Name: Alex Age: 2;10 Language: English/Spanish Speech Diagnosis: ModeratelySeverely Impaired Diagnosis: Verbal Apraxia Evaluation by: Catherine J. Crowley, J.D., Ph.D., CCCSLP. October 24, 2014 Background Information This evaluation took place in the family’s home in Elmont, New York. His mother provided the background information and was present throughout the evaluation. His mother is considered a very reliable informant. His mother was present during the evaluation and said that his performance was an accurate representation of his speech and language skills. Alex is an adorable, bright, and engaging 2 year 10 month old boy who lives with his mother and father. He attends a five day a week preschool where only English is spoken. His maternal grandmother took care of him four days a week from 7 am to 4 pm from when he was four months old until September 2014 when he began school parttime. She continues to care for Alex when he finishes school and before his mother gets home from work. Alex’s mother has a master’s degree in school psychology and has worked in preschools for children with disabilities for the past 14 years. His father is a high school graduate who is currently working as a commercial truck driver. His parents were born in the United States. His mother is ColombianPuerto Rican and his father is of mixed European heritage. Family history of speech and language disabilities is significant. Alex’s mother has a first cousin who has a daughter, now 17, with learning disabilities and speech and language delays. His father has a first cousin with Asperger’s Syndrome that was diagnosed in 1977. Alex was born premature at 33 1∕2 weeks of gestation. He was born jaundiced and because he was premature, he remained in the neonatal intensive care for a week and a half after birth. Alex was colic as a baby for about three weeks. He had a protein allergy and reflux, both of which resolved. Developmental milestones were within normal limits. He walked at 12 months and though the mother did not remember other motor milestones, she said she was not concerned as she felt they
were all within normal limits. The mother indicated that he is not a clumsy child and is wellcoordinated. Speech developmental milestones were within normal limits, babbling at 89 months, first word around 1 year, but two word combinations were a bit late at 24 months. The mother indicated that the babbling and the development of vocabulary were not robust. Preschool Experiences In September 2014 Alex began going to an integrated preschool where he is one of the community students, i.e. the students without disabilities. He started parttime but his teacher noted that Alex was having difficulties interacting with his peers. As a result, the family recently increased his preschool time so he is now in preschool five full days a week. When asked how Alex’s language compares to his peers, his mother indicated that his language skills are not at the level of the other community students in his preschool class. In addition, she and the teacher have noticed that Alex will avoid using language with the other children. He generally will not ask a child what is their name, or engage in verbal exchanges. Rather he communicates to a great extent nonverbally. He is not aggressive, but he is physical with the other students and will grab, push, or snatch toys from his peers in the classroom. Yet, he is very interested in his peers but engages in mostly nonverbal play with them. SpeechLanguage Development and Prior Services Alex’s mother became concerned about his speech and language development when he was 16 months old. He said very few words such as “mas,” “no mas,” “Mamum” (for Mommy), “Dadum” for Daddy, “pan” (bread), “agua” (water), and “Dame” (give me). His mother was concerned about his speech but he did not qualify for NYSDOH early intervention services. (In NYSDOH, Alex would have qualified for early intervention services with a diagnosis of developmental apraxia.) The family continued to be concerned about his speech and language development. In March 2014 the family contracted to pay a private agency to provide speechlanguage services to Alex. Since March 2014 Alex has received 2 sessions of speechlanguage therapy each week from a licensed speechlanguage pathologist. A review of Alex’s notebook on what he works on with his speechlanguage pathologist is concerning. While he is not yet 3 years old, the SLP is working on production of sounds that would not be considered delayed until several years later. For example, she is working with Alex on acquiring the “l” and “sp” blends. In addition, many of the pages focus on nonspeech oral motor exercises such as pursing the lips, protruding the tongue, and coordinating the jaw. His communication notebook reveals that the SLP has not provided support for Alex’s
speechlanguage delays in an evidenceinformed approach. Based on a review of this communication notebook from the SLP, it is unlikely that Alex has received any useful services to address the delays that he has. Language Background and Use Alex is an only child. His mother is bilingual in Spanish and English but reports that she is more comfortable in English unless she is with others who are speaking Spanish. Alex’s father is a monolingualEnglish speaker. While Alex’s mother is interested in him acquiring Spanish, she tends to speak only English with him unless her mother is in the room. Alex’s maternal grandmother is from Bogota, Colombia. She has taken care of Alex all day since he was 4 months old and uses Spanish virtually all the time she is with him. Alex’s first word was “agua.” More recently, Alex’s daily exposure to English has increased. His school is monolingualEnglish and he is there now five full days a week. The SLP that Alex has been seeing since March 2014 is a monolingualEnglish speaker because, his mother indicated, it is difficult to find a bilingual SLP. During the evaluation, Alex responded to Spanish in English, but this was likely influenced by the fact that the evaluator used English during the parent interview. Nonetheless, Alex can understand Spanish but has significantly stronger language skills in English. Evaluation Hearing The mother reported that before his first speech and language evaluation, Alex had a full audiological evaluation, which revealed his hearing to be normal. His mother said that he only had one ear infection that occurred recently, and was treated with antibiotics. Speech Assessment and Intelligibility Alex is able to produce all ageappropriate sounds and also sounds that well above his age expectations including /m, p, b, n, t, d, k, g, s, z, sh, dz, f, v/. While his earliest speechlanguage evaluations indicated that he had phonological processes, this is not the case for several reasons. First, most of the phonological processes identified in the evaluations are developmentally
appropriate such as stopping of the /s/ and cluster reductions. Secondly, Alex’s sound production is extremely variable and is continually changing. The impact of this variable and inconsistent expressive production is likely due to developmental apraxia, affecting the planning, sequencing, and production of sounds and words, which greatly affects his intelligibility. Errors are not predictable, making intelligibility very poor. His intelligibility is addressed further at the end of the language assessment section to distinguish the planning, sequencing, and production variability from a language impairment. Oral Peripheral Examination Structures are adequate for speech and feeding. Motor tone appears within normal limits. No jaw instability was observed. He was able to use his tongue, lips, and mouth to produce all developmentally appropriate speech sounds appropriately. He has a normal closed mouth and breathes through his nose. Normal saliva was observed including when speaking. Mother reports no feeding concerns. Language Assessment Evaluation materials: ● Parent interview ● Language sample ● Narrative sample ● Clinical observations ● Dynamic assessment ● SLAM (Schoolage Language Assessment Measures) ● Subway Picture ● Nonword repetition tasks ● Vocabulary ● Following directions ● Responding to questions Receptive Language English: Alex demonstrated at least ageappropriate understanding of functional uses of objects. He knew that we use a cup to drink water, a knife to cut our food, and a bowl to eat cereal. He also showed at least ageappropriate understanding of spatial relationships, including “under,” “on,” “on top of,” “in,” and “next to.”
Alex exhibited good problem solving skills and the ability to understand cause and effect. For example, when asked what he would do if his shirt had food on it, he said, “I jus [just] throw it in da washin” and when asked what to do when it is raining, Alex said, “On nocoas [raincoat].” Alex understood whquestions and other questions, such as “Who do you play with at school?” (“Simo”), “Where did you put them?” (“Downstairs”), “What would you do if it was raining outside?” (“Put on a raincoat”), “What happened next?” (“He a put socks on” [He put his socks on]), “How many boys are there?” (“One, two”), and “How does Daddy put you to sleep?” (“He Cick Cak Boo” [He reads Click Clack Boo]). Alex even answered some highlevel questions such as “Why did he tap on the barn?” (“’Cuz de duck in da ban [‘Cuz the duck is in the barn]”). Alex demonstrated understanding of complex sentence question forms such as “Show me the girl who is drinking juice.” Alex understood one and two step commands without prompts including “Take Thomas the Train over to mommy and give her a kiss” and “Hide Thomas the Train under the little chair.” Spanish: His receptive Spanish skills are significantly less strong because they are now less supported in his current linguistic environment. He could understand some simple words such as “manzana” (apple), “lluvia” (rain), and “gato” (cat), but not bicycle, shoe, or bird in Spanish. He also understood some simple sentences such as “Qué come la niña?” [What is the girl eating?], “Enséñame la bebé que está durmiendo”[Show me the baby who is sleeping], “Enséñame el bebé que está bañándose” [Show me the baby who is taking a bath], and “Qué pasó?” [What happened?]. He undoubtedly understands his grandmother when she speaks to him, but his English skills are significantly stronger. With exposure, his Spanish skills will continue to develop. In summary, Alex’s comprehension of English language is at least ageappropriate. He is bright, engaged, and interested in language and learning. Metalinguistic Understanding of Bilingualism The mother reported that Alex is developing a metalinguistic understanding of the two languages in his life. Recently the mother decided to read a book to Alex in Spanish, one that was in English print and that he had heard a number of times in English. As the mother read the book in Spanish, Alex almost immediately said, “No, stop it, Mommy” while pointing to the print text and saying, “Do this, Mommy” asking her to read the book as it is written, in English. He also responded correctly when he and his mother had a recent conversation about who speaks English and who speaks Spanish in the family. Later that day at bedtime, Alex handed his mother a book
to read and said, “Read, Mommy.” When the mother sat down to read the book, he said “English,” telling her to use English with the book. After reading the first book in English, the mother then chose another book and read it to him in Spanish. That night his mother said, “Buenos noches mi amor. Te quiero mucho.” [Good night, my love. I love you a lot.”] Alex responded, “Good night, Mommy. I love you.” Through these bilingual interactions, Alex demonstrated his metalinguistic understanding of the two languages and their places in his life. He is showing advanced metalinguistics and executive functioning for his age. Expressive Language Skills Throughout the evaluation, Alex did not use any Spanish expressively. During the Spanish section of the evaluation, Alex sometimes responded to Spanish in English showing that he understood what was said, but he did not use Spanish. His mother says that he tends to respond to Spanish with English at home and even sometimes with his grandmother who speaks virtually all Spanish to him. Alex uses language for many purposes and can even tell at least an ageappropriate narrative. He can problem solve with language, answer many different kinds of questions, talk about his day, ask a variety of questions, create commands, comment, and talk about movement and location. His expressive language is robust and rich. This evaluation provides below an analysis of the linguistic features focused on speech and intelligibility that impact his expressive language skills so that Alex should definitely meet the requirements for speechlanguage therapy skills. The mother provided a list of the most advanced sentences that she heard Alex use in the days before the evaluation took place. As can be seen, Alex uses language for a variety of purposes, including locative state and action (“Take little bicycle downstairs, Mommy”), existence (“Mommy, look juice on pants”), dative (“Pull zipper up Mommy”), additive (“Eat donut with blanket and pillow and cookie monster”), attribution (“Uh oh. Look at this dirty”, “scary”), recurrence (“Go see spider again” and “one more minute, Mommy”), quantity (“one”), notice (“Look. Watching scary Toy Story”), temporal (Polar Bear finish, Daddy”), state (“Juice spill on pants”), and numeration (“I do that first”). He has acquired the morphemes ing, plural “s,” prepositions “in” and “on” and uses prepositional phrases (“I going to pet store”). He also can produce whquestions including “what” (“What Daddy doing?”) and “where” (“Where one apple go, Mommy?”) and make declarative sentences (“Pull zipper up, Mommy”).
In the sentences from his mother and during the evaluation, Alex used simple sentences, which is typical for children of his chronological age. During the evaluation he used one complex sentence. When asked why the farmer is tapping on the barn window, Alex said, “’Cuz de duck in da ban” (because the duck is in the barn). Alex demonstrated emerging narrative skills that were at least age appropriate. With prompting, Alextold parts of the story of “Click Clack Boo” which is currently his favorite book. [What happened?] “Farmer Brown.” [“What did he do?”] “Farmer Brown xxx a candy on a porch.” [“What did Farmer Brown do?”] “Farmer Brown locks a door.” [“What did he do next?”] “He a put socks on.” [“Why did he put the socks on?”] “He xxx sleeping.” [“What happened next?”] “He is ta ta tapping on a window.” [“Why is he tapping on the window?”] “’Cuz de duck in da barn.” [“What was he doing in the barn?”] “Going give xxx candy in a party.” Alex’s expressive language skills in terms of syntax, morphology, and semantics are ageappropriate. His development of speech sounds is also least ageappropriate. Sequencing and Planning of Sounds, Syllables, and Words While Alex can produce all the phonemes that would be expected for his age, his speechlanguage impairment lies in the coordination and placement of the sounds within a word, of omission and addition of syllables, and even of words in sentences. For example, he named his favorite toy, Thomas the Tank as “Thomas che chen” and “Thomas a ten” and for the name of the book “Click Clack Boo,” Alex variously described the book as “Cick Cack Boo” and “Chee Chah Boo.” An example of the syllable addition was in how he said the sentence “Farmer Brown locks the door.” Alex said, “Fama Bown woks doey.” While the deletion of the /r/ and w/r substitutions are age appropriate, the addition of the syllable, causing the word “door” to have two syllables is not typical. An example of the deletion of sounds occurred when Alex was asked to explain what happened when shown a picture of a bicycle on the ground with a bent tire. When asked what happened, Alex said, “It’s broke” and then when asked to describe what happened, he said, “A tiecycle soh,” which seemed that he was saying, “The tire on the bicycle was soft.” Alex can produce all the phonemes in that sentence, but he omitted some single syllable words and combined the tire and bicycle into tiecycle, making the sentence unintelligible without context. This problem with maintaining all the features of the sentence, adding and omitting sounds, syllables, and single syllable words, and with maintaining the sounds in order was evident when Alex repeated nonsense words. Alex was able to repeat single and twosyllable nonwords such
as “kooch” and “Baboo.” For example, when Alex was asked to repeat the three syllable nonword, “Dee Dah Doh,” Alex repeated it differently each time after the same three syllable prompt was repeated: First, “Dah ee Dee Dah,” then “Dee Dah Dahee Dah,” then “Deh Dah Dahee Doo.” This example shows the variability of the vowels, number of syllables, and that his production did not improve with three repetitions. A final example of this occurred when the evaluator read Alex the book, “From Head to Toe.” In that book there is a movement made and the child is asked, “Can you do it?” to which the child responds, “I can do it.” During the first readthrough of the book, Alex hesitated greatly in saying, “I can do it.” His repetitions of the sentence were so variable that it was often difficult to realize that he was attempting to say, “I can do it.” Each time was different and greatly variable in length and number of syllables and the phonemes used. The second time the book was read, however, Alex waited for the evaluator to give him the prompt of “I” and to give him some intonation prompts and tap out the syllables on his arm. When the story was read a second time, Alex had all the words in place and only occasional minor variability in the first phoneme and last syllable. This indicated that Alex has great potential for a multisensory approach, has high modifiability and is stimulable. It is likely that Alex’s difficulty in planning sounds, syllables, and words combined with great variability is affecting his interactions at school. Alex is clearly aware that his speech and language cause great intelligibility issues. Even during the reading of “From Head to Toe,” he paused and waited for the “I” prompt, knowing it would help him. Also when this evaluator did not understand him, Alex would look a little concerned and look to his mother to help him be understood. One area of strength is in his production of many final words in his sentences. Those final words tend to be intelligible 80% of the time, given developmental errors. Alex often emphasizes the final consonant of a word which helps in understanding what he is saying. Voice and Resonance Within normal limits. Fluency Within normal limits. Conclusions
1) Alex is a bilingual 2 year 10 month old boy. He has significantly stronger skills in English, although his continues to be exposed to Spanish especially by his maternal grandmother. 2) Alex can produce all sounds expected for his age level, and many not expected until later including /p, b, m, t, d, n, k, g, s, z, ch, sh, dz/. 3) Alex’s development of morphology, syntax, and semantics is within normal limits for receptive and expressive language. Alex can understand ageappropriate 2 step directions and can respond to many question forms, indicating that he does not have an auditory processing problem. 4) Alex’s intelligibility is greatly affected by planning and ordering sounds, syllables and onesyllable words. He will often use different sounds and put the sounds out of order. 5) The final word in Alex’s sentences is often intelligible. He emphasizes the last consonant of that final word, which helps the listener understand what he is saying. 6) Alex is aware that his utterances are difficult to understand. It is likely that this is why Alex does not speak much with his peers in his school. 7) A great strength for Alex is his mother. She is a school psychologist and is deeply committed to working with him to increase his intelligibility. She is a gifted teacher and she and her husband have provided Alex with books, puzzles, and toys, and have created a rich learning environment for him in the home. Summary 1) Alex would benefit for speechlanguage therapy focusing on using a multisensory approach using intonation and tapping or clapping sounds and/or syllables in repetitions of key phrases and words, nonword repetition tasks, including a focus on vowels. These drills must be fun and gamelike, and delivered as quickly as Alex can manage. The focus is on increasing his intelligibility. Alex needs multisensory feedback developing intraword phoneme organization for the planning, sequencing, and formation of sounds, words, and sentences. 2) Therapy will focus on short sentences that will help Alex verbally interact with his peers at school, such as, “What is your name?,” “Can I play with you?,” “Want to play with me?,” “Let’s go to the block center,” or whatever phrases he may need in school. 3) Encourage songs and stories with repeating lines, especially if a multisyllabic approach can be used, such as the songs “Head Shoulders Knees and Toes,” “Wheels on the Bus,” and the Eric Carle books, “Brown Bear, Brown Bear” and “Head to Toe.” /s/ Catherine J. Crowley, J.D., Ph.D., CCCSLP Bilingual SpeechLanguage Pathologist
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