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Feeding and Language Therapy in a Child with Congenital Cytomegalovirus and TBI
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
35 Feeding and Language Therapy in a Child with
Congenital Cytomegalovirus and Traumatic Brain Injury
Debra L. Kerner
35.1 Introduction
This case illustrates the challenges across multiple areas of
communication related to a complex medical history, including
feeding difficulties and language deficits as well as cognitive
and auditory challenges. An evidence-based rationale is provided for treatment approaches.
1–3,4,5–6
35.2 Clinical History and
Description
MD was an 8.6-year-old boy born at 35 weeks via emergency
C-section due to nonresponse from ultrasound stimuli. At birth,
he weighed 5.4 lb and was 18 in. long. Complications following
birth included congenital cytomegalovirus, grade 2 intraventricular hemorrhage (IVH), hypotonia, liver failure, low platelets, high
bilirubin, profound hearing loss, as well as patent ductus arteriosus (PDA ). He also had a history of retinopathy, nystagmus, and
retinitis, and wore corrective lenses. Before he was 12 months old,
he had multiple surgeries, including 14 blood transfusions,
PDA repair, gastrostomy button (G-button) insertion due to poor
feeding, and bilateral cochlear implantation. His G-button was
employed f or medications and occasionall y f or hydration, as
needed. MD consumed liquids, purees, and mechanical soft foods
for caloric intake orally. He was nonverbal and used ProLoQuo2Go
as his primary means of communication. He also occasionally
used minimal sign language. MD attended a privat e school that
focused on education for children with disabilities. He received
private occupational therapy , physical therapy, and hippotherapy
in addition to speech therapy as well as group speech therapy,
music therapy, and occupational therapy at school.
35.3 Clinical Testing
An initial evaluation by this clinician, conducted at age 6.4
years, revealed his overall functioning was age equivalent to 12
to 18 months in all areas of communication. Using the San
Diego Occupational Therapy Feeding Skills checklist and Morris
and Klein feeding checklist, his feeding skills were age equiva-
lent to 6 to 8 months. His augmentative and alternative communication (AAC) device had yet to be introduced at his initial
evaluation and he only communicated via sign language characterized by less than 30 signs recognized by familiar communicative partners only.
At the next evaluation, age 8.2 years, MD was not appropriate
for standardized testing due to his cognitive level as well as his
communication skills. The Peabody Picture Vocabulary Test,
Fourth Edition, was attempted, but was discontinued. A Functional Communication Profile Revised (FCP-R) was administered (▶ Table 35.1). The Rossetti Infant-Toddler Language Scale
was also completed to assess overall communication skills
(▶ Table 35.2). Although this test was not appropriate for his
chronological age, it did provide meaningful clinical information given his poor cognitive function across all communicative
domains. His overall scores in all areas confirmed inconsistent
skills. He scored at 15 to 18 months for interaction attachment,
15 to 18 months for pragmatics, 21 to 24 months for play, 24 to
27 months for gestures, 30 to 33 months for language comprehension, and 18 to 24 months for language expression.
Table 35.1 Functional communication profile
Domain
assessed
Sensory x
Motor x
Behavior x
Attentiveness
Receptive
language
Expressive
language
Pragmatic/
social
Speech x
Voice x
Oral x
Fluency x
Normal Mild Moder-
ate
x
Severe Pro-
found
x
x
x
Table 35.2 Rossetti Infant-Toddler Language Scale
Age (mo) Interaction attachment Pragmatics Gesture Play Language comprehension Language expression
9–12 2/4 2/3 5/5 4/6 12/12 5/8
12–15 3/5 3/5 3/6 7/9 8/13
15–18 2/3 2/3 4/4 5/6 4/7
18–21 1/4 1/4 1/3 4/5 3/5
21–24 2/5 2/3 2/4 3/8
24–27 2/4 1/3 3/4 2/5
27–30 2/3 2/3 1/6
30–33 0/3 2/4 1/6
33–36 0/3 1/5 0/6
129
Feeding and Language Therapy in a Child with Congenital Cytomegalovirus and TBI
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Using several feeding checklists and guidelines, MD’s overall
feeding skills were 12 to 14 months. He consumed thin liquids
and ground, mashed, and mechanical soft solids. He developed
compensatory strategies when eating nonpureed foods, including a nondissociated munch chew where he suckled food on
the surface of his tongue, pooled the bolus on the anterior surface, and suckled the food behind his front central incisors.
Boluses were also held intraorally for an extended period of
time to promote bolus breakdown. He was learning to transfer
food laterally to the center of mouth when it was placed on the
back molars and his lips were active during chewing. He swallowed liquids from a cup with a sucking movement without
anterior spillage, although he struggled at times with multiple
swallows. He was also learning to independently feed himself
finger foods.
AAC evaluation was completed using a variety of checklists,
including the AAC Needs Assessment Checklist (VanTatenhove).
MD performed at Brown’s stage 2; MD could demonstrate
relational functions (greetings, recurrence, rejection, cessation
of activities, commenting, directives, and associative). He also
used semantic relationships, including agent-action, actionobject, locatives, and attributes. MD navigated mult iple screens
to request desired items/activities as well as to comment spontaneously on events occurring in structured activities.
35.4 Questions and Answers for
the Reader
1. MD eats purees and mechanical soft foods that he can swal-
low without mastication. Of the four stages of swallowing, in
which stage does he exhibit the most difficulty and why?
a) Oral stage.
b) Oral transit stage.
c) Pharyngeal stage.
d) Esophageal stage.
Answer: a is correct. This is the initial phase where the food is
triturated (chewed and moistened) and then the tongue carries
the food to the postcanine region and rotates laterally, placing
the food onto the occlusal surface of the lower teeth for food
processing. During this stage, the tongue and soft palate together
move cyclically in coordination with jaw movement. Tongue
motions are coordinated with buccal movement to keep food on
the occlusal surfaces of the lower teeth. The hyoid bone also
moves constantly during feeding and helps control the movements of the jaw and tongue. When food is placed in the mouth,
the mouth closes and the buccal muscles tighten to prevent remnants of food from pocketing in the lateral buccal sulci. Chewing
mixes the food and saliva and prepares the bolus for the swallow.
a is correct because MD is not able to masticate his food and thus
moves immediately into the transport stage once food enters
the oral cavity.
b is incorrect. When a portion of the food is ready to be swallowed, food is placed on the tongue surface and propelled back
through the fauces to the oropharynx. The tongue tip rises
touching the alveolar ridge, while the posterior tongue drops to
open the back of the oral cavity; the tongue surface then moves
upward, squeezing the chewed food back along the palate and
into the pharynx. The duration of bolus aggregation in the oropharynx ranges from a fraction of a second to about 10 seconds
in normal individuals eating solid food. MD is able to manipulate his jaw and tongue, and is able to propel boluses to the
oropharynx without difficulty.
c is incorrect. This is the most complex phase of swallowing
and also the most rapid sequential activity that occurs within a
second involving (1) food passage, propelling the food bolus
through the pharynx, and upper esophageal sphincter (UES) to
the esophagus, and (2) airway protection, insulating the larynx
and trachea from the pharynx during food passage to prevent
food from entering the airway. The soft palate closes the nasopharynx to ensure food does not enter the nasal cavity simultaneously, while the vocal folds close and the larynx moves
upward, which results in tilting of the epiglottis and closure
of the larynx enabling the trachea to be protected from food.
The three pharyngeal constrictor muscles contract from top to
bottom to transport the bolus into the esophagus. MD does not
demonstrate difficulty with this phase.
d is incorrect. This is the last phase of the swallowing process
where the bolus enters the esophagus, which is from the lower
part of the UES to the lower esophageal sphincter (LES). The LES
is also tensioned at rest to prevent regurgitation from the stomach and relaxes during the swallow to allow the bolus to pass
into the stomach, while the larynx is lowered and the vocal
folds open, allowing the patient to take a breath. MD does not
demonstrate difficulty with this.
2. Given MD’s medical history and aversion for attempting
foods with different textures, what approach is most likely
to yield favorable outcomes in feeding therapy?
a) Purely behavioral approach.
b) Combination of variety of approaches.
c) Purely sensory approach.
d) No approach (e.g., let him develop the skills independ-
ently).
Answer: a is incorrect. Purely behavioral feeding programs use
preferred foods, toys, books, or television to reinforce children
for eating challenging foods. This approach does not account for
the sensory and motor challenges MD demonstrates. Also, this
type of program encourages children who have compromised
motor skills to swallow purees only and can often be at risk for
choking at the introduction of solids.
b is correct. One singular approach for feeding therapy is
likely inappropriate for MD. He responded well to both structured and behavioral approaches to therapy. It is important to
consider auditory stimuli, environmental surroundings, gustatory and olfactory sensitivities, as well as tactile, vestibular, and
proprioceptive input during mealtimes when considering therapeutic approaches. He required direct teaching of oral motor
skills as well as a modified behavioral approach for feeding. He
made great progress when working in conjunction with occupational therapy for feeding and progressed 6 months in a span
of 12 months with his overall feeding skills.
c is incorrect. Using a strictly sensory approach encourages
children to smell, feel, play, and taste the food. However, this
approach does not help MD with his limited motor skills to
develop the skills needed to eat safely.
d is incorrect. Without direct intervention, he would not gain
the skills needed to become a more proficient eater, and due to
his disabilities could be at risk for malnutrition or becoming
even a more picky eater.
130
Feeding and Language Therapy in a Child with Congenital Cytomegalovirus and TBI
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
3. What language therapy approach would be appropriate for
MD?
a) No specific approach.
b) Core vocabulary approach.
c) Applied behavior analysis.
d) Play-based therapy.
Answer: a is incorrect. Not using specific evidence-based therapeutic approaches is neither efficacious nor productive and
could result in lack of reimbursement from insurance. It is also
within our scope and sequence as practicing speech-language
pathologists to use evidence-based therapy approach(es) for
therapy.
b is incorrect. Core vocabulary is not appropriate because it is
intended for children with inconsistent speech disorder when
the underlying deficit is a phonological planning deficit and not
a cognitive-linguistic deficit. Since MD is nonverbal, it is not an
appropriate therapy approach.
c is incorrect. Although evidence based, it is not appropriate
to use for MD. Applied behavior analysis (ABA) principles for
feeding often have a significant negative impact, especially in
the context of poor motor skills. ABA is also very time intensive
for the family (25–40 h/wk).
d is correct. Play-based assessment involves knowledge of
communication skills for each level of play. Play-based therapy
is effective for young children as they are often highly energetic
with decreased attention. Play-based therapy allowed MD to
lead activities and for opportunit ies to model therapeutic tasks.
Therapy incorporated videos to maintain motivation and attention as well as his ProLoQuo2Go.
4. Initially, how should MD’s ProLoQuo2Go be programmed
and what type of vocabulary should be employed?
a) Combination of core and fringe vocabulary of 20 icons per
screen.
b) Core words only.
c) Full vocabulary screen with 1 ×1 icons that consisted of
64 icons.
d) Program words as needed or as staff/parents requested.
Answer: a is correct. Due to his visual deficits as well as his
language skills, MD required a limited amount of stimuli on the
screen including core vocabulary. His high-frequency words
were used initially with the intention of expanding this list as
his communication skills improved. Personal and motivating
fringe vocabulary was also programmed.
b is incorrect. Although core vocabulary is a necessity, not
incorporating fringe vocabulary limits requesting personal
items/actions, which is often motivating. If personal words are
used often, this fringe vocabulary must be considered when
programming.
c is incorrect. Providing comprehensive vocabulary with
small icons to an emergent language learner can be overwhelming. Additionally, MD’s visual and motor deficits may
also be problematic and, furthermore, he is unlikely to utilize
these icons based on his current language skills.
d is incorrect. This approach does not incorporate evidencebased core vocabulary critical to language development. Programming vocabulary based on only the needs of his surroundings is unlikely to yield improved vocabulary.
35.5 Description of Disorder and
Recommended Treatment
MD presented with several communication disorders that, when
combined, created a unique challenge for treatment. He was
diagnosed with traumatic brain injury, resulting from IV H grade
2 at birth, hearing impairment, receptive and expressive language disorder, and feeding difficulties. He also presented with
significantly impaired cognitive function as well as autism-like
characteristics, including difficulty with socioemotional reciprocity, abnormal eye contact and body language when engaging with others, and deficits in developing relationships with
others.
With regard to feeding, treatment focused on improved tolerance of foods with different textures as well as gaining necessary skills for chewing and eating a variety of foods. Using a
combination of approaches and strategies, improved oral phase
skills emerged. With regard to language, a combination treatment approach was executed involving play-based therapy
with a focus on movement and cause/effect. This approach
created an opportunity for MD to develop natural and spontaneous language using his AAC device. Following the hierarchy
of Brown’s stages of development, recommended treatment
was systemic and followed the natural progression of language
for his cognitive level. Classroom themes were incorporated in
therapy to help promote communicative opportunities.
35.6 Outcome
The prognosis for MD to improve feeding was fair, secondary to
limited follow-through outside of therapy. He made steady
progress for 10 months during feeding therapy, progressing
from strictly purees to a combination of purees and mechanical
soft foods. He required assistance to place the foods on his
occlusal molars and begin mastication versus using the phasic
bite and suck pattern. He also improved in self-feeding with
finger foods and drank from a cup without anterior spillage.
Follow-through for therapeutic feeding suggestions was minimal among both school staff and MD’s family.
Significant progress was also noted in MD’s communicative
efficacy. At the start of therapy, MD’s overall communication
skills were determined to be between 12 to 18 months. Within
24 months of therapy, his overall communication skills
increased to a range spanning 8 to 33 months. Competency
with the ProLoQuo2Go required methodical and consistent routine as well as play-based activities that maintained MD’s interest and created natural communicative opportunities. He was
extremely motivated by electronics, so videos and video modeling were often used during treatment. He was able to formulate
two- to three-word utterances (Brown stage 2) and navigate
multiple screens. Increased core vocabulary and progress
toward Brown stage 3 were targeted in continued therapy.
35.7 Key Points
●
AAC assessment is vital for nonverbal clients to determine the
ideal mode of communication.
131
Feeding and Language Therapy in a Child with Congenital Cytomegalovirus and TBI
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
●
Formal diagnoses of medical conditions are not always indicative of function. Thorough assessment of competencies, interests, and communication skills is critical to determine appropriate intervention strategies.
●
A thorough understanding of typical development of feeding
skills is necessary to determine appropriate therapeutic strategies. Developmental feeding skills are not always commensurate with chronological age.
Suggested Readings
[1] Sharp WG, Jaquess DL, Morton JF, Herzinger CV. Pediatric feeding disorders: a
quantitative synthesis of treatment outcomes. Clin Child Fam Psychol Rev.
2010; 13(4):348–365
[2] American Speech-Language-Hearing Association. Augmentative and alterna-
tive communication: knowledge and skills for service delivery [Knowledge
and Skills]. Available at: http://www.asha.org/policy/KS2002–00067/.
doi:10.1044/policy.KS2002–00067
[3] Van Tatenhove G. Normal Language Development, Generative L anguage &
AAC 2007;1– 11. Available at: http://www.texasat.net/Assets/1–normal-language–aac.pdf
References
[1] Morris SE, Klein MD. Pre-Feeding Skills: A Comprehensive Resource for Meal-
time Development. 2nd ed. Austin, TX: Pro-Ed; 2000
[2] Fernando N, Potock M. Raising A Healthy, Happy Eater: A State-by-Stage
Guide to Setting Your Child on the Path to Adventurous Eating. New York, NY:
The Experiment; 2015
[3] Rowell K, McGlothlin J. Helping Your Child with Extreme Picky Eating. Oak-
land, CA: New Harbinger; 2015
[4] ASHA Pediatric Feeding History and Clinical Assessment Form (Infant 6
months and older). Available at: http://www.asha.org/uploadedFiles/Pediatric-Feeding-History-and-Clinical-Assessment-Form.pdf
[5] AAC Needs Assessment Checklist by Gail M. Van Tatenhove PA. 2016. Avail-
able at: http://praacticalaac.org/praactical/aac-assessment-forms/
[6] Typical Developmental Feeding Skills. Available at: http://sandiegooccupatio-
naltherapy.com/wp-content/uploads/2012/01/TypicalDevelFeeding.pdf
[7] ASHA Traumatic Brain Injury Deficits. Available at: http://www.asha.org/pub-
lic/speech/disorders/TBI/#deficits
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Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
36 Psycholinguistic Approach to Assessment and Treatment
of Complex Speech-Language Impairment in a School-Age
Child
Toby Macrae, Emily Berteau, and Kaitlin Lansford
●
36.1 Introduction
Children with complex speech-language impairment may have
deficits in one or more levels of speech processing (e.g., input
processing, stored linguistic knowledge, and/or output processing). A psycholinguistic approach may be employed to identify
levels of deficits in these children and, therefore, provide specific targets for treatment.
36.2 Clinical History and
Description
HH, a 6.11-year-old girl, received speech therapy services since
she was approximately 4 years old when she was diagnosed
with a speech-sound disorder (SSD). Although some therapeutic gains were achieved, she recently plateaued and f ull speechlanguage reassessment was completed.
Expressive vocabulary: Expressive Vocabulary Test, Second
Edition (EVT-2).
●
Receptive vocabulary: Peabody Picture Vocabulary Test,
Fourth Edition (PPVT-4).
●
Phonological processing (including phonological awareness,
phonological memory, and rapid naming): Comprehensive
Test of Phonological Processing (CTOPP)
Phonological Awareness Test, Second Edition (PAT-2).
●
Nonsense word repetition (NWR): Syllable Repetition Task
12
(SRT).
●
Real and nonsense word decoding: Test of Word Reading
Efficiency, Second Edit ion (TOWRE-2).
●
Speech motor control: Oral and Speech Motor Protocol
(OSMP).
●
Speech-sound production: Goldman–Fristoe Test of
Articulation, Second Edition (GFTA-2).
●
Token-to-token inconsistency: Word Inconsistency Assessment from the Diagnostic Evaluation of Articulation and
Phonology, American Edition (WIA).
8
9
10
and portions of the
13
14
15
16
11
36.3 Clinical Testing
As a framework for testing and intervention, a seven-step
evidence-based practice (EBP) decision-making process
employed to evaluate the evidence regarding a psycholinguistic
approach to assessment and treatment of speech-language
impairment. Specifically, the following clinical question was
posed (step 1), using the PICO (population, intervention,
comparison, outcome) format: Does the psycholinguistic
approach (I) result in improved speech-language performance
(O) in comparison to baseline performance or alternative treatment approaches (C) in children with speech-language impairment (P)? Several research articles supporting this approach
to speech-language assessment and treatment were identified
and critically evaluated (steps 2–5).
evidence, this approach was determined to be appropriate for
this complex case of speech-language impairment (step 6).
According to the psycholinguistic model, children may have
deficits in input processing, stored linguistic knowledge, and/or
output processing.
precise deficit levels in speech processing. Identifying the level
of breakdown has implications for skills to be targeted in
treatment. Assessment of input, storage, and output in this case
included the following:
●
Hearing screening: pure-tone audiometry involving presentation of 500, 1,000, 2,000, and 4,000 Hz at 20 dB.
●
Auditory discrimination: informal (discriminating between
recordings of participant’s own correct and incorrect productions of speech sounds in words) and formal (Speech Assessment and Interactive Learning System [SAILS])
●
Overall expressive and receptive language: Clinical Evaluation
of Language Fundamentals, Fourth Edition (CELF-4).
5
Comprehensive testing attempts to identify
2–4
Based on the supporting
6
assessments.
1
was
7
36.4 Questions and Answers for
the Reader
1. Which area(s) of speech processing (input, storage, and/or
output) are assessed via auditory discrimination tasks?
a) Input only.
b) Input and storage.
c) Storage only.
d) Output.
Answer: b is correct. Auditory discrimination tasks involve listening to the stimuli presented (input) and calling upon stored
knowledge of the perceptual features of sounds and words.
a is incorrect. Successfully discriminating between correctly
and incorrectly produced sounds requires the listener to have
well-formed categorical representations for those sounds in
long-term memory.
c is incorrect. Auditory discrimination tasks necessarily
involve auditory input and therefore involve more than just
storage.
d is incorrect. These tasks require the child to point to a
happy face if the sound was produced correctly or a sad face if
the sound was produced incorrectly, and thus do not involve
speech output.
2. In which area(s) of speech processing (input, storage, and/or
output) did HH have difficulties?
a) Input.
b) Storage.
c) Output.
d) All of the above.
133
Psycholinguistic Approach to Assessment and Treatment of Impairment in a School-Age Child
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Answer: d is correct. HH showed difficulty with auditory
discrimination (input and storage), auditory memory (storage),
and speech-sound production (storage and output), for example, reflecting deficits in all levels of speech processing.
a is incorrect. HH showed difficulty with tasks that involved
more than just input.
b is incorrect. HH showed difficulty with tasks that involved
more than just storage.
c is incorrect. HH showed difficulty with tasks that involved
more than just output.
3. Rapid naming involves many of the same skills as which of
the following?
a) Auditory discrimination.
b) Speech-sound production.
c) Fluent reading.
d) Reading comprehension.
Answer: c is correct. Rapid naming involves rapidly processing
visual as well as phonological information, skills that are also
required for fluent reading.
a is incorrect. Rapid naming involves speech output, whereas
auditory discrimination does not.
b is incorrect. Rapid naming involves, among other things,
rapidly processing visual information, whereas speech-sound
production does not.
d is incorrect. Reading comprehension is closely related to
oral language abilities, including vocabulary, whereas rapid
naming is closely related to processing visual and phonological
information.
36.5 Description of Disorder and
Recommended Treatment
Based on this assessment strategy, HH presented with deficits
in input, storage, and output. With regard to input, although
HH passed the hearing screening, she had difficulty with both
informal and formal assessments of auditory discrimination.
Auditory discrimination tasks tap input as well as some aspects
of storage (e.g., stored knowledge of the perceptual qualities of
sounds and words). HH was required to point to a happy or sad
face representing correctly and incorrectly produced sounds
within words; sounds that she had difficulty producing were
targeted. She had difficulty discriminating between her correct
and incorrect productions of /kr/ (50% accurate), /kw/ (50%
accurate), /fl/ (50% accurate), /sl/ (50% accurate), /ð/ (8% accurate), and /v/ (50% accurate) in the initial position in words.
She also had difficulty discriminating between other speakers’
correct and incorrect productions of /r/ (60% accurate) and /θ/
(75% accurate) in the initial position in words. With regard to
storage, HH scored 101 on the PPVT-4, suggesting age-appropriate receptive vocabulary. Her standard score of 89 on the
EVT-2 confirmed age-appropriate expressive vocabulary, which
reflects aspects of both storage and output. With regard to output, HH’s total functional score of 106 on the OSMP suggested
some difficulty with func tional speech motor tasks (e.g., loudness variation). In addition, HH scored more than two SDs
below the mean for children aged 6.6 to 6.11 years from Robbins and Klee
diadochokinetic tasks (rapidly alternating speech movements)
14
(the oldest age group tested) on three of the five
on the OSMP. HH’s standard score of 73 on the GFTA-2 revealed
difficulties with speech-sound production. This task also
involved aspects of storage, as it requires access to stored representations for words, including phonological representations.
HH obtained subtest scaled scores of 6 for recalling sentences
and 5 for formulated sentences on the CELF-4, suggesting difficulties listening to and accurately repeating spoken sentences
and formulating semantically and grammatically correct sentences. HH’sdifficulties with these subtests may be attributable,
at least in part, to auditory memory deficits. With regard to
phonological processing, HH had difficulty with rapid naming
with standard scores of 79 on the rapid naming composite and
57 on the alternate rapid naming composite on the CTOPP.
Rapid naming involves some of the same skills as reading fluently (i.e., rapidly processing visual as well as phonological information) and has been shown to be one of the strongest predictors of later reading fluency.
appropriate scores on the phonological awareness tasks on the
CTOPP and the PAT-2. She had some difficulty identifying
medial and final phonemes in words on the PAT-2. HH received
a standard score of 88 on the phonological memory composite
on the CTOPP, revealing low average phonological memory. She
also had difficulty with phonological memory on the NWR task
(SRT). NWR tasks involve aspects of input, storage, and output.
The majority of HH’s consonant substitutions on this task (7/8)
reflected different manner classes to the consonant targets,
revealing auditory-perceptual encoding difficulties.
addition, HH had difficulty repeating nonsense words of
increasing syllable length (two syllables: PCC [percent consonants correct] = 100%; three syllables: PCC = 72%; four syllables:
PCC = 56%), revealing difficulties with phonological memory.
19
HH used a typical number of consonant additions in her
NWRs, in comparison to similarly aged children with speechlanguage impairment,
ning/programming. This finding was used to rule out a diagnosis of childhood apraxia of speech (CAS). Although HH’sWIA
score was 44%, suggesting some difficulty producing words
consistently, increased token-to-token inconsistency has been
seen in children with typical speech development and children
with non-CAS SSDs.
for real words and 78 for nonsense words on the TOWRE-2,
suggesting poor single-word decoding.
A psycholinguistic approach does not prescribe a specifically
designed therapy program, but rather emphasizes the importance of implementing treatment tasks that address the particular skill deficit. Deficits in input, storage, and output were
identified as targets, and given the importance of reading for
academic success, decoding was identified as a primary target
for treatment. The Lindamood Phoneme Sequencing Program
for Reading, Spelling, and Speech, Fourth Edition (LiPS-4)
used to target phonemic awareness, decoding, and spelling
directly as well as other deficits secondarily. Phonemic awareness was also targeted directly using tasks that required HH to
identify medial and final consonants in words. With regard to
input, HH’s auditory discrimination difficulties were targeted
by bringing HH’s attention to the perceptual qualities of and
differences among sounds produced in isolation and in words
during LiPS activities. Particular attention was paid to minimal
pair words that differed by a target sound that HH had difficulty
producing and her error sound, when she also misperceived
18
revealing normal speech motor plan-
20
Lastly, HH received standard scores of 73
17
HH received mostly age-
18,19
21
In
18,
was
134
Psycholinguistic Approach to Assessment and Treatment of Impairment in a School-Age Child
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
this difference (e.g., /ʃ/ and /s/ in “shoe” and “Sue”). With regard
to output, HH’s speech-sound production difficulties were targeted by focusing on HH’s use of the correct sound in spoken
words during LiPS activities. Part icular attention was paid to
minimal pair words that differed by a target sound and HH’s
error. If incidental treatment of these difficulties during the LiPS
was ineffective, they were targeted directly using the SAILS perceptual training program and formal speech-sound intervention (e.g., minimal pair therapy). HH’s auditory memory
difficulties were targeted recalling details from and answer
questions about spoken sentences.
36.6 Outcome
Step 7 in Gillam and Gillam’s1EBP decision-making process
involves evaluating the outcome of a particular approach to
treatment. Data were collected to determine the effectiveness
of treatment. HH’s performance in real and nonsense word
decoding and spelling in the LiPS treatment activities was
tracked each session and shown in ▶ Fig. 36.1 and ▶ Fig. 36.2,
respectively. With regard to both decoding and spelling accuracy, HH showed variable performance over approximately 4
months of treatment. CV (consonant-vowel) and VC (vowelconsonant) word shapes were the initial focus, CVC shapes were
then targeted throughout treatment, and complex shapes were
introduced toward the end of treatment. Sessions of low accuracy were limited; sessions of 60% or higher for reading and
70% or higher for spelling predominated. Furthermore, new
objectives were introduced during most (72%) sessions, including new letters and sounds and new decoding and spelling conventions (e.g., “e” at the end of a word makes the vowel say
its name; when two vowels go walking, the first one does the
talking). HH maintained encouraging levels of accuracy as new
skills were targeted. The DIBELS nonsense word fluency probes
were administered approximately weekly as an independent
measure of reading fluency. HH had a slightly increased total
number of letter sounds decoded correctly and words read
completely as treatment concluded (ranges: 22–32 and 5–9,
respectively) in comparison to the beginning and middle stages
of treatment (ranges: 19–26 and 4–7, respectively). HH continued to exhibit difficulty decoding words fluently. Treatment is
ongoing and will continue to target decoding and spelling skills.
Improving self-monitoring and self-correction strategies, accuracy, and consistency will be prioritized from session to session.
Once accuracy and consistency improve, focus will shift to
decreasing response latency in an attempt to improve reading
fluency.
HH’s performance on phonemic awareness tasks involving
identification of medial and final sounds is shown in ▶ Fig. 36.3.
HH steadily increased in the accuracy and these tasks were discontinued. The DIBELS phoneme segmentation fluency probes,
which required HH to segment as many spoken words into
component sounds as possible in 1 minute, were also administered weekly. These probes served as a measure of generaliza-
Fig. 36.1 Accuracy of single real and nonsense word decoding during LiPS activities.
135
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Fig. 36.2 Accuracy of single real and nonsense word spelling during LiPS activities.
Fig. 36.3 Accuracy of medial and final sound identification in spoken words.
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Psycholinguistic Approach to Assessment and Treatment of Impairment in a School-Age Child
Branski and Molfenter, Speech-Language Pathology Casebook (ISBN 978-1-62623-487-1),
copyright © 2020 Thieme Medical Publishers. All rights reserved. Usage subject to terms and conditions of license.
Fig. 36.4 Number of phonemes accurately segmented from spoken words within 1 minute.
tion from sound identification to the more advanced skill of
segmenting words. HH’s performance on these probes is shown
in ▶ Fig. 36.4. HH showed steady improvements in segmentation fluency throughout treatment. HH’s performance on auditory memory activities was tracked each session. HH performed
consistently throughout treatment, but only once scored above
70%. This skill will continue to be targeted in treatment with an
emphasis on teaching HH strategies to improve auditory memory, for example, visualizing items or characters to be recalled.
36.7 Key Points
●
Making evidence-based decisions about treatment
approaches for children with speech-language impairment is
a methodical process that involves creating a clinical question,
finding and evaluating evidence that pertains to the question,
making a decision by integrating the evidence, and evaluating
outcomes.
●
A psycholinguistic approach to speech-language assessment
and treatment involves identifying deficits in input processing, stored linguistic knowledge, and/or output processing
and targeting these deficits in treatment.
●
A psycholinguistic approach may be appropriate for some
children with complex speech-language impairment,
although speech-language pathologists should not always
expect to see rapid gains in all areas.
1
5
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