which the hierarchical order for comprehension of morphosyntactic categories in the order of most difficult to least difficult was listed: that is, future tense, participle construction, comparatives, conjunction, present and past tense, sociative case markers, negatives, ablatives, instrumental, genitive, dative, accusative, intransitives, transitives, and plurals. It is evident from Table 1 that the most difficult category for all the subjects to comprehend was the future tense. However, most of the categories, namely: negatives, ablatives, instrumental, genitive, dative, accusative, intransitives,

100

transitives, and plurals were easier for the subjects. Although few of the subjects had difficulty with present and past tense, the future tense was the most difficult. Most of the subjects tended to select present tense (e.g., “kutti marathil keyarunnu” / “child is climbing the tree” instead of corresponding future tense (e.g., “kutti marathil kayaraan pogunnu” / “child will be climbing the tree”). Subjects had difficulty in comprehending participle constructions, comparatives, and conjunctions.

Syntactic Expression The percentage of correct responses for the expression tasks was calculated (see Ta-


ble 1) and a hierarchical order for the expression of different morphosyntactic structures from most difficult to least difficult category was listed, that is: participle construction, comparatives, ablatives, conjunction, plurals, sociative, instrumental, future tense, accusatives, datives, intransitives, genitives, past tense, transitives, present tense, and negatives. Scrutiny of the percentage value (%) in Table 1 indicates that participle construction (e.g., “kutti odunna thivandiyil ninnu thaale veenu” / “child fell down from the moving train” was the most difficult category. However, there was no difficulty observed for the negatives in expression. The subjects were using two different utterances representing subjects or objects used in the comparatives (e.g., “aankuttigal penkuttigalekaal vannamundu” / “boys are fatter than girls” was expressed as “aankuttigal vannamundu . . . penkuttigal illa”). Subjects were splitting the sentence into two simple sentences instead of adding conjunctions. (e.g., “meshapurath bukkum penayum undu” / “there is a book and pen on the table” was expressed as “mesham bukku undu . . . pena undu” / “table there is a book . . . there is a pen”). Under the category of plurals, subjects manifested difficulty but could indicate plurality by assigning numbers to the items presented. (e.g., “aankutti nilkunnu…aankuttigal nilkunnu” / “boy is standing . . . boys are standing” was expressed as “oru aankutti nilkunnu. . . randu aankutti nilkunnu” / “one boy standing . . . two boys standing”). Subjects showed difficulty in using future tenses. It was observed that the future tenses were substituted by present tense markers. (e.g “kutti marathil kayaraan pogunnu” / “child will be climbing the tree” was expressed as (“kutti marathil keyarunnu” / “child is climbing the tree”). Past tense was found to be slightly difficult as compared to present tense. Among the case markers, the most difficult was ablative. Most of the subjects expressed the sentences with the usage of subject-verb form omitting the object portion where the case marker is to be attached. (e.g., “aval kinattil ninnu welam korunnu” / “she taking

water from the well” was expressed as “aval kinar welam korunnu” / “she taking water well”). Even with the object cue provided by the experimenter, subjects found it difficult to attach the corresponding case marker. The order of difficulty among the case markers from most to least difficult was ablative followed by sociative, instrumental, accusative, dative and genitive. Among the verbs, the transitive verbs were slightly easier to produce for the Broca’s aphasics compared to the intransitive verbs. Negatives were easy to produce for all the subjects in the present study.

Difference Between Comprehension and Expression To obtain the difference between the performance in comprehension and expression among each category, Wilcoxon’s signed-rank test was applied using the SPSS version 10. The “p” values for each of the categories are shown in Table 2. There was no statistically significant difference between the comprehension and expression performance in the categories of present tense, past tense, and negatives. A statistically significant difference was seen for the following categories of: plurals, future tense, conjunctions, participle constructions, transitive and intransitive verbs, accusatives, datives, genitives, sociatives, instrumentals, ablatives, and comparatives.

Discussion It was evident from the present study that the most difficult category for all the subjects to comprehend was the future tense. The deficit was relatively marked on expression in comparison to comprehension although this falls in the most difficult category in the hierarchy. Some comprehension deficit was observed in participle construction, comparatives, conjunctions, present and past tense, and sociative case markers. This is in con-


Table 2. p Category

Value

in

Each

Plural

*0.003

Present

0.15

Past

0.194

Future

*0.02

Conjunction

*0.003


*0.003

Transitive verb

*0.038

Intransitive verb

*0.01

Accusative case marker

*0.006

Dative case marker

*0.023

Genitive case marker

*0.011

Sociative case marker

*0.008

Instrumental case marker

*0.005

Ablative case marker

*0.001

Comparative

*0.003

Negative

1

*significant at 0.05 level.

sonance with the study of Chengapppa and Bhat (2000) where they reported that future tenses and past tenses were difficult to recognize. This is so as generally irregular future tense markers are seen in the Kannada language, which are more difficult to access. It was also observed from the present study that the past tense was found to be slightly difficult compared to the present tense in expression. This order of difficulty in tense is reported in the literature by Slobin (1991). Tenses as a whole are less affected, probably because of their lower level of representation in the syntactic tree (Pollock, 1989). In this context, it is also appropriate to recall the Tree Pruning Hypothesis (Friedman, 1994) which states that the tense is more severely impaired than agreement in the production of agrammatic speakers (DeVilliers, 1978; Goodglass & Berko, 1960; Nadeu &

Rothi, 1992). However, this hypothesis may not be strictly in agreement among the various tense markers, especially in the present study. Negatives, intransitives, transitives, datives, ablative, genetives, accusatives, and plurals were easier for all the subjects to comprehend in the present study. This finding is in agreement with the reports by Hagiwara (1995) on comprehension of negatives, Berndt, Michum, Maringes, and Sandson (1997), and Kim and Thompson (2000) on verb retrieval/comprehension in aphasics. Caramazza and Zurif (1976) suggested that agrammatic use a chemistic procedure of deciding on the grounds of semantic plausibility how the context words in the sentences they hear are related, but have no knowledge of the syntactic structure. Syntactic expression in the present study reveals that all the morphosyntactic categories considered are affected except negatives. The utterances were characterized by content words and lacking complete sentential construction. As reported in the literature (Chengappa & Bhat 2000; Meyerson & Goodglass, 1972; Tesak & Hummer, 1994), nouns are abundant in Broca’s aphasic’s speech whereas there is a dearth of other structures like verbs, prepositions, auxiliaries, and so forth. This may be attributed to Broca’s aphasic’s lack of access to such syntactic structures. Another reason for less complex utterances could be the compensation for the motoric disability. It would be easier to use only content words to convey the message rather than have function words in the sentence. This has been earlier referred to as “law of economy” (Meyerson & Goodglass, 1972). Mihailesciu, Weigl, and Kreindler (1972) and Slobin (1991) have reported similar findings. Broca’s aphasics rarely produce utterances of more than one clause. Therefore, interclausal forms like conjunction hardly ever occur in their speech (Slobin, 1991). Difficulty in the production of case markers reflected in the form of errors characterized by omissions with no evidences of substitution. Grodzinsky (1984) stated that


Broca’s aphasics either omit or substitute inflectional elements, but only if the morphology of the language permits such omissions as the patients observe rules of lexical wellformedness and never produce nonwords or word parts. In both verbal and nominal inflected elements, omissions of inflectional morphemes are observed if a bare stem is a real or licit word; otherwise, in words where omission of inflection is illicit, this may result in nonwords leading to substitution errors. It may be hypothesized that the omission of case markers in the present study could be due to the fact that in the Malayalam language, omission of case markers will produce real words. Among the verbs, the present study revealed that the transitive verbs were slightly easier to produce for the Broca’s aphasics compared to the intransitive verbs. This correlates with the literature studies, namely for English (Jonkers, 2000; Thompson, Lange, Schneider, & Shapiro, 1997), German (Kauschke & De Bleser, 2000), and Italian (Luzzatti, Toraldo, & Guasti, 2001). It has been stated that the syntactic factor-transitivity plays a role in verb retrieval. Several studies have examined the influence of syntactic, argument structure properties of verbs, and others have examined semantic features (Breedin, Saffran, & Schwartz, 1998; Kim & Thompson, 2000; Thompson et al., 1997). Results have shown that both syntactic and semantic attributes of verbs influence their production in aphasia. However, this has not been the scope of the present study and hence may be considered in future studies on the Malayalam language. Negatives were easy for all the subjects to comprehend and produce in the present study as reported in the literature (Slobin, 1991), which may be attributed to the fact that negations are acquired earlier during the development of language. Jakobson (1941) proposed a regression hypothesis where he reported that the order in which a language is lost is the reverse of that in which it was first acquired in childhood. As negation is acquired earlier, it was preserved.

It was found in the present study that there was a similar performance in the comprehension and expression of present tense, past tense, and negatives. Differences in the performance were observed for the other morphosyntactic categories, namely: plurals, future tenses, conjunctions, participle constructions, transitive and intransitive verbs, accusatives, datives, genitives, sociatives, instrumentals, ablatives, and comparatives. Druks and Marshall (1991), Kolk, Van Grusven, and Keyser (1985), and Miceli, Mazzucchi, Mann, and Goodglass (1983), reported describing the patient’s being agrammatic in production, but with unimpaired comprehension. Chengappa and Bhatt (2000) reported that analysis of correlation between syntactic comprehension and production revealed that Broca’s aphasics who produced syntactically complex utterances could comprehend complex structures better. However, mixed results were obtained from the present study which might be explained in terms of the existing dissociation between comprehension and expression of the morphosyntactic categories except for present and past tense. Therefore, it implied that the context plays a major role in understanding the sentence rather than knowledge of grammatical rules of that language. However, the knowledge of grammatical structures is essential for the production of grammatically correct sentences.

Conclusion Morphosyntactic structures are differentially affected in terms of comprehension and production in Malayalam-speaking Broca’s aphasics. This study provides a insight into the hierarchy and patterns of morphosyntactic deficits in Malayalam-speaking Broca’s aphasics. Evidence of mild comprehension deficits in morphosyntactic structures are not uncommon in Malayalam-speaking Broca’s aphasics. Most often, predominant use of content words with omission of function words is noticed in Malayalam-speak-


ing Broca’s aphasics. Present tense and past tense were equally affected unlike other morphosyntactic structures in comprehension and expression. However, no specific deficits in negatives were observed. The findings of this study help speech-language pathologists in understanding the pattern of morphosyntactic deficits in Malayalam Broca’s aphasics. Furthermore, it may assist in devising a tool for detailed syntax assessment and in enabling an appropriate intervention plan. The limitation of the study is probably its small sample size. Future studies with increased sample size could be helpful in drawing strong inferences regarding complex morphosyntactic categories in Malayalam-speaking individuals with Broca’s aphasia. Future studies in other Indian languages would ultimately add to our understanding of crosslinguistic variation in morphosyntactic deficts in agrammatics. Acknowledgments. The authors would like to acknowledge the subjects who participated in the study. We also thank Dr. Sreekumaran Nair, Professor and Head, Department of Biostatistics, Manipal University, for his guidance in data analysis. Address Correspondence to: Venkataraja Aithal U, Associate Professor, Department of Speech and Hearing, Manipal College of Allied Health Sciences, Manipal, Karnataka, India, 576104 ; Tel: 0820-2922748/ +91-9448824363; Fax: +91-820-2571915; E-mail: [email protected]

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