Strategic Plan National…

                                       Strategic Plan
       National Institute on Deafness and Other Communication Disorders (NIDCD)
                                       FY 2006-2008

                                          OVERVIEW

We depend on our ability to communicate effectively to function in our modern society. Yet,
approximately one of every six Americans experiences some form of communication disorder,
which, for the purposes of the National Institute on Deafness and Other Communication
Disorders (NIDCD) includes disorders that affect hearing, balance, smell, taste, voice, speech, or
language. While science and technology have increased our capacity and need for
communication, many aspects of contemporary life remain profoundly difficult for individuals
with communication disorders. These disorders often compromise social, recreational,
emotional, educational, and vocational aspects of an individual's life. The cost of these disorders
in quality of life and unfulfilled potential is substantial. As the population ages and as the
chances for survival improves for medically fragile infants and individuals who have sustained
injury or acquired disease, the number of citizens with communication disorders will continue to
increase.

What Is the NIDCD?

In 1988, Congress established the NIDCD as a separate Institute within the National Institutes of
Health (NIH). The mission of the NIDCD is to conduct and support research and research
training in the normal and disordered processes of hearing, balance, smell, taste, voice, speech,
and language. These processes of sensing, interpreting, and responding are fundamental to the
way we perceive the world and to our ability to communicate effectively and efficiently. Basic
and clinical research focused on understanding the normal processes and disorders of human
communication are motivated by intrinsic scientific interest, by the goal of allowing more
individuals to reach their potential, and by reducing costs, both tangible and intangible, to
individuals and to the nation.

The NIDCD Strategic Plan

Historically, the NIDCD strategic plan for human communication research was primarily
developed internally, with segments updated on a regular cycle by panels of extramural scientific
experts from one or two of its seven mission areas. In 1999, in an effort to solicit more input
from the public and the research community, the NIDCD embarked on a new strategic planning
process, convening a group of distinguished scientists, clinicians, and members of the public to
serve as the Strategic Planning Working Group. The NIDCD charged the Working Group with
identifying priority areas of research within the NIDCD mission for Fiscal Years 2000-2002,
while considering research currently supported by the Institute as well as NIH-wide scientific
initiatives. Individuals and representatives of public and private organizations as well as
scientific organizations were invited to provide input to the Strategic Planning Working Group.
These responses helped ensure that the public's perspective was assimilated into the
recommendations for the Strategic Plan.




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Following a review of this input, the Strategic Planning Working Group defined broad scientific
areas for NIDCD-supported research over the three-year period. The final draft of the plan was
discussed in detail at the National Deafness and Other Communication Disorders (NDCD)
Advisory Council in May 1999 and implemented shortly thereafter. The NDCD Advisory
Council also reviewed and updated the plan in 2002 for Fiscal Years 2003-2005 and in 2005 for
Fiscal Years 2006-2008.

Below are highlights of the compelling needs of individuals who have communication disorders
and the extraordinary research opportunities in the NIDCD's mission areas that address these
needs.

                                       BACKGROUND

       Diseases and Disorders of Human Communication are Significant Health Problems

Statistics

   Birth and Early Childhood

       Each year, approximately two to three out of 1,000 babies born in the United States have
       a detectable hearing loss, which can affect their speech, language, social, and cognitive
       development.

       About eight percent of American children in kindergarten have a disorder called specific
       language impairment (SLI). These children have difficulty developing and using
       language. These difficulties affect not only speaking but also reading and writing tasks.

       Middle ear infections (otitis media) are the most frequent reason that a sick child visits
       the doctor. The estimated total cost of otitis media in the United States is $5 billion per
       year. Children with otitis media can suffer temporary hearing loss during the infection as
       well as during treatment, and some may suffer permanent hearing loss.

       Approximately one out of every 200 American children is diagnosed with autism, a
       disease that interferes with normal language and social development. Boys are four times
       more likely than girls to be born with autism. Girls with the disorder, however, tend to
       have more severe symptoms and greater cognitive impairment.

       Roughly one million American children stutter. Stuttering affects individuals of all ages,
       but occurs most often in young children who are beginning to develop language skills.
       Boys are three times more likely to stutter than girls.

       Approximately five percent of American children entering first grade have noticeable
       speech (phonological) disorders, ranging from a few substituted and missing sounds to
       serious impairments that make their speech difficult to understand. These speech
       disorders are about 1.5 times more prevalent in boys than girls. The majority of these
       speech disorders have no known cause.



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  Flavor is the primary determinant of whether children under the age of two eat certain
  foods. Based on taste alone, about one-fourth of American infants and toddlers between
  seven and 24 months consume no vegetables and about one-fourth consume no fruits on a
  given day, which has important nutritional consequences.

Adulthood

  Approximately 15 percent (32.5 million) of American adults report some degree of
  hearing loss.

  There is a strong relationship between age and reported hearing loss: 18 percent of
  American adults 45-64 years old, 30 percent of adults 65-74 years old, and 47 percent of
  adults 75 years old or older have a hearing impairment. At all ages, more men (18.6
  percent) than women (12.6 percent) report problems with their hearing.

  Approximately 10 percent (22 million) of American adults between 20 and 69 years old
  have suffered permanent damage to their hearing from exposure to loud sounds or noise
  at work or in leisure activities. Noise-induced hearing loss is more prevalent in men than
  in women.

  Nearly one million American adults have aphasia, a language disorder that results from
  damage to the language centers of the brain, and that can occur after a stroke or other
  brain injury.

  More than six million adults over the age of 60 have swallowing problems. Some
  swallowing disorders, such as from stroke, can put people at risk for aspiration
  pneumonia.

  Each year, 55,000 Americans develop cancer of the head and neck. Treatment for these
  cancers and other types of cancer may subsequently result in a loss of hearing, balance, or
  the ability to speak and swallow.

  Approximately four percent (almost eight million) of American adults report a chronic
  problem (lasting three months or longer) with balance, while an additional 1.1 percent
  (2.4 million) of American adults report a chronic problem with dizziness alone. Overall,
  the cost of medical care for patients with balance disorders exceeds $1 billion per year in
  the United States.

  Balance disorders are a major cause of falls by American older adults, and are the most
  common reason individuals over the age of 75 visit their primary care physician. Patient
  care costs for these falls are more than $8 billion per year.

  An estimated 24.5 percent (approximately 15 million) of Americans 55 years old or older
  suffer olfactory impairment, which increases with age. Approximately 30 percent of
  Americans between the ages of 70 and 80 and 62.5 percent over age 80 experience



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       problems with their sense of smell. Impairment in olfaction can have serious
       consequences, such as the inability to detect the foul smelling odorants that are added to
       natural gas as a warning sign of leaks.

What Research Progress Has Been Made?

What Is Known? Research has produced many important discoveries and many new
technologies to identify and help individuals with communication problems. As a result of
research:

       Vaccines now prevent many illnesses that once were major causes of hearing loss, such
       as measles, mumps, meningitis, and rubella.

       Understanding the consequences of reduced hearing in childhood has led to prompt
       treatment of middle ear infections in children, preventing hearing loss later in life, and
       enabling children to acquire speech and language skills on schedule with their peers.

       Genetic mutations that lead to inherited forms of hearing loss have been identified and
       the functions of many of the proteins they encode are now understood. The era of precise
       genotype-based diagnosis is at hand.

       Many genes that control the development of the inner ear and the organization and
       orientation of sensory hair cells within it have been identified.

       Molecules that are critical to the functioning of sensory hair cells have been identified.
       Significant progress has been made in defining how they are organized and how they
       function in the hearing process.

       Newborn babies with hearing loss and toddlers with language problems are identified at
       an early age so that developmental consequences are minimized through prompt and
       early involvement in intervention.

       Understanding the ototoxic action of antibiotics has led to the development of strategies
       for minimizing damage to hearing.

       Understanding that exposure to noise results in hearing loss has led to the increased use
       of ear protection by people who are routinely involved in loud or noisy activities.

       Scientists know more about how infants who are deaf learn sign language and about how
       sign language compares with spoken language.

       Scientists have learned that the more we communicate with children, either verbally or
       through sign language, the faster they learn language and, perhaps, the more proficient
       they become.




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       More is known about reading ability in adults who are deaf. This information may lead
       to improved methods of reading instruction.

       Knowledge of the biology of neurons continues to grow. Synapses, the points of contact
       between neurons, have been shown to be highly "plastic" (capable of change) at all ages.
       For example, this is important for understanding age-related hearing loss as well as the
       restoration of hearing through cochlear implants.

       Cochlear implants allow children who have a profound hearing impairment to attend
       mainstream schools and enable adults to communicate more effectively.

       Hearing aids are designed to work better in noisy environments, for example, by
       detecting the direction from which sounds arise.

       Recent research shows that short electrodes for cochlear implants can be used together
       with hearing aids for some common age-related hearing disorders.

       Advances in technology and science have created new opportunities to design devices
       that restore or improve function for individuals with balance, voice, and speech disorders.
       For example, improvements have been made in vestibular devices to assist individuals
       with a balance disorder, in electronic larynxes (the organ that produces voice), and in
       computer-aided speech devices.

       The genes that code for olfactory receptors have been identified. This pioneering
       advancement, which earned the discoverers the 2004 Nobel Prize in Physiology or
       Medicine, together with the discovery of the genes for many taste (gustatory) receptors,
       open new frontiers in understanding chemosensory disorders.

       Genetic studies have begun to identify the genes that contribute to stuttering,
       phonological disorders, and language disorders.

       New surgical approaches and combinations of chemotherapy and radiation have
       improved rates of preservation of voice and speech when treating cancers of the head and
       neck.

What Needs to Be Studied? Despite the considerable advances that have been developed to
help individuals with communication challenges, more work remains to be done and questions
remain unanswered. For example, more studies are needed to help answer the following general
questions:

       Can we develop a way to study sensory processing function in the laboratory that more
       realistically mimics the complexities of the real world?

       Can we pinpoint how and where in the nervous system certain communication disorders,
       such as tinnitus, are generated, so that treatments can be optimally targeted? (Tinnitus is
       a hearing disorder that involves ringing in the ears or hearing phantom sounds.)



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       Given our new understanding of the genetic and molecular basis of many communication
       disorders, is it possible to use genetic or molecular interventions to treat these disorders?

       How can existing or new diagnostic tools, such as brain imaging, gene-based diagnostics,
       and computer-based testing programs help doctors choose the best treatment for
       individuals with communication disorders?

       How do communication patterns change during the natural history of a disease,
       particularly in aging or neurodegenerative diseases, and how can this information be used
       to deliver the most effective treatments?

       Why does a particular treatment for a communication disorder work well for some
       individuals but not for others?

       What methods can be used most efficiently to identify infants at risk for communication
       disorders and what types of intervention would be most beneficial?

       What are the best ways to help children with communication disorders learn to
       communicate and develop learning skills?

       How can devices and treatments for communication disorders be improved or developed?
       What are the best techniques for assessing performance, so that improvement can be
       measured objectively and devices can be adjusted for optimal results? Which of these
       devices or treatments can help the largest group of people who have a particular disorder?

       How can basic and clinical research and research training be used to address the need to
       eliminate gender, racial/ethnic, or socioeconomic health disparities in communication
       disorders?

RESEARCH AREAS THAT OFFER EXTRAORDINARY SCIENTIFIC OPPORTUNITY

With help from scientists and the public, the NIDCD has identified four areas that offer
extraordinary research opportunities in the field of human communication sciences. These areas
are:

  I.   Determine the Molecular and Epidemiological Bases of Normal and Disordered
       Communication Processes

 II.   Study the Development, Deterioration, Regeneration, and Plasticity of Processes
       Mediating Communication

III.   Study Perceptual, Cognitive, and Sensorimotor Processing in Normal and Disordered
       Communication




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IV.    Develop and Improve Devices, Pharmacologic Agents, and Strategies for Habilitation,
       Rehabilitation, and Prevention of Human Communication Disorders

Where Do Future Research Opportunities Exist?

These four research areas are described in greater depth in the following section. A detailed list
of the NIDCD's research priorities is included for each area.


      I. Determine the Molecular and Epidemiological Bases of Normal and Disordered
                                 Communication Processes

Scientists know that genes play a key role in many communication diseases and disorders;
however, this area of research requires much more intense study. Likewise, more research is
needed on non-genetic factors that also affect communication processes, such as infection,
toxins, and environmental exposures. Both of these areas (molecular and non-genetic) are
research priorities for the NIDCD.

Understanding Molecular Causes (Proteomic and Genomic)

One of the most rapidly developing areas of research involves determining the identity, structure,
and function of genes, a discipline referred to as structural and functional genomics. The Human
Genome Project has shown that human beings have about 22,000 genes. Considerable progress
has been made in identifying which genes are involved in human communication and how these
genes are altered in individuals with communication disorders. Hereditary disorders result not
only from abnormalities in single genes but from combinations of particular forms of genes. In
fact, genetic mutations cause or play a role in a variety of communication disorders, including at
least one-half of all cases of congenital or childhood-onset hearing loss. Individual variations in
the severity of hearing loss are common and typically attributed to environmental factors and
"modifier" genes, genes that do not cause communication disorders on their own but that can
affect the severity of a disorder caused by a mutation. Understanding the genetic basis of
hereditary disorders can help clinicians select the most effective treatments and enable families
to make informed decisions as they deal with these disorders. Much of the success and progress
in genomics is a direct result of the willingness and generosity of families with hereditary
communication disorders who agree to participate in studies with clinicians and scientists.
Clearly, without them, research in this field would not have advanced to its current state of
knowledge.

Genes influence cells by determining whether certain proteins are made and, if so, by influencing
their structure and function. Proteomics is the study of how proteins interact within cells.
Proteins are the building blocks of all living cells. They carry out the tasks that allow cells to
grow and divide in development, and they help mature cells to thrive. The cells, in turn, form
every internal system in the human body. Mutations in one gene can have a dramatic effect on
complex functions such as hearing, balance, smell, taste, voice, speech, and language.
Understanding how the function of proteins is altered in individuals with communication




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disorders of either genetic or non-genetic origin, is an essential first step in developing precise
molecular diagnoses, pharmacological treatments, and behavioral interventions.

Mutations in genes contribute to numerous communication disorders, in some cases directly by
causing a critical group of cells to malfunction, and in other cases indirectly by increasing the
body's sensitivity to damage from infections, certain drugs or medications, or exposure to loud
noise over an extended period. Continued research is needed to identify and characterize genes
and modifier genes and to understand their function in complex communication disorders with
multiple deficits that overlap with other conditions (such as hearing loss, stuttering, speech sound
disorders, autism, and dyslexia). This knowledge will enable more accurate diagnosis and
classification of individuals with communication disorders. This knowledge can also be used in
the long-term planning of clinical interventions. For example, children diagnosed with a mild
hearing loss at birth with a gene mutation that will cause progressive hearing loss or deafness by
their teen years may receive and benefit from early education programs so that they may achieve
their full potential.

Understanding Non-Genetic Causes (Infectious, Environmental, and Toxic)

Not all communication disorders have a genetic basis. Some are rooted in experiential factors,
and others result from a combination of genetic and experiential factors. For example, hearing
loss can occur as a result of infections, noise damage, or toxicity associated with certain
medications or other chemicals. Infants with hearing loss may have difficulty learning to speak
or understanding language later in life, if appropriate education and training are not provided. At
any age, impaired language skills affect a person's ability to function in today's complex,
communication-driven society. Besides childhood hearing disorders, speech and language
impairments can also be caused by an injury to the brain or a problem in brain development.
Diseases of the larynx can be caused by infections or by the presence of a tumor. Further, in
occupations with high voice usage, such as teaching, voice problems can limit an individual's
ability to perform certain tasks at work, can result in missed workdays, and can sometimes lead
individuals to consider changing occupations. More research is needed to identify the many
causes and mechanisms that result in communication disorders.

Strategic Plan Research Agenda -- Priority Area I

Research is needed to help determine the molecular (proteomic and genomic) and non-genetic
(infectious, environmental, and toxic) bases of communication processes in the following areas:

       Use genomic, proteomic, informatic, bioinformatic, and expression profiling
       technologies, as well as other molecular biologic and genetic approaches, to understand
       the molecular bases of normal and disordered human communication. This examination
       would include gene identification, regulation, and expression, as well as associated
       mutations.

       Bring emerging technologies in genetics and molecular biology (including DNA
       microarrays, biomarker identification, and other genomic strategies) to the clinical setting




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       and encourage the use of multidisciplinary approaches to prevent, diagnose, and treat
       communication disorders.

       Encourage multidisciplinary collaboration between scientists in fields such as chemistry,
       biology, pharmacology, genetics, and medicine to develop methods for preventing,
       detecting, diagnosing, and treating communication disorders.

       Study the common variations, including genetic modifiers, in human DNA and their
       impact on susceptibility to a range of human communication disorders.

       Investigate complex disorders of human communication caused by the interactions of
       several genes. Identify and analyze factors that influence variability and susceptibility to
       disease and response to treatment.

       Develop in vitro and animal model systems to study the function of specific disease
       genes; identify and isolate specific cell populations; and investigate cellular processes by
       using such techniques as gene and protein expression systems, organ and cell culture
       systems, and stem cell research.

       Explore the pathogenesis, treatment, and prevention of viral and bacterial infections that
       may contribute to communication disorders.


             II. Study the Development, Deterioration, Regeneration, and Plasticity
                            of Processes Mediating Communication

Understanding how the brain and the sensory organs involved in human communication recover
or adapt to injury or damage is another research priority for the NIDCD.

Increasing the Potential for Recovery -- How the Body Creates New Cells

Certain parts of the human body, when damaged by illness or injury, can heal by regenerating
healthy cells to replace the damaged or lost cells. Yet, other parts of the body, including the
highly specialized hair cells of the inner ear, do not regenerate spontaneously.

Until recently, scientists believed that these hair cells, which are critical for hearing and balance,
could never be replaced if they were injured or destroyed. However, scientists have recently
discovered in guinea pigs that mammalian hair cells can be regenerated from nearby supporting
cells if certain genes are expressed in that region of the ear. This finding inspires hope that the
same can be accomplished in humans. Before genes are introduced into humans, however, it is
essential to determine that the molecular machinery that delivers the genes to the ear is safe and
that the long-term health consequences of the added genes are fully understood.

Human olfactory receptor neurons in the nose show a remarkable ability to regenerate
throughout life. We need to study the unique ability of these regenerated cells to make proper
connections to brain regions that recognize and discriminate odors. If we understand how



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olfactory receptor cells regenerate, researchers can work to develop clinical intervention
strategies that promote nerve cell regeneration not only in the nose but also throughout the
nervous system.

The central nervous system adapts to changes by reorganizing connections among neurons.
When a part of the brain involved in speech and language is injured by a stroke or an infection,
changes in the connections between neurons ­ called "plasticity" -- may allow other parts of the
brain to learn or take on that function. Understanding how such adaptive changes occur and
recognizing their limitations opens the door to treatments that optimize the ability of the brain to
make such changes.

Adaptation to changes can also have harmful consequences. Many people whose auditory
systems are damaged acquire tinnitus, a disturbing disorder marked by ringing, roaring, clicking,
or hissing in the ear. Most treatments available today involve learning how to live with tinnitus
or covering up the tinnitus with other sounds. Currently, there is no cure for tinnitus; however,
understanding what changes in the auditory system lead to tinnitus and determining where the
changes occur are necessary first steps in developing treatment. Plasticity is also important to
the function of the vestibular (balance) system. Damage to one vestibular organ is rapidly
compensated by changes that occur in the brain. Understanding how the vestibular system
adjusts to changes may be an important step in developing treatments for vestibular disorders.

Adults who suffer brain damage from a stroke often experience problems expressing their
thoughts through speech and language. These speech and language disorders severely limit a
person's ability to communicate and often restrict job opportunities, which in turn, decreases
quality of life. In contrast, infants and young children who have suffered brain damage from
birth injuries, childhood trauma, or extensive brain surgery are more likely to develop or recover
speech and language abilities than adults with similar damage. Additional research is needed to
uncover and understand how and why young children can recover from, or adapt to, severe brain
damage so that new methods can be developed to promote recovery in adults.

Early in life, sensory cells in the hearing and balance organs of the inner ear develop connections
with specific brain regions. At certain times in a young child's life, the brain is more adept at
forming these connections. The ability to develop critical brain connections may be lost forever
if these time-sensitive opportunities are missed, such as when an infant's severe hearing loss
goes undetected. Research is needed to identify these critical "windows of opportunity" for
developing brain connections essential to communication. Important research findings in this
area have already been used to mobilize major national public health efforts, such as the
screening of millions of newborns for hearing loss each year.

Stem cells have the ability to regenerate and differentiate into a multitude of specialized cells. If
scientists understand the events that allow stem cells to differentiate (become a certain type of
tissue), they may be able to use these cells for a variety of therapeutic purposes, driving the
regeneration of cells damaged or destroyed in the sensory organs of the ear, nose, and mouth as
well as in the brain.




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Strategic Plan Research Agenda -- Priority Area II

Research is needed to determine how development, deterioration, regeneration, and plasticity
contribute to the communication process in the following areas:

       Characterize age-related changes in structural and functional plasticity of communication
       processes. For example, the inner ear is very complex. Any variations in its early
       development may contribute to malformation or dysfunction. Therefore, it is important
       to understand the normal development of structures and processes related to
       communication at the molecular level so that gene variants that may cause subsequent
       malformations can be identified. This information may also lead to further understanding
       of how these structures can be degenerated or regenerated.

       Develop and apply techniques such as functional magnetic resonance imaging (fMRI)
       and positron emission tomography (PET) to assess structural and functional plasticity.

       Determine the cellular and molecular mechanisms underlying the degeneration and
       regeneration of sensory cells, such as cochlear and vestibular hair cells, olfactory cells,
       and gustatory, or taste, cells. Such information may lead to the development of new
       therapeutic interventions.

       Use in vitro assays to investigate molecular factors involved in stimulating embryonic
       and adult stem cells to differentiate into specific cell types used in communication.

       Use culture and organ tissue/cell systems to investigate how specific cell types involved
       in communication processes signal one another when growing in the laboratory.

       Investigate cellular and molecular mechanisms used by the body to protect auditory,
       vestibular, olfactory, and gustatory receptor cells. Develop methods to enhance these
       processes to improve survival of sensory cells following trauma or disease.

       Determine and categorize mechanisms involved in the development, maturation, aging,
       and recovery of function needed for communication, including cell proliferation,
       differentiation, neuron axon targeting, pattern formation, cell death, and survival.

       Understand changes in the brain that result from the loss of sensory input, as with
       deafness, anosmia (inability to smell), or aguesia (inability to taste). Such knowledge is
       important for making the best use of drug treatments, behavioral interventions, and
       assistive devices.

       Develop animal models for human disease to study the underlying processes of
       communication disorders. For example, because of the subjective nature of tinnitus, it
       has been difficult to find a suitable animal model for study. (How can you tell if an
       animal's ears are ringing?) However, efforts need to continue despite these limitations.




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       Determine the optimal clinical interventions -- timing, quantity, and method of treatment
       -- by incorporating knowledge from studies of neuroplasticity as it occurs in normal
       development and in response to injury.

       Investigate the molecular mechanisms of neurotransmission at peripheral and central
       synapses associated with hearing, balance, smell, taste, voice, speech, and language.
       Understanding how these mechanisms function normally and under disease conditions
       may help us determine the best drugs for treating communication disorders.


           III. Study Perceptual, Cognitive, and Sensorimotor Processing in Normal
                               and Disordered Communication

Obtaining a more detailed understanding of how the brain acquires, organizes, and interprets
information is another research priority for the NIDCD.

Perceptual Processing

Human communication relies on complex perceptual skills by using the senses (hearing, vision,
touch, pain, smell, and taste) to receive and interpret information from the outside world.
Human communication also requires mental abilities, such as attention and memory. Scientists
do not fully understand how all of these processes work and interact, or how they malfunction
when there is a communication disorder. They do know that many communication disorders
occur even when the peripheral sensory organs appear completely normal.

Recently, new methods have been developed to study what happens after sense organs receive
information. With computerized imaging, it is now possible to directly view regions of the brain
at work. This advanced technology allows scientists to see changes as information flows from
sensory organs to the brain. For example, a functional magnetic resonance imaging (fMRI) scan
can be used to observe brain activity as language information (written, spoken, or signed words)
is received, processed, and interpreted. Research using brain-imaging techniques is now
allowing scientists to challenge the old belief that there is a fixed part of the brain just for
organizing language. Studies in both adults and children indicate that brain organization can be
modified. After an injury to either the right or left side of the brain, the organization of language
that normally takes place in those locations begins to take place in other brain regions. For some
individuals, this rerouting may allow relatively normal language abilities to be restored.
Scientists cannot obtain detailed information on human speech and language by studying
animals, so new imaging studies involving humans are crucial.

Moreover, imaging studies are already giving scientists new insights into how sounds are
processed by the brain. Some of these studies are directed at understanding auditory processing
disorders (APDs). APDs adversely affect learning and language acquisition. Many individuals
with APDs describe their symptoms differently. Studies of twins have determined that certain
auditory processing abilities are often inherited. It is necessary to continue using twin studies to
evaluate the aspects of APD that are inheritable and to study the families of individuals with




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APD to estimate the number of genes that may contribute to APD and the magnitude of their
effects.

Cognitive Processing

Improved methods of functional brain imaging, together with modeling of complex systems,
ultimately will allow an understanding of multi-region brain activation, or the way in which
various parts of the brain participate in complex tasks such as object recognition, language
comprehension, and language formulation. A better understanding of these neural processes in
healthy children and adults is essential for the effective study of cognitive disorders. These
methods also are the means by which scientists can study the neural reorganization that occurs
following brain injury or that results from various kinds of treatment. The use of functional
imaging and neural modeling to study the effects of clinical treatment could improve treatment
methods and point to new discoveries of brain functions underlying normal and impaired
cognitive processes. For example, brain scans of autistic individuals as they perform language
processing tasks reveal key structural and functional differences when compared with brain scans
of individuals who do not have autism -- differences that are tied to language problems
associated with autism. These imaging techniques also have been used to study changes in the
brain following therapy for aphasia and stuttering and can be applied to other language-impaired
groups, such as individuals with dementia.

Strategic Plan Research Agenda -- Priority Area III

Research is needed to determine perceptual and cognitive processing (how individuals learn to
communicate) in normal and disordered communication in the following areas:

       Use imaging and multi-electrode, multi-unit recording methods such as positron emission
       tomography (PET), functional magnetic resonance imaging (fMRI), and
       electroencephalography (EEG) in animal models and humans to dissect the pathways and
       define the location and sequence of neuronal activity essential for peripheral and central
       processing of sensory input. Identify and define abnormal neural pathways and
       spatiotemporal neuronal activity patterns associated with disordered communication.

       Develop quantitative methods to analyze sensory, sensorimotor, and cognitive processing
       in humans, in particular, those processes not readily studied in animal models.

       Investigate the perceptual and cognitive consequences of disordered communication and
       measure changes that result from treatment, including how the development of language
       is affected by variations in the quality, quantity, and timing of linguistic input.

       Investigate how structural and functional differences occur in and affect individuals with
       communication disorders.

       Combine cellular, molecular, and physiologic approaches with behavioral analyses in
       basic science and clinical studies to understand normal mechanisms of sensory
       processing, cognition, and perception.



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  IV. Develop and Improve Devices, Pharmacologic Agents, and Strategies for Habilitation,
            Rehabilitation, and Prevention of Human Communication Disorders

It is central to the mission of the NIDCD to enable individuals who have, or who are at risk of
having, communication disorders to maximize their quality of life. Therefore, research on the
intervention for and prevention of communication disorders is another research priority for the
NIDCD.

Improving/Restoring Communication Abilities and Preventing Communication Disorders

As described in the previous sections, NIDCD-supported scientists have made great progress in
recent years toward understanding human communication and its disorders. These advances
were made possible because of unprecedented breakthroughs in genetics as well as other basic
sciences and technologies, such as microelectronics. As more is learned about the function of
the brain and other organs important for communication and more genes associated with specific
communication disorders are identified and their functions revealed, progress will continue to be
made.

Clinical research uses this new knowledge to study human behavior and disease. For example,
hearing screening programs around the country are beginning to identify infants and young
children who have significant hearing loss. The technology for screening newborns was
developed as a result of basic laboratory studies that measured electrical signals from auditory
centers in the brain (auditory brainstem response) and sounds generated by the inner ear
(otoacoustic emissions). Rigorous clinical trials should be performed to determine the most
effective treatments for infants who are hearing-impaired, including hearing aids and cochlear
and brainstem implants, as well as the most effective education programs for this target group.
In addition, researchers should conduct clinical trials to determine the age at which treatment
should begin to achieve maximum success in language development.

Clinical research is also needed to describe how hearing, balance, odor detection, and speech
abilities evolve over an individual's life span. These differences may be tied to an underlying
gene or genes, which in turn may help identify individuals who are at greater risk for developing
problems. Once this information is obtained, clinical trials are needed to find safe and effective
ways to treat specific communication disorders through behavioral interventions, medications, or
other therapies. Several examples include laser therapy to treat cancer on the vocal folds,
electrical stimulation and medications to treat tinnitus, and physical therapy involving special
positioning of the head for loss of balance (positional vertigo).

The NIDCD is committed to conducting and supporting research to develop devices or
interventions that improve or restore communication abilities, or prevent communication
disorders. For example:

       Cochlear implants have helped many children who were born deaf as well as individuals
       who became deaf later in life. According to the U.S. Food and Drug Administration's



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2005 data, more than 96,000 people worldwide have received cochlear implants. In the
United States, roughly 22,000 adults and nearly 15,000 children have cochlear implants.
Most adults who have received an implant have benefited greatly and many are able to
communicate effectively by telephone after an extensive training period. Continued
research on cochlear implants and sound processing should help improve communication
for implant users while increasing our understanding of the auditory system. Methods
need to be developed to assess performance by cochlear implant users in order to provide
future recipients with more effective implants. Research is also needed to determine
whether deaf children will benefit from having implants in both ears. Finally, studies
need to be done to determine how language instruction can best help young implant users
learn language, including the type of instruction, amount, and developmental stage at
which it begins.

Although hearing aid technology has advanced rapidly over the past few decades, hearing
aids still do not work well when sound comes from more than one source. They are also
not particularly effective when a listener tries to pay attention to a single speaker among
many competing speakers or when there is a lot of loud background noise. To meet these
needs, improvements continue to be made in directional hearing aids and other hearing
aid technologies that will help users understand speech from specific sources within a
noisy environment.

The combined use of a hearing aid in one ear and a shortened electrode array inserted into
a portion of the cochlea of the other ear have proven to be effective in allowing
individuals with hearing loss in the high frequencies to regain hearing. More work needs
to be done to determine which individuals should receive these combined devices, as well
as which devices yield the most benefit, and when combination devices should be
recommended.

Oral communication is often difficult for individuals with severe speech impairments
caused by muscular dysfunctions (dysarthria). These impairments are associated with a
variety of causes, including trauma and neurodegenerative diseases. However, much
progress has been made in developing augmentative or assistive communication devices
that help individuals with dysarthria to express themselves. Present research is
evaluating whether a low-cost, laser-activated keyboard would enable users to access
personal computers. If so, individuals with speech or language disorders could use
personal computer programs and speech synthesizers to increase their communication
capabilities. The development of automatic speech recognition systems tailored to the
speech patterns of individuals with dysarthria may permit computer-based
communication using computer-generated speech or text.

Advances in basic science research and in bioengineering continue to contribute to: (1)
the development of the electro-larynx, which partially restores voice after the larynx is
removed; (2) digital programmable hearing aids that fit inside the ear canal; (3) cochlear
and brainstem implants, which improve the communication ability of adults and children
with profound hearing loss; and (4) video-game-like computer programs that treat
disorders associated with childhood language and learning disabilities.



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       By using biological principles of odor recognition, it should be possible to design
       "electronic noses," improved biosensors that could be used to detect and discriminate
       complex chemical signatures of importance to biomedicine, biodefense, and biosafety.

       Information from epidemiological, biological, and behavioral studies can be used to
       develop recommendations to prevent communication disorders or to minimize their
       effects. Advances in knowledge in several areas create new opportunities to identify
       strategies for prevention.

Important advances have been made in the development of assistive devices, drugs, and other
therapeutic interventions, and there is excellent potential for further developments. However, it
is important that the basic developmental work be accompanied by clinical research to ensure
that these interventions are safe, efficacious, and used to maximum benefit. The ultimate utility
and success of current and future devices or other interventions can only be determined through
clinical research studies that include the participation of volunteers who normally use the devices
or interventions.

Translational research must be promoted to ensure the timely and effective progression from
basic research to clinical research. Translation of new discoveries -- from animals to humans,
from laboratory to bedside, and from bedside to widespread clinical practice -- is essential to
achieve maximum benefit for individuals with communication disorders.

Strategic Plan Research Agenda -- Priority Area IV

Research is needed to improve the quality of life for individuals with communication disorders
through assistive devices, drugs, and other therapeutic interventions in the following areas:

       Capitalize on emerging technologies to design and improve devices that enhance
       communication, including short electrodes for cochlear implants, brainstem implants, and
       drug-delivery devices. If users are to capitalize on their devices, they need optimal
       therapy to teach them how to use them properly.

       Use clinical trials and other clinical studies to evaluate the safety and efficacy of newly
       developed devices, drugs, and other therapies for individuals with communication
       disorders. These studies should also be used to develop and assess medical and
       behavioral interventions for infants and children who have a communication disorder.

       Make early diagnosis and early prevention of communication disorders easier by
       developing and refining diagnostic criteria and improving diagnostic technology.

       Screen FDA-approved drugs to determine beneficial or harmful effects on individuals
       with communication disorders.




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       Develop cost-effective techniques to assess the various patterns of communication
       currently used in the United States, including languages and dialects, taking into account
       the needs of all cultural and ethnic groups.

       Develop engineered reconstructive tissues that could be used to restore function in
       individuals who have suffered structural loss through disease or trauma.

       Integrate information from epidemiological studies with knowledge gained from
       biological and behavioral research to develop strategies for prevention of communication
       disorders. Early identification of children at risk for communication disorders is a first
       step in the prevention of many disorders. Efforts in early identification must be coupled
       with research to determine the most effective ways to prevent a disorder or to minimize
       its effects.

       Identify environmental exposures that contribute to communication disorders and
       determine ways of preventing or eliminating these exposures and reducing their harmful
       effects.

                                           SUMMARY

Disorders of human communication, which when broadly defined include disorders of hearing,
balance, smell, taste, voice, speech, or language, affect millions of Americans. Fortunately, over
the past few decades, research has greatly advanced the understanding of human communication
and communication disorders. There is a greater understanding of how information is received
and interpreted in the brain and how an individual's communication abilities can be
compromised by factors such as infection, loud noise, and genetic abnormalities. In addition,
many new technologies have been developed to improve or restore communication abilities.

Extraordinary research opportunities have led to scientific breakthroughs in the study of genes,
proteins, stem cells, and molecular processes that directly affect the understanding of
communication disorders. These advances have been accompanied by substantial progress in
behavioral studies that increase the understanding of communication processes in health and
disease. New imaging techniques, electronic devices, computer databases, animal models, and
clinical trials have enhanced our ability to understand, prevent, diagnose, and treat disorders of
human communication.

The NIDCD is committed to further advancing the science of human communication and its
associated disorders. NIDCD-supported research has been essential to many of these advances
but many opportunities remain. The strategic priorities outlined in this plan provide a blueprint
for future scientific initiatives and investigator-initiated research aimed at improving the quality
of life for individuals who face the daily challenge of living with a communication disorder.




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