ࡱ> KMHIJ` zbjbj :Rsrhfff8D,.../]m}$hT*LLLLr,L,6v `Z꺺"f6V0r~X~8~:- LXLLLL177o17o University of WashingtonFile #:XXXX0000SPEECH AND HEARING CLINICClient:Smith, Client4131 15TH Ave NEDOB:02/0X/0XSeattle, WA 98105Parent/s:Name & NameSmith206-543-5440Address:Phone: SPEECH-LANGUAGE PATHOLOGY REPORT Date of Evaluation:January X, 200XLead Clinician:Student 1, B.S.Interviewer:Student 2, B.A.Supervisor:Laura Sargent, Ph.D., CCC-SLP HISTORY Identifying Information, Referral source and Chief Concerns Client, age 4;11, was seen for a speech and language evaluation at the University of Washington Speech and Hearing Clinic (UWSHC) on January X, 200X. He came with a diagnosis of Autism Spectrum Disorder (ASD). The family was referred by Teacher at the Experimental Education Unit (EEU) at the UW. Clients father accompanied him to the assessment and provided information for the interview. According to the information provided by Mr. Smith via the application and the interview, the familys primary reason for seeking services is to get a detailed assessment of Clients expressive and receptive language abilities and to structure a plan to help Clients language development. A main concern is Clients difficulty in expressing complex or abstract thoughts or ideas, as demonstrated by his limited sentence length and vocabulary. The family is also concerned about his comprehension, exemplified by his tendency to respond to contextual questions by providing irrelevant information. The family reports that while they can understand most of Clients speech, he is difficult to understand by unfamiliar listeners due to imprecise articulation and sound substitutions. Medical/Birth Birth weight and gestational age were within normal limits, but Client was born face up, causing a long labor. Because he was slightly blue in color, Client was given oxygen immediately after birth, but was otherwise healthy and taken home within two days. Client has had less than five ear infections (one was bilateral) as an infant, but they were treated successfully within a short time. Client has had an otherwise uneventful medical history, and is not currently taking any medications. Developmental Motor milestones were reported as within normal limits. Canonical babbling (gagaga) and first words appeared by nine months (within normal limits), but variegated babbling (gabigoo) appeared at three years (delayed). Word combination milestones were reported to begin at typical ages, though parents report that sentence length has not progressed past 3-4 words since age three. Social/Behavioral Client lives with his mother, father and younger sister (~2 years younger), who is also diagnosed with ASD. Mr. Smith reports that Client plays both independently with a variety of age-appropriate toys, and interactively with his sister and peers, and estimates that when playing with others, Client spends 40% on independent play, while the rest involves appropriate initiation, turn-taking, and cooperation. Mr. Smith reports that Client is successful in social situations at school and in public, and that he has overcome much of his shyness through continued social contact, demonstrated by appropriate participation in group activities and use of attention-getting strategies. Client is reported to have improved in performing daily routine activities independently (e.g., getting dressed), and appears pleased at his success and independence. Mr. Smith notes that Client often becomes anxious when transitioning between activities, especially if transitions come abruptly or unannounced. However, anxiety decreases markedly in structured and predictable environments such as in the classroom, according to Mr. Smith. He also notes that Client almost always offers and responds to expressions of affection and appreciation appropriately, and asks others to change their behavior (e.g., to move over) when necessary. Language Mr. Smith reports that Client frequently has difficulty communicating his thoughts and feelings, especially in situations involving complex or abstract concepts, though he regularly comments on his own and others actions, often in the form of seeking affirmation (e.g., We are going to the park, right?). His parents notice that Client often expresses frustration by becoming upset when listeners do not understand due to nonspecific words or incorrect word order, but that he attempts to compensate with gestures such as pointing, and to use words when prompted. Mr. Smith noted that Client consistently refers to himself in the third person. Other perceived areas of weakness include Clients tendencies not to request help or clarification when needed, and his apparent lack of ability to express a detailed sequence of information. According to Mr. Smith, Client frequently repeats a phrase, question, or comment several times, even though it has been acknowledged in the interaction. Client enjoys interactive reading activities with his family, and often spontaneously expands on story elements, as well as recognizes some letter-sound correspondences. Educational Client currently attends a peer model preschool classroom at the EEU at the University of Washington, and attends three full days and two afternoons per week. At the time of this report, academic progress records from the EEU were not available. Mr. Smith reports that Client receives specialized attention for his speech articulation skills, which he perceives is helpful in increasing Clients intelligibility. The family plans to remain enrolled at EEU. Previous Evaluations At age 3, Client was given a speech and language evaluation at Wilson Pacific School (Seattle Public School District), and was deemed eligible for speech and language services hour once per week. In 2004, Client underwent an evaluation at the UW Center for Human Development and Disability (CHDD) and was diagnosed with Autism Spectrum Disorder. Reports from these assessments were unavailable at the time of this writing. EVALUATION Test Environment and General Behaviors The assessment took place in a quiet clinic room at the UWSHC. Client quickly warmed-up with unfamiliar clinicians and willingly participated in all activities. Client exhibited good task focus, and was attentive and cooperative throughout the evaluation with only a few short breaks. Assessment Tools A selection of subtests from the Clinical Evaluation of Language Fundamentals-Preschool, 2nd Edition (CELF-P2) was administered to formally assess receptive and expressive language. The Pragmatics Profile of the CELF-P2 was completed by Clients father. Low-structured free play with a dollhouse, story sequence cards, and question cards were used to informally assess receptive and expressive language skills, as well as social use of language. Hearing Client passed a hearing screening for pure tones in both right and left ears at 500, 1000, 2000, 4000, and 8000 Hz at 25 dB. Language Test Results The Clinical Evaluation of Language Fundamentals Preschool, 2nd edition (CELF-P2) assesses both receptive and expressive language. Results are reported below. CELF-P2 SubtestThis evaluated Clients ability toStandard Score*Percentile Rank Age *** EquivalentInterpretationSentence StructureUnderstand sentences of increasing length and complexity.42nd<3 yrs.Significantly delayedWord StructureUnderstand word structure rules that change word form; understand pronouns for people, objects, and possessive relationships.42nd<3 yrs.Significantly delayedExpressive VocabularyName people, objects, and actions.42nd<3 yrs.Significantly delayedConcepts & Following DirectionsUnderstand and follow verbal directions of increasing length and complexity.2<1st<3 yrsSignificantly delayedRecalling SentencesRepeat sentences of increasing length and complexity without modifying meaning, form, or sentence structure.55th3.2 yrs.Significantly delayedComplete TestThis evaluated Clients ability toStandard Score*Percentile RankInterpretationCELF-P2 QuotientUse receptive and expressive language65**1stn/aSignificantly delayedExpressive IndexUse expressive language67**1stn/aSignificantly delayed* 7 13 is average ** 85 115 is average *** Age equivalents are provided for descriptive information only. Receptive Language Formal Measures Results for the Sentence Structure and Concepts and Following Directions subtests of the CELF-P2 are reported in the table above. The Sentence Structure subtest assesses knowledge of sentence structure rules, and the ability to derive meaning and context from pictures and spoken information. Client was able to identify pictures depicting common present progressive verb tenses (is running, is sleepy), infinitives (to bake), and adjectives (spotted). He had difficulty with prepositional phrases (in the box), future tense verbs (will find), and sentences of longer length with embedded clauses (The girl who won the prize at the school party was very excited) The Concepts and Following Directions subtest measures comprehension of spoken language about concepts and relationships between pictured items (such as location and size), a skill necessary for remembering and following directions. Client had difficulty with multi-step directions, and on five test items only pointed to the first of two pictures he was asked to point to. This could be due to difficulty with temporal concepts (then, after) or with holding multiple items in memory. Memory difficulties would be consistent with his performance on the Recalling Sentences subtest (discussed in the Expressive section below). He also missed items depicting comparative relationships (faster, fastest). It appeared at times that Client did not examine all of the pictures to attend to distinctions, but instead focused on one picture in spite of reminders to look carefully at all the pictures. Informal Observations Question Comprehension: Comprehension of questions was probed during low-structured free play and with question cards. The following table summarizes the results: Question TypeTypical age of masteryNumber/% correct NotesYes/No2.0+4/5 (80%)Answered no to Do you buy things with money? What2.6+4/4 (100%)Where2.6+3/3 (100%)Who3.0+3/3 (100%)How many3.0+2/2 (100%)Why3.0+1/3 (33%)Answered 2 questions with a where or when response: Why do you wear mittens? ( (in the snow, with glove and boots rather than to keep hands warm) Why do you use a flashlight? ( (when its dark rather than so you can see in the dark)Which3.0+2/3 (67%)Picked bicycle as faster than airplane When4.6+3/3 (100%)Choices of potential correct responses presented for one trial Responses to why questions indicated comprehension of the question context, with substitution of an associational answer (when, where) for a because or cause-effect answer. Following one step directions: Client followed one step directions when he was asked to move his chair, place objects, or hand objects to the clinician. Locatives: Comprehension of locational prepositions was probed during low-structured play through requests for placement of objects. Client exhibited comprehension of in, on, in front of, beside, and behind but did not respond appropriately to under. Expressive Language Results for the Word Structure, Expressive Vocabulary, and Recalling Sentences subtests of the CELF-P2 are reported in the table above. The Expressive Index is a composite score which gives a general indicator of expressive language ability. Client scored as significantly delayed in expressive language for each subtest and the overall composite score. Expressive language was assessed in three areas: the form, content, and use of language. Form. The Word Structure subtest of the CELF-P2 examines understanding of pronouns and word structure rules (morphology), knowledge that allows derivation of new words and extension of word meaning. Client scored as significantly delayed on this subtest. He displayed correct use of common progressive verb tenses (sleeping, walking, sitting), plurals (horses, dogs) and simple prepositions (in), but had difficulty with more advanced forms such as copulas (is), noun derivations (sing ( singer), comparatives and superlatives (faster, fastest), and subjective (he), objective (her) and possessive (hers) pronoun classes. Client also scored as significantly delayed on the Recalling Sentences subtest of the CELF-P2, which assesses recall and repetition of sentences with retention of morphology (word endings) and sentence structure. This subtest has no visual cues or pictures, and relies solely on comprehension, memory, and organization of language. Client was able to repeat simple sentences that described familiar things (The boy fell and hurt himself), but had difficulty repeating questions with unfamiliar forms (Didnt the boys eat the apples?). He also omitted clauses in longer sentences. For more abstract sentences (Because tomorrow is Saturday, we can stay up late tonight), Client was unable to reproduce any of the sentence content and responded with verbal groping (yeah, I I. I.). A 125 utterance, 13 minute language sample from the free play dollhouse activity was analyzed to gather informal measures of language form. Client had a mean length of utterance (MLU) of 3.74, compared to an expectation of 4.0+ for his age. He used a number of morphological word forms, as summarized in the table below: Word FormTypical age of mastery (in months)Usage ExamplesPresent progressive -ing19-28going, coming, knocking, falling, sleeping, workingRegular plural -s24-33strawberries, grapes, bananasin, on27-30on other one, in the stove, in the bathroomIrregular past tense25-46found, broke. Possessive s26-40Sxs, ClientsUncontractible copula is27-39this isArticles28-46a, theRegular past -ed26-48stayed, startedRegular third person -s26-46goes, stays, matches. Incorrect use of eat for eats.Irregular third person (does, has)28-50Where does this go?Contractible copula/aux -s29-50thats, someones, kittys, swings, Im, wheres, its Client used the objective pronouns he, I and you, but did not use subjective pronouns (her, him). No opportunities presented for use of possessive pronouns (his, hers). Client only used the uncontractible is copula with this and it. All other uses of is were in the contracted form. Because Client frequently stated its is, his copula use may reflect an incomplete understanding. Client used adjectives on only two occasions (green and big). Although he demonstrated appropriate use of semantic relations such as agent-action and action-object, many sentences were incomplete and lacked a subject or object. He did not use joined or embedded clauses, and utilized the conjunction and only to join items (strawberries and bananas). Client frequently used inappropriate syntax, with many false starts, revisions, and abandoned phrases. This may indicate that language formulation difficulties cause him to abandon phrases and revise others as he searches for the correct form of expression. Examples of his poorly constructed sentences are: I just got the kitty says that xx. (xx=unintelligible) What happen to the man can go? Where seen the kitty in here? I do but how this is another one and stayed on other one. The following are three examples of Clients most complex language use: Someones going to knock on the door. Its going in the bathroom. Ill help with the bedroom. Content. The Expressive Vocabulary subtest of the CELF-P2 assesses the ability to name people, objects, and actions, as well as the ability to describe events. Client scored as significantly delayed on this subtest. His vocabulary was limited to common everyday objects (carrot, sock) and common actions (riding, pouring, crying). He described the function or nature of some items he could not name (telescope = put your eyes and footprint = feet track) and substituted related terms for others (branch = stick, wrapping a present = packing a present). On other items he gave no response. Context: During low-structured play activities, Client confined his conversation to the here-and-now. When asked about topics outside of the present context, such as where he sits for dinner at home, he appeared confused and did not answer. When asked about a future event (his birthday), he responded with The men got it. It pick it up, Mommy pick it up. Mommy do it by herself. Vocabulary: Clients language reflected frequent usage of general terms such as here, there, this, and that to refer to items or locations, rather than usage of more specific terms. A type-token ration (TTR) of .32 was calculated from the 125 utterance language sample gathered during low-structured free play. This measure reflects the variety of different words used. Children from 2-8 years of age generally have a TTR of .42 to .50. A lower TTR could indicate perseveration, word-retrieval difficulties, or a restricted vocabulary. Description: Client spontaneously named objects without prompting by the clinician. He had difficulty with language content when he was asked to describe events. In a task using sequencing picture cards, he could not place three cards in sequential order. He appeared to have difficulty discussing abstract temporal concepts (first, last, then, after), but could point to which card came first when given two choices and a description of each card. After a story was told using the sequenced cards, Client still could not place them in correct order. With a choice structure, he was able to order 2 of the cards correctly. Temporal event sequence skills typically emerge between the ages of 3 and 5, and they require the ability to hold and organize information in memory during language formulation. Although Client described each card individually, he did not join the utterances to form a connected event description even after modeling. His difficulties with holding several pieces of language in memory (as reflected on the Recalling Sentences subtest) may contribute to his difficulty with temporal event description. Client perseverated with subject content a couple of times, inappropriately answering questions with content related to an exchange immediately prior to the current one. His ability to clearly express content was also hindered by false starts, incomplete utterances, and revisions. The informal measures of language content support the measures derived through formal testing. Use. Client was very shy in the waiting room, clinging to his father and making only fleeting eye contact. He quickly warmed-up during free play and demonstrated appropriate social communication. Client used language to communicate a variety of intentions. Examples appear in the table below: Communicative IntentionCommunicative FunctionNotesGreetingInteractionalClient greeted and established eye contact with the clinician in the waiting room. Attend/Joint referenceInteractionalClient easily established joint reference with the clinician during free play, responding to and talking about objects and activities she introduced. CommentInteractionalClient commented on his actions and the attributes of toys.Contingent responseInteractionalClient usually responded within the context set by the clinician rather than talking about unrelated topics in parallel.AnswerInteractional/InformativeClient readily answered questions posed by the clinician, although not all responses were contingent.Request objectInstrumental/RegulatoryClient requested objects from the clinician to use in play. Request actionInstrumental/RegulatoryExamples: Can I listen?, Do I get a choice now?Request informationInteractionalExamples: What does that say?, Wheres the baby ball?Request clarificationInteractionalExample: Where does this go? repeated twice, then Here? after not understanding a clinician directive to put the lamp on the shelf. ProtestRegulatorySaid no when asked to put the cat on the roof of the dollhouse.Communicative Functions: Instrumental: to satisfy needs or desires; Regulatory: to control the behavior of others; Interactional: to define or participate in social exchange; Informative: to provide information.  Client initiated and maintained topics in the context of play. Client did not consistently use eye contact, but he remained engaged and interactive throughout the evaluation. He used socially appropriate nonverbal language such as facial expression and gestures, and maintained appropriate physical proximity and body posture. Client responded to indirect requests (handing the clinician an item after she said were all done with that) and to body language (handing an item to the clinician when she reached out her hand for it). Client usually did not attempt to repair communication breakdowns. When he did not understand something, he typically responded with yes, an inappropriate answer, or silence accompanied by restless body language. The Pragmatics Profile of the CELF-P2 was completed by Clients father during the session. He selected a 2 (sometimes) for the majority of skills in Rituals and Conversational Skills, with a few ratings of 3 (often). Higher ratings were given for greetings, turn-taking, and participation/ interaction. Lower ratings were primarily for eye contact and verbal skills. Mr. Smith rated the majority of Clients skills within Asking For, Giving, and Responding to Information as a 2 (sometimes) or 3 (often). He indicated that Client never asked for time of events and never asked for or gave information related to reasons and causes. He rated Clients skills at a 4 (always) for offers of affection and responses to affection. In the Nonverbal Communication Skills, Mr. Smith rated most items as 3 (often), with ratings of 2 (sometimes) for skills related to use of body language, voice intonation, knowing the feelings of others, and reading social situations. Speech Clients speech and intelligibility were informally assessed during low-structured activities and conversation. He presented with the following age appropriate speech sound errors: vowelization of /r/ (in words such as here), substitution of /w/ for both /r/ and /l/ (right, ladder, lion), substitution of /d/ for // (there, that), substitution of /f/ for /(/ (tooth), and reduction of blends (sicker for sticker). Client was observed to have some lateral sliding of the jaw and reduced lingual (tongue) movement during speech. He also exhibited restricted lip rounding and excessive labiofacial retraction (retracted lip corners) during speech. These motor control issues may interfere with the clarity of his articulation. Client was judged to be 85% intelligible within context. His intelligibility was impacted by imprecise articulation, and false starts and revisions that obscured the context and content of his language. Voice and Fluency Client spoke quietly at times, but his voice characteristics were judged to be within normal limits. His fluency was sometimes disrupted by phrase and whole word repetitions. These appeared to occur as filler when he was having difficulty formulating his thoughts into language. No avoidance behaviors or atypical disfluencies such as part-word repetitions, blocks, or sound prolongations were noted. Related Factors Play skills Client engaged in appropriate symbolic play with the dollhouse. He placed furniture in rooms, put people in different locations (such as at the dinner table), and played with a doll on the slide. He also labeled the bedrooms Clients and Sxs. Client initiated an interactional role-play where one doll came to the back of the house and knocked to come into the house for dinner. SUMMARY Client, age 4;11, presents with significant receptive and expressive language delays, secondary to a diagnosis of Autism Spectrum Disorder. His comprehension skills are characterized by difficulties with longer sentences and multi-step directions, limited understanding of time and causality, and difficulty with advanced grammatical forms (prepositional phrases, future tense verbs, embedded clauses, and comparatives/superlatives). He also has difficulty understanding visual sequences of events. He has good comprehension for most wh (except why) and yes/no questions, locatives, and single-step directions. Clients expressive skills are characterized by limited vocabulary, difficulty with description, frequent revisions and repetitions, and an absence of more advanced grammatical forms (copulas, noun derivations, comparatives/superlatives, and objective and possessive pronouns). He also has difficulty repeating longer sentences, a task that requires holding the parts of a sentence in memory. His difficulties with sentence repetition, temporal event description, and spontaneous formulation of sentences might be due to the resource demands required to manipulate the parts of language in memory as he formulates his thoughts. Client is able to label common objects and actions and use early developing grammatical forms (plurals, simple prepositions, articles, past and progressive verb tenses, possessives, subjective pronouns, contractible copula, and the third person singular form). Client is able to use language for a range of communication functions. He demonstrates appropriate social communication skills as evidenced by social greetings, joint attention and reference, contingent responses, interactive play, and the ability to initiate and maintain topics. He lacks skills in producing sequential narratives, repairing communication breakdowns and indicating when he does not understand. Clients speech, fluency, voice, and hearing are all within normal limits. Clients prognosis for treatment is good. His ability to maintain task focus, participate in treatment activities, and follow clinician directions makes him a good candidate for treatment. RECOMMENDATIONS Based on the results of this assessment, the following recommendations are made: Language treatment is recommended for Client. He is a good candidate for treatment at the UWSHC and is currently on the clinic waiting list. His parents were provided with the Frequently Asked Questions handout pertaining to the waiting list at the parent conference. Areas of treatment should include: Receptive Language: Processing and understanding longer sentences Following multi-step directions Concepts of time and causality Comprehension of more advanced grammatical forms (such as future tense and pronouns) Expressive Language Expansion of vocabulary, particularly for more abstract concepts Sentence formulation skills Early narrative skills such as scripts or temporal event descriptions Acquisition of more advanced grammatical forms (such as pronouns, noun derivations, and comparatives/superlatives) Pragmatics and Language Use Repair of communication breakdowns, letting people know when he does not understand, and asking for more information. Use techniques at home to facilitate successful functional communication and provide opportunities for language expansion: Use simple one-step instructions rather than instructions or explanations with multiple parts. Check in when Clients comprehension appears uncertain. Encourage him to say I dont know or ask questions when he doesnt understand. Label and describe objects or actions in Clients environment, particularly those he is attending to and shows interest in. Develop and practice scripts for familiar home routines that have multiple steps. Example: Its time to get ready to bed what do we do first? Thats right, first we have to brush our teeth. What do we do next? Next, we have to put on our pajamas. Use visual cues such as toothbrush and pajamas if needed to support language. Reframe incomplete or inappropriately formed sentences and model them. Expand It big to Its a big strawberry or The strawberry is big. Encourage Client to use more specific language rather than general use of it, there, and that. Demonstrate appropriate establishment of references for pronouns. If Client says it up there, reply Yes, the bird is on the roof. Its up there. Continue reading Client familiar stories so that he can practice rehearsed language with visual support. Introduce new stories to model new vocabulary and new language forms. Follow up at CHDD for an assessment of current status across all domains. Suggested book: More Than Words: Helping Parents Promote Communication and Social Skills in Children with Autism Spectrum Disorder by Fern Sussman. The chapter Help your Child Understand What You Say has a number of techniques to enhance language comprehension for better communication with family members. Student 1, B.S. 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