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Early Identification and Intervention in the 0-3 Population

Fig. 30.1 KLPA-3 summary of standard scores and percent of occurrence of the core phonological processes for CJ at age 2,9.

109

Early Identification and Intervention in the 0-3 Population

Fig. 30.2 KLPA-3 phonetic inventory of consonants in single words for CJ at age 2,9.

Fig. 30.3 KLPA-3 summary of consonants analysis: phonetic inventory, core phonological processes, other phonological processes, and process per

word (PPW).

●

Use of nine Other Phonological Processes: Interdentalization, palatalization, denasalization, alveolarization, reduplication, labialization, addition of stridency, addition of schwa, nasal assimilation.

●

Extremely limited phonetic repertoire consisting primarily of labial and alveolar stop consonants, with infrequent instances of fricative sounds.

●

Vowel elongation.

30.4 Questions and Answers for the Reader

1. Early and regular developmental and behavioral screening is

recommended by the American Academy of Pediatrics (AAP) at:

a) Every well-child check appointment.

110

Early Identification and Intervention in the 0-3 Population

b) Developmental screening at 9, 18, and 24 or 30 months

and autism-specific screening at 18 and 24 months.

c) The AAP does not recommend screening and instead

relies on ongoing surveillance by pediatricians.

d) The AAP does not have a recommendation regarding

autism-specific screening.

Answer: b is correct. In 2006, the AAP adopted a set of guidelines for developmental and autism screening.

a is incorrect. Though some pediatricians may screen children at every well-child visit, the current AAP guidelines call for a periodicity schedule of developmental screening at 9, 18, and 24 or 30 months with specific autism screen at 18 and 24 months.

c is incorrect. The AAP recommends surveillance by pediatricians at every well-child check visit and developmental/behavioral screening at 9, 18, and 24 or 30 months. The AAP supports the concept that early childhood screening is an essential component of health supervision and provides a foundation for monitoring and supporting healthy physical, cognitive, and psychosocial development.

d is incorrect. The AAP guidelines include a periodicity schedule for administration of an autism-specific tool at ages 18 and 24 months.

2. EI is a federally mandated ser vice for children and their fam-

ilies who: a) Are determined eligible for services by demonstrating

delays, typically at least by 25%, in one or more develop-

mental domain. b) Qualify by being at 100% below the federal poverty level. c) Use English as the primary language in the home. d) Are located in metropolitan areas near EI programs.

Answer: a is correct. This response is correct. EI providers complete a comprehensive, multidisciplinary assessment to determine the eligibility for services. States determine the percent of delay that a child must demonstrate in one or more developmental domains to be determined eligible.

b is incorrect. Income level is not part of the eligibility criteria for EI services. EI programs provide services to families across the income spectrum.

c is incorrect. Primary home language of English is not part of the eligibility criteria for EI services. EI programs provide services to eligible families regardless of the primary home language.

d is incorrect. Geographic location is not part of the eligibility criteria for EI services. EI programs provide services to eligible families regardless of residence.

3. According to the DSM-V, SSDs are defined as:

a) Persistent diﬃculty with speech sound production. b) Disturbance causes limitations in eﬀective communica-

tion that is interfering. c) Onset in early developmental period. d) Not attributable to congenital or acquired conditions. e) All of the above.

Answer: e is correct. The DSM-V definition for SSD includes criteria of the four components listed above. SSD is a persistent condition that interferes with communication via multiple

speech sound production errors. It presents in early childhood without a known congenital or acquired cause.

4. A phonological approach to assessment of SSDs in children resulting in unintelligible speech involves:

a) A quick screening of a child’s speech production to iden-

tify correct production of individual, early developing sounds.

b) An in-depth analysis of a child’s speech production sys-

tem to identify the phonological processes, phonetic environment, and phonetic inventory that capture the rules that are governing speech sound errors and the sound repertoire available to a child.

c) A spontaneous speech sample in which the target produc-

tions are not able to be identified.

d) A methodology that enables clinicians to design treat-

ment plans at a phonological systems level to impact change in an eﬃcient manner.

e) b and d.

Answer: e is correct. A phonological approach to assessment provides the clinician with in-depth information regarding a child’s speech production system and enables the clinician to integrate the results into treatment plans.

a is incorrect. A phonological approach to assessment of SSDs in children is an in-depth analysis of the rules and patterns that govern a child’s multiple speech production errors. The approach involves identifying the phonological processes or patterns that the child employs that contribute to reduced speech intelligibility.

b is one of the correct answers. A phonological approach to assessment of SSDs in children requires the collection of a preponderance of evidence including phonological process usage, phonetic environment of patterns of errors, and the phonetic inventory of available sounds.

c is incorrect. When a child presents with SSD, typically there is reduced speech intelligibility, oftentimes unintelligible speech production the majority of the time. Phonological assessment requires the examiner to compare the child’s speech production to the intended target word or phrase, a task that is often not possible with children presenting with highly unintelligible speech.

d is one of the correct answers. The summary from a phonological assessment provides the information needed to determine phonological treatment goals and objectives and to identify treatment stimuli.

30.5 Description of Disorder and Recommended Treatment

EI, a federally mandated service, is operated in states as a comprehensive, coordinated interagency system that provides multidisciplinary interventions for infants and toddlers with or at risk for developmental delays. EI is designed to serve children under the age of 3 and their families. Communication diﬃculties are among the most widely reported developmental delays in this age group. Speech-language pathologists (SLPs) and audiologists play an essential role in the early identification of developmental concerns to ensure linkage to services. Commu-

111

Early Identification and Intervention in the 0-3 Population

nication delays may present in various ways; however, SSDs are highly prevalent and are identified in approximately 15.6% of 3-year-old children. The majority of children receiving EI serv-

ices qualify with a communication delay. The DSM-V

provides the following criteria for SSD: (1) persistent diﬃculty with speech sound production; (2) disturbance causes limitations in eﬀective communication that is interfering; (3) onset in early developmental period; and (4) not attributable to congenital or acquired conditions. SSD includes the conditions formally referred to as articulation disorders and phonological disorders.

CJ presented with a severe SSD characterized by frequent use of multiple phonological processes, both typical and atypical, along with a limited phonetic repertoire. Through his EI program, CJ received weekly visits from a certified SLP and bimonthly visits from a developmental specialist. Initially, a sound-by-sound articulation treatment approach was used as demonstrated by the goal: “Correct production of initial /p/ and /b/.” After 6 months of EI services, CJ’s speech remained highly unintelligible with a high frequency of multiple phonological processes usage and speech sound errors.

When CJ transitioned from EI services to the public school developmental preschool services, the treating SLP used a systems-level phonological approach to intervention. Broad diversity exists in the literature regarding approaches to target

selection, intervention, and service delivery.

Though the importance of a systematic approach to target selection is indisputable, some advocate for a developmental approach by building on early-to-develop, stimulable sounds, while others advocate for a paradoxically distinct complexity approach that promotes the prioritization of late-developing, nonstimulable sounds.

Treating children with SSD presents challenges. Assessment relies on the accurate transcription of unintelligible speech and a deep analysis of the rules, or phonological processes that impact the sound changes. Furthermore, clinical decisions include:

●

Service delivery:

○

Individual or group.

○

Dosage:

– Number of days per week. – Length of session. – Duration of treatment.

●

Target selection:

○

Where to begin.

●

Impact on intelligibility:

○

Developmental or complex strategy.

●

Treatment approach

●

Method of feedback

●

Discharge decisions

a percent of accuracy. The research on phonological remediation reports generalization of accurate production to sounds that are not targeted directly, thereby increasing the likelihood of improved speech intelligibility while decreasing the time achieving this goal.

After review of CJ’s comprehensive evaluation for speechlanguage services within the part B special education preschool program, a developmental approach to treatment was recommended. Initial targets included the decrease of Stopping. Typically, stopping involves the sound change from fricatives and aﬀricates to stop consonants. In CJ’s case, he used stopping not only for fricative and aﬀricates, but also on nasals and glides. Stopping of other sounds is considerably less common than stopping of fricatives and aﬀricates and has a negative impact on intelligibility. In spite of the consistent occurrence of Stopping, CJ’s phonetic inventory included instances of fricative productions in word-initial, word-medial, and word-final positions. Treatment methodology benefited from CJ’s fricative productions in his phonetic repertoire to influence the decrease of stopping.

30.6 Outcome

At 3 years of age, CJ qualified for services through the public school part B special education services based on his severe SSD. He participated in a 4-day per week developmental preschool program designed for children with severe SSDs and received individual therapy for 30 minutes, 4 days a week. The SLP collaborated with the special education preschool teacher to integrate opportunities for CJ to practice his speech/language goals within classroom activities. CJ also received follow-up audiological services every 3 months to monitor hearing acuity and middle-ear function.

KLPA-3 was administered after 6 months of intervention.

▶ Table 30.1 demonstrates the change in the quantitative met-

rics. CJ demonstrated a 25% reduction in the raw score, a metric based on the number of occurrences of the 12 Core Phonological Processes. CJ’s KLPA-3 standard score and percentile rank continued to qualify him for speech/language services. The process-per-word measure was sensitive to the improvement in CJ’s overall speech intelligibility.

Qualitative measures such as the percent of occurrence of individual phonological processes decreased for the Core Phonological Processes, and CJ used fewer overall Supplemental/ Other Phonological Processes. The phonetic inventory included an increase in the use of fricatives in all word positions, the use of the initial nasals /m/ and /n/ (previously absent in phonetic inventory), and the use of word-initial aﬀricates.

In summary, a phonological approach to intervention with children with SSDs is based on the rule-governed nature of the phonological system. Phonological processes describe patterns of errors within a phonetic environment. Treatment goals may target entire classes of sounds (e.g., decreasing the use of stopping of fricatives and aﬀricates), word structure (e.g., decreasing deletion of final consonants), and/or distinctive features such as voicing errors (e.g., decreasing final devoicing) rather than targeting correct production of individual sounds toward

Table 30.1 KLPA-3 scores at onset of treatment (36 months of age) and after 6 months of treatment (42 months of age)

KLPA-3 scores Prephonological

treatment

Raw score 93 70

Standard score 70 75

Percentile rank 2nd 5th

Process per word 2.55 1.91

Post-6-month course of treatment

112

Early Identification and Intervention in the 0-3 Population

At 42 months, CJ’s mother reported that he had recently demonstrated a significant gain in his overall speech intelligibility. Family members and his preschool teachers were better able to understand CJ’s speech production. As well, CJ’s expressive language skills improved, and he appeared more confident and willing to engage with others at school and at home.

30.7 Key Points

●

SLPs and audiologists play an essential role in the promotion of developmental monitoring as well as early and regular developmental and behavioral screening that improve early identification practices.

●

EI for children with speech, language, and/or hearing delays/ disorders relies on the early identification eﬀorts of health care providers and early childhood professionals, including SLPs and audiologists.

●

SSDs are reported in 15.6% of 3-year-olds, and communication concerns, in general, surface early as parental concerns.

●

A phonological analysis is a critical component of a comprehensive evaluation for children with unintelligible speech.

●

Though approaches to treatment vary, a phonological approach to the remediation of SSDs instructs clinicians to target aspects of a child’s phonological system that can lead to improved speech intelligibility.

References

[1] Khan L, Lewis N. Khan–Lewis Phonological Analysis. 3rd ed. San Antonio, TX:

Pearson; 2015

[2] Goldman R, Fristoe M. Goldman–Fristoe Test of Articulation. 3rd ed. San An-

tonio, TX: Pearson; 2015

[3] American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013

[4] Baker E, McLeod S. Evidence-based practice for children with speech sound

disorders: part 1 narrative review. Lang Speech Hear Serv Sch. 2011; 42(2): 102–139

[5] Council on Children with Disabilities, Section on Developmental Behavioral

Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening. Pediatrics. 2006; 118(1):405–420

113

Treatment of Pragmatic Language Disorders in Preschool and School-Age Children

31 Treatment of Pragmatic Language Disorders in Preschool and School-Age Children

Jessie L. Ginsburg

31.1 Introduction

CJ was a 3-year-old boy who was referred for speech and language therapy after being diagnosed with a social communication disorder by a psychologist at a state-funded agency. At 3 years of age, children typically begin preschool and are expected to interact with peers and participate in preacademic activities. Strong social communication skills are needed to build and maintain friendships, as well as form the foundation for academic success.

31.2 Case Description

CJ was a 3-year-old male born at 38 weeks via cesarean section following an unremarkable pregnancy. He lived with his biological parents and English was the only language spoken in his home. CJ said his first word at 12 months, walked at 15 months, and combined words at 30 months. At CJ’s 3-year checkup, his pediatrician recommended speech and language evaluation due to concerns with his language development. A psychologist from a state-funded agency diagnosed CJ with a social communication disorder. At 3.6 years, CJ’s parents enrolled him in a private preschool 5 days per week, where he reportedly followed directions and participated in classroom activities without diﬃculty. His teachers observed repetitive behaviors that led his parents to seek a developmental evaluation through the local school district.

At 3.8 years, a school psychologist assessed CJ’s cognitive skills and his performance qualified him to receive special education services based on the criteria of aut ism. CJ’s parents rejected the services oﬀered as the school district was unable to provide transportation to and from therapy.

Two m onths later, CJ’s p arents obtained a developmental evaluation for CJ through a s tate-funded agency. A psychologist assessed him using the Vineland Adaptive Behavior Scales, Second Edition (VABS-II). He scored in the fif th percentile in the socialization domain, indicating significant deficits in social skills. The psychologist also assessed CJ using the Autism Diagnostic Obser vation Schedule, Second Edition (ADOS-2). Based on the results of that assessment, the psychologist diagnosed CJ with low-to-moderate level of autism.

31.4 Questions and Answers for the Reader

1. What major deficit area(s) should be addressed in CJ’s treat-

ment goals? a) Receptive and expressive language. b) Expressive language and auditory processing. c) Pragmatics. d) Expressive language and pragmatics.

31.3 Clinical Testing

At 3.6 years, a speech-language pathologist (SLP) in CJ’s school district assessed his language using the Preschool Language Scale, fifth Edition (PLS-5), and diagnosed him with an expressive language disorder (▶ Table 31.1). CJ’s parents brought him to a private clinic where an SLP performed an informal assessment of his play using the Floortime Observation Checklist. This assessment revealed that CJ demonstrated diﬃculties with continuous interaction, answering questions, problem solving, perspective taking, and emotional thinking.

Table 31.1 Preschool Language Scale, Fifth Edition

Standard score Percentile rank

Auditory comprehension

Expressive communication

97 42nd

84 14th

Answer: d is correct. CJ’s score of 84 on the expressive commu- nication subtest of the PLS-5 was below average, and, therefore, expressive language should be addressed in treatment. CJ was diagnosed with autism spectrum disorder, which suggests he has deficits in his social use of language. Accordingly, improving CJ’s pragmatic language should be a primary goal in his treatment.

a is incorrect. CJ did not show deficits in his receptive language on the PLS-5, nor did his teachers or parents have concerns with his language comprehension.

b is incorrect. CJ’s auditory processing skills had not been assessed.

c is incorrect. CJ’s pragmatic language should be targeted in therapy; however, it is not the only deficit area that should be targeted.

2. In addition to individual speech and language therapy, what

other type of therapy would you recommend for CJ? a) Occupational therapy. b) Physical therapy

114

Treatment of Pragmatic Language Disorders in Preschool and School-Age Children

c) Social skills groups. d) Vision therapy.

Answer: c is correct. Social skills groups should be recommended to address CJ’s pragmatic language deficits.

a is incorrect. While it may be appropriate to recommend an evaluation for occupational therapy, it would not be within an SLP’s scope of practice to recommend therapy sessions.

b is incorrect. CJ’s parents did not voice concerns regarding CJ’s motor development.

d is incorrect. CJ’s parents did not voice concerns regarding his vision or visual processing.

3. What role(s) should CJ’s parents play in therapy?

a) Participate in coaching sessions with the SLP. b) Target CJ’s goals in the home. c) Demonstrate an understanding of the SLP’s therapy

approach.

d) All of the above.

Answer: d is correct. Parent education and training is key to the success of CJ’s treatment. The SLP must educate CJ’s parents on her therapy approach, CJ’s goals, and how to target his goals at home. The SLP should also demonstrate strategies and provide parents with the opportunity to participate in therapy sessions. Parent education and training helps ensure CJ’s generalization of new skills.

a is incorrect. Participating in coaching sessions is a key element; however, it is not the only role that CJ’s parents should play in his treatment.

b is incorrect. Targeting CJ’s goals in the home is crucial; however, it is not the only role that his parents should play in his treatment.

c is incorrect. Demonstrating an understanding of the SLP’s therapy approach is important; however, it is not the only role that CJ’s parents should play in his treatment.

4. What other professional should CJ’s SLP communicate with

on a regular basis? a) Teacher. b) Audiologist. c) Occupational therapist. d) Physical therapist.

Answer: a is correct. It is important for CJ’s SLP to collaborate with his teacher to improve his treatment outcome. CJ’s teacher should be made aware of his treatment goals and should be taught strategies that she can use to target his goals in the classroom.

b is incorrect. CJ has no history of hearing loss or ear infections.

c is incorrect. CJ has not been assessed by an occupational therapist.

d is incorrect. CJ does not receive physical therapy.

Table 31.2 Diagnostic Evaluation of Language Variation

Domain Scaled score Percentile rank

Pragmatics 7 5th

31.5 Description of Disorder and Recommended Treatment

CJ began receiving individual speech and language therapy sessions at a private clinic two times per week at the age of

3.6 years. Treatment focused on improved expressive and pragmatic language skills, with a strong emphasis on parent education and training. Therapy goals included answering WH-questions, engaging in multistep symbolic play schemas , and conversational turn taking. CJ’s teachers were continuously informed of his treatment goals and were also taught strategies to employ in the classroom. The SLP recommended an occupati onal therapy evaluation; however, due to diﬃculties with scheduling, his parents decided they would have him assessed at a later date.

At 3.9 years, CJ was placed in a social skills group in the private clinic with one other peer. Five months later, an additional peer was added to the group. Throughout this time, CJ continued to receive individual speech and language therapy in the private clinic one to two times per week.

31.6 Outcome

At 4.6 years, the CELF-P (Clinical Evaluation of Language Fundamentals Preschool) was readministered. CJ tested in the average range in all subtests of the CELF-P, scoring in the 55th percentile. These results suggested that he no longer demonstrated deficits in the area of expressive language. He used appropriate grammar, answered age-appropriate WH-questions, and had a typical mean length of utterance for his age.

At 5 years, CJ’s social language was assessed via the Developmental Evaluation of Language Variation (DELV). He scored in the fifth percentile on the pragmatics subtest with significant diﬃculties with social use of language (▶ Table 31.2). CJ’s language was also reassessed using the CELF for school-age children. He scored within the average range on all subtests with the exception of the pragmatics profile, in which he scored in the first percentile (▶ Table 31.3).

Table 31.3 Clinical Evaluation of Language Fundamentals, Second Edition

Subtest Scaled score Percentile rank

Sentence comprehension

Linguistic concepts 8 25th

Word structure 9 37th

Word classes 10 50th

Following directions 11 63rd

Formulated sentences

Recalling sentences 7 16th

Understanding spoken paragraphs

Pragmatics profile 3 1st

15 95th

10 50th

7 16th

115

Treatment of Pragmatic Language Disorders in Preschool and School-Age Children

CJ is currently 5.7 years. He recently completed a 12-week integrated day program for children with autism in the neuropsychiatric department of a local hospital. The program consisted of five children and three special education teachers. During the program, CJ received intensive speech therapy and occupational therapy, and was followed by a psychologist and neurologist. He showed great gains in his expressive language and cognitive skills. The program’s occupational therapist recommended that he continue occupational therapy to improve sensory processing, although he showed considerable improvement in this area. Professionals in the program recommended he continue attending social skills therapy to improve pragmatic language. CJ is currently participating in two social skills groups per week in a private clinic. These group sessions target conversational skills such as topic maintenance, continuous interaction, and appropriate commenting. These sessions also target cognitive and play skills necessary for successful social interaction, including turn taking, problem solving, perspective taking, and emotional thinking.

31.7 Key Points

●

SLP collaboration with parents and teachers is critical to the success of a child’s speech and language treatment . Parents

and teachers should be educated regarding a child’s treatment goals and trained in the strategies they can use to target these goals in home, at school, and in other environments. This education and t raining is crucial to ensuring a child’s generalization of skills across settings.

●

Children on the autism spectrum may test in the average range for receptive and expressive language, but show significant deficits in their use of social language. Assessments of pragmatic language and play skills are crit ical to obtain baseline measurements and show progress in treatment.

●

Social skills groups are key in treating pragmatic language disorders.

Suggested Readings

[1] Greenspan S, Wieder S. The Child with Special Needs: Encouraging Intellec-

tual and Emotional Growth. Reading, MA: Perseus Books; 1998

[2] Greenspan S, Wieder S. Engaging Autism: Using the Floortime Approach to

Help Children Relate, Communicate, and Think. Philadelphia, PA: Da Capo Press; 2009

116

Cognitive-Linguistic Deficits in Pediatric Acquired Brain Injury

32 Cognitive-Linguistic Deficits in Pediatric Acquired Brain Injury

Shayne Kimble

32.1 Introduction

This case study outlines the evaluation and treatment of a pediatric client with a cognitive-linguistic disorder secondary to acquired brain injury. Acquired brain injuries in pediatrics can be caused from a variety of situations, including motor vehicle accidents or nonaccidental traumas (i.e., abuse). They can vary from patient to patient, where diﬀerent clinical symptoms are shown based on neuropathophysiology.

32.2 Clinical History and Description

AB was a 9-year-old, right-handed male admitted to inpatient rehabilitation following an unrestrained motor vehicle accident. At the time of the accident, AB had no significant past medical history. He was in the third grade, where he made “good” grades with no previous history of therapy services or intervention. He lived at home with both parents and one sister.

Upon arrival to the acute care facility, a magnetic resonance imaging of the brain revealed an extensive shear injury and multiple contusions. After AB was medically stable, he was transferred to an inpatient rehabilitation facility for evaluation. He presented in a minimally conscious state with a G-tube in place for all hydration and nutrition. The term "minimally conscious" is applicable when “vegetative/unresponsive patients show minimal signs of consciousness, but are unable to reliably communicate.” groups, MCS(+) and MCS(–). The diﬀerence between the two states is contingent on the level of behavioral responses produced by the patient, higher (i.e., following commands) versus lower level behaviors (i.e., localizes to noxious stimulation).

The term is further subcategorized into two

32.3 Clinical Testing

AB was evaluated at bedside with both parents present to serve as informants. He was evaluated to determine current functional status with regard to cognitive-linguistic and swallowing skills. Although the purpose of this chapter is focused on cognitive-linguistic skills, a clinical bedside swallow examination was completed during initial evaluation where the patient continued to be NPO (nil per os) secondary to, but not limited to, no volitional cough/volitional purposeful oral-motor movements. An interdisciplinary evaluation was completed by physical therapy, occupational therapy, and speech-language pathology, and each discipline administered portions of the JFK-Coma Recovery Scale (CRS). assist with diﬀerential diagnosis, prognostic assessment, and treatment planning in patients with disorders of consciousness. The scale has six assessment domains, including consistent movement to command, object recognition, object manipulation, oral reflexive movement, and eye opening with stimula-

The purpose of this numeric scale is to

tion. AB presented with eyes opening without stimulation (CRS Arousal Scale: 2), no auditory startle or localization (CRS Auditory Function Scale: 0), a visual startle (CRS Visual Function Scale: 1), flaccid with no other motor responses (Motor Scale:

0), oral reflexive movements (CRS Oro-Motor/Verbal Function Scale: 1), and no nonfunctional (intentional) communication (CRS Communication Scale: 0). AB’s mother reported some minimal vocalizations, but none were observed during the evaluation. AB presented with a left visual fixation, which was consistent throughout the evaluation.

32.4 Questions and Answers for the Reader

1. Based on the diagnosis of the patient, which assessment would be best to be included in your evaluation?

a) Test of Language Development Primary (TOLD-P). b) Comprehension of Spoken Language (CASL). c) Goldman–Fristoe Test of Articulation (GF TA). d) Pediatric Test of Brain Injury (P TBI).

Answer: d is correct. The PTBI may be better suited secondary to the content corresp onding with deficits generalized from brain injuries. Skills such as memory, orientation, and organizational language skills are typically aﬀected by acquired brain injuries; therefore, these should be assessed during an initiation evaluation in the inpatient rehabilitation setting. Of course, a standardized assessment should only be one key portion of your complete evaluation, but can be a valuable tool.

a, b, and c are incorrect. Although some information may be beneficial for the academic and back-to-school setting, some subtests of developmental language/articulation assessments may assess skills that are not typically aﬀected by an acquired brain injury (i.e., morphology/phonology).

2. What member would drive the care of this patient on the

inpatient rehabilitation acquired brain injury team for a

patient similar to this? a) Orthopedic surgeon. b) Neurologist. c) Physical medicine and rehabilitation physician (PM&R).

Answer: c is correct. Although team members may vary from facility to facility along with their roles, the most common individuals are PM&R, pediatrician, clinical psychologist, physical therapist, occupational therapist, speech-language pathologist, social worker, care coordinator, nurse, child life specialist, recreational therapist, nutritionist, school specialist, and orthotics doctor.

a is incorrect. The orthopedic surgeon, at times, is an important consult on the brain injury team as the patient may have sustained a variety of trauma to the musculoskeletal system.

117

Cognitive-Linguistic Deficits in Pediatric Acquired Brain Injury

This team member may make some decisions within the care of their field, but may not drive the care for the patient holistically.

b is incorrect. Again, like the orthopedic surgeon, the neurologist is a key consult when making decisions regarding the neurological system, but may not drive the care in the specific setting.

3. Which of the following is not a disorder of consciousness?

a) Coma. b) Minimally conscious state. c) Vegetative state. d) Mild traumatic brain injury.

Answer: d is correct. Mild traumatic brain injury is typically the term given for a concussion. Although it is believed that individuals with mild traumatic brain injuries, or concussions, may go through disorders of consciousness quickly and progressively, it itself is not a disorder of consciousness.

a is incorrect. A person who presents at this level of disorder of consciousness usually presents with no behavioral evidence or arousal and demonstrates no voluntary response to stimuli. This individual may present with no arousal/eye-opening, impaired spontaneous breathing, and impaired brainstem reflexes.

sciousness is a severely altered consciousness with behavioral evidence present for self- or environmental awareness. This individual may present with spontaneous eye opening, some reproducible behavioral signs of awareness, response to verbal directions, and object localization and manipulation.

sciousness is similar to the coma state, but with preserved capacity for spontaneous or stimulus-induced arousal. This individual may present with arousal/eye-opening and no purposeful behaviors, and may grimace to pain/localize to sounds inconsistently.

4. Which of the following is not a type of attention?

Answer: a is correct. Metacognition is not a type of attention but is a cognitive domain that is typically assessed by speechlanguage pathologists to gain further insight into self-awareness.

respond to internal and external stimuli.

between tasks.

attention to complete tasks.

attention in the presence of competing distractions.

simultaneously to multiple task demands.

b is incorrect. A person who presents at this level of con-

c is incorrect. A person who presents at this level of con-

a) Metacognition. b) Focused. c) Alternating. d) Sustained. e) Selective. f) Divided.

b is incorrect. Focused attention is the ability to perceive and

c is incorrect. Alternating attention is the shift of focus

d is incorrect. Sustained attention is the ability to maintain

e is incorrect. Selective attention is the ability to maintain

f is incorrect. Divided attention is the ability to respond

32.5 Description of Disorder and Recommended Treatment

AB presented initially as minimally conscious (–) with a cognitive-linguistic disorder and oropharyngeal dysphagia. The patient presented with no functional communication skills upon evaluation and received continuous feeds via G-tube. Patient was showing some emerging skills such as a visual startle and eye opening without stimulation. When treating acute, acquired brain injuries, it is important for the clinician to adapt and engage in critical thinking, given that the child’s status may change rapidly. Regular reassessment is required for driving modification of treatment goals, as a patient one day may be unable to answer basic yes/no questions, but the next day being able to answer complex “WH” questions. As AB progressed in therapy, the team’s goals and intervention were frequently altered. AB was seen initially three times daily for 30 minutes for 10 weeks.

Week 1–4: During initial therapy sessions, basic cause/eﬀect relationships were trialed. A B utilized a one-cell device with a picture of his sister, which would play a message read by his sister when selected. This meaningful reward was used to target intentional active movements of his upper extremities. Physical prompts were given initially as other rewards were integrated into the cause/eﬀect select such as bubbles, familiar music, pleasant smells, and deep pressure. During this time, dysphagia was targeted in regard to rebuilding motor plan for oro-motor skills such as labial seal around a dry spoon/jaw grading when presented with a dry spoon. Patient continued intensive dysphagia therapy to further target coordination of the swallow.

Week 5–6: As AB progressed, higher level goals were incor- porated. Basic two-step sequential motor directions were targeted to improve receptive language skills, reduce impulsivity, and increase attention. As these increased, commands then incorporated verbal output (expressive language) and more difficult directions. Following directions targeted multiple language skills and higher executive functioning skills. A s the ability to follow directions increased, it is important to note at this time that AB received a Modified Barium Swallow Study where the patient was cleared for a regular diet and thin liquids.

Week 7–10: As AB’s language skills improved, his goals were expanded to target following commands, organizational language, memory, and other executive functioning skills. Functional therapy tasks included following written recipes during baking activities, following visual directions during Lego building activities, creating age-appropriate narratives, and concrete/ abstract divergent naming. Functional and engaging activities are necessary to aid attention and to promote carryover of skills.

32.6 Outcome

The CRS was administered weekly by each discipline (▶ Table 32.1). As AB progressed and demonstrated emerging cognitive-linguistic skills, the team administered the PTBI to further assess more specific cognitive-linguistics deficits. His scores over time are shown in ▶ Table 32.2.

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