Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

Книга_4523_Библиотеки_им_академика_М_И_Перельмана

.pdf

Скачиваний:

Добавлен:

31.08.2026

Размер:

30 Мб

Скачать

☆

<<< < Предыдущая 5 6 7 8 9 10 11 12 13 14 15 1617 / 3517 18 19 20 21 22 23 24 25 26 27 28 29 > Следующая >>>

Treatment of Communication and Feeding Disorders in a Complex Pediatric Patient

37 Treatment of Communication and Feeding Disorders in a Complex Pediatric Patient with a Neurogenic Disorder

Alicia Morrison-Fagbemi

37.1 Introduction

Medically complex pediatric cases require clinicians to develop specialized person-centered intervention plans that involve family and caregivers. This case describes a pediatric patient with a neurogenic syndrome resulting in both feeding and communication deficits. The treatment approach used in this case highlights the pedagogy of neurogenic communication etiologies, dynamic assessment, and best practices in treatment.

37.2 Clinical History and Description

LG was a 15-month-old male child born following a full-term, uncomplicated pregnancy. No anoxic events during birth were reported. LG weighed 7.8 lb with normal APGAR (appearance, pulse, grimace, activity, and respiration) scores. LG demonstrated feeding diﬃculties characterized by dyscoordination of systems within the first 2 postpartum months. At 3 months of age, motor delays and ocular delays were noted. No accidents, illnesses, or hospitalizations were repor ted. Following genetic testing, LG was diagnosed with Mowatt–Wilson’s syndrome aﬀecting motor movement and language development. Beyond physical impairments of gross and fine motor control, LG presented with limited verbal repertoire characterized by isolated open vowels with minimal nonverbal communication.

37.3 Clinical Testing

LG was referred for an outpatient speech and language assessment by early intervention to develop and support the Individ-

ualized Educational Program. Clinical testing included both formal and informal measures of communication ability. The communication matrix was used to evaluate LG’s communication abilities and to support goal derivation. The communication matrix is an online assessment tool designed to identify how a child is communicating, and to provide a framework for determining communication goals. It was designed primarily for speech-language pathologists and educators to use to document communication skills in children with severe or multiple disabilities, including children with sensory, motor, and/or cognitive impairments. The online version also provides a parent design so that the parent and professionals working with the child can access the profile to describe communication in the home (▶ Fig. 37.1; www.communicationmatrix.org).

The Communication Matrix Profile describes four major aspects of communication: (1) four reasons for communicating, (2) seven levels of communication, (3) 24 specific messages (e.g., “I want that”), and (4) nine categories of behaviors used to communicate (e.g., simple gestures). The profile is a matrix providing a visual representation of communication behaviors and messages employed. Informal measures were collected during play; LG presented at level 1 (preintentional behavior). Promisingly, LG demonstrated joint attention skills during paired communication with voice and simple sign language, indicating receptiveness to alternative means of communication.

Informal evaluation of feeding skills was completed during a typical morning meal; LG was presented with applesauce, mashed potatoes, and cereal. Two incidences of gagging with apple sauce were observed, followed by arching and crying. He refused mash potatoes by turning his head away and crying. Approximately 10 minutes following the meal, LG began cough-

Fig. 37.1 LG’s online assessment confirms goal formulation based on his use of precursory means of communication at only a level 2 communication stage (represented by the gray box). The yellow box represents LG’s ability to express discomfort, demonstrate comfort and regulation with family members, and attention to others. These target domains provide a framework for activities to communicate likes and dislikes, and pairing language to these areas. In addition, the image displays how the child demonstrated joint attention skills during paired communication with voice and simple sign language, indicating receptiveness to alternative means of communication. (The Communication Matrix is a service of the Design to Learn Projects at Oregon Health & Science University, 2017 Charity Rowland, PhD.)

139

Treatment of Communication and Feeding Disorders in a Complex Pediatric Patient

ing and vomiting. He was then given a bottle, which appeared to resolve this discomfort. When seated on his mother’s lap, LG arched his head and neck backward. He coughed and turned away from pureed food. He appeared unhappy and/or uncomfortable during feeding, and fell asleep at one point during the feeds. He tolerated about 1 oz of pureed food per meal as noted by his mother. Thin liquids were bottle fed by the parent. An upright, slight tilt was recommended to ensure safe liquid intake. His mother reported that he does not cough on liquids. Advancing from the bottle to flexible weighted straw sippy cups was recommended.

The family was encouraged to follow up with their physician to obtain a modified barium swallow and nutrition evaluation. Modified barium swallow (MBS) indicated oral dysphagia characterized by decreased mastication and oral aversion to solids. Laryngeal elevation and epiglottal inversion was within normal limits. No pharyngeal residue was noted. No laryngeal penetration or aspiration was observed.

37.4 Questions and Answers for the Reader

1. Given the unknown etiology of a rare genetic disorder, what

is an appropriate starting point for the family and child? a) Discuss natural language development and reevaluate in 3

months.

b) Discuss alternative and augmentative communication

immediately, stating that early intervention is needed immediately.

c) Provide information on a total communication approach

that involves use of voice paired with gestures, simple sign language, and exploration of augmentative and alternative communication (AAC) needs.

d) Provide information related to language development and

the supportive communication strategies a parent can provide with their child to foster speech and language skills.

e) c and d.

Answer: e is correct (c and d). The optimal starting point involves a total communication approach that incorporates multiple modalities and parent counseling. A total communication approach promotes voice, gestures, facial expression, sign language, and simple augmentative communication aids to support comprehensive learning.

a is incorrect. It does not provide the family with the support of communication needs for their child. Discussing language development is important to educate the family; however, the child needs early intervention. Reevaluation is not appropriate at this time.

b is incorrect. Multiple communication strategies are critical to promote speech and voice as well as enhance communication.

2. When considering use of augmentative means of communi-

cation, which answer describes a good starting point for intervention? a) Picture cue representation of abstract objects. b) Simple speech generation devices to indicate simple

requests to continue an activity or request recurrence of an activity.

c) Pair all communication exchanges with not only gesture

and simple sign language, but also voice.

d) b and c.

Answer: d is correct (both b and c). A total communication approach is appropriate. And, as such, pairing voice with a simple augmentative communication device set the foundation knowledge for use of a dynamic language display for AAC, while use of voice also promotes but does not suﬀocate the chance of the individual to express simple needs and wants with open vowel productions. Simple sign language gestures also promote fast communication expression during direct cause/eﬀect tasks (e.g., requesting “more” or “give me”).

a is incorrect. Picture cue representation of an abstract item is the first step in communication. Communication symbols are built from concrete to abstract development when discussing AAC. Concrete items have stronger connections to the meaning of the intended message.

3. Given the MBS results, what is the first step of feeding inter-

vention? a) Begin with solids and promote rotary movement. b) Allow for natural feeding skills to develop over time. c) Begin to work to address his aversion of food by address-

ing the smell/touch of various stimuli within a close range without intake to promote comfort and supportive feeding experience.

d) Test for food allergies to address why the individual is

arching during feeding in discomfort.

e) c and d.

Answer: e is correct (c and d). In therapeutic feeding, it is critical to address the aversion and fear of food. Creating tolerance of smell and the proximity to food is stage one (sequential oral sensory [SOS] approach). It is important for a physician to rule out food allergies to address the causes of physical body arching and/or discomfort during eating. Routine follow-up is required to ensure safety of the swallowing mechanism. Consultation with both the nutritionist and gastroenterologist is also likely indicated.

a is incorrect. The child is not appropriate for this level of in-

tervention based on his current deficits.

b is incorrect. Natural feeding skills are impaired and require

intervention to improve to maintain appropriate nutrition.

4. When considering ongoing treatment and goal derivation for the child, what should be considered for speech and language?

a) Speaking with the family to educate them on the treat-

ment trajectory and school transition.

b) Reassessing communication skills with a reevaluation of

milestones met utilizing informal measures with the communication matrix.

c) Exploring options of AAC for high-tech devices and apps

that may be the preferred communication options for the individual.

d) Ensure that social closeness and pragmatic skills are nur-

tured into the intervention plan.

e) All of the above.

Answer: e is correct. All of the strategies are required to ensure the appropriate evaluation of intervention planning. It is impor-

140

Treatment of Communication and Feeding Disorders in a Complex Pediatric Patient

tant to maintain dynamic assessment, encourage plan development in intervention, goal derivation, and action plans for the family. The family is critical to the therapeutic process, and family support, advocacy, and school transition are prioritized. It is also important to remember that pragmatics is an integral part of intervention in individuals who utilize AAC; peers and social closeness must be promoted and encouraged.

37.5 Description of Disorder and Recommended Treatment

LG presented with a moderate-to-severe neurogenic communication disorder characterized by severe language and feeding impairment. He also presented with gross and fine motor deficits that may aﬀect his ability to employ sign language as well as dynamic, high-tech augmentative communication devices. His treatment plan included intervention targeting both communication and feeding simultaneously. A total communication approach paired with low-tech alternative/augmentative communication device was recommended. A major focus was also placed on family education and counseling; they were informed of speech and language milestones as well as strategies to include alternative means of communication including sign language, gesture, and pragmatic functions to promote language expression. Although augmentative/alternative communication strategies were considered in LG’s treatment plan, they were not employed to replace speech and/or voice production. Treatment was provided four times a week for 30-minute sessions. Two sessions were dedicated to feeding therapy and two sessions were devoted to speech and language development and augmentative communication inter vention.

37.6 Outcome

After six treatment sessions, LG developed a language system that was multimodel. At 3 years of age, he was able to use lowtech communication, gestural language, and nonverbal commu-

nication. LG gained skill in the use of an iPad with predesigned icons to support communication. LG’s speech was limited to approximations of sounds to indicate “more,” paired with a sign. He steadily developed preliteracy skills through the use of word combinations in pairs as he accessed the device to communicate. Ongoing reassessment utilized the communication matrix online system to mark progress and alter therapy goals.

LG’s feed skills improved; however, oral preparatory deficits persisted. Currently, LG tolerates a range of foods and textures and has advanced to straw drinking with weighted support. Gluten and dairy allergies were diagnosed; diet change was initiated and regular consultations with a nutritionist support the family. Routine follow-up with the swallowing specialist and gastroenterologist are planned.

37.7 Key Points

●

It is important to utilize a multimodal total communication approach and person-centered intervention when planning intervention and goal advancement. Family involvement in all aspects of assessment and goal planning is critical to support therapeutic progress.

●

The speech-language pathologist is critical in family and caregiver education.

●

A hierarchical approach should be employed when assessing communication to support appropriate development of language milestones.

Suggested Readings

[1] Stremel-Campbell K, Rowland C. Prelinguistic communication intervention:

birth-to-2. Top Early Child Spec Educ. 1987; 7(2):49–58

[2] Rowland C, Schweigert P. Tangible symbols, tangible outcomes. Augment Al-

tern Commun. 2009; 16(2):61–78

[3] Rowland C, Schweigert P. Cognitive skills and AAC: Where we've been, what

we know and the questions we should ask. In: Light J, Beukelman D, Reichle J, Eds. Communicative Competence for Individuals Who Use AAC. Baltimore, MD: Paul Brookes; 2003

141

Language Assessment in a Child with Minimal Verbal Skills

38 Language Assessment in a Child with Minimal Verbal Skills

Kristen E. Muller and Nancy C. Brady

38.1 Introduction

This case involves communication assessment and recommended treatment for an individual with an intellectual and developmental disabilities and minimal verbal skills.

JZ is an 11-year-old boy with a diagnosis of fragile X syndro-

me and autism spectrum disorder (ASD).

38.2 Clinical History and Description

JZ was an 11-year-old boy diagnosed with ASD and fragile X syndrome when he was 2.6 years old. At the time of evaluation, he was able to produce the word “no” and sign “please,”“more,” and “eat.” He had TouchChat on his iPad, but his parents and teachers reported that he never used it. JZ’s classroom teacher reported that he often attended to a “work task” for about 3 minutes and would then get up and run around the room. However, his teacher reported that he was easily redirected to return to his seat. JZ did not interact with his peers at school unless they had an item that he wanted. JZ was described as “pretty easygoing” by his mother, unless an unexpected change in his schedule arose or if he could not have a toy that he really liked. In these scenarios, JZ hit his head, legs, and torso, and banged his wrists together. JZ’s mom expressed concerns that JZ was safe and able to communicate basic wants and needs.

38.3 Clinical Testing

Assessment of JZ’s language employed the communication matrix, Peabody Picture Vocabulary Test, Fourth Edition (PPVTIV), and Communication Complexity Scale (CCS). The communication matrix is a parent-report measure that presents profiles of how individuals with complex communication needs request and reject items and activities, comment, and ask questions.

JZ’s communication matrix profile indicated that he communicated consistently at the “unconventional communication" level; he used body movements, vocalizations, facial expressions, and simple gestures to communicate. JZ was beginning to communicate at the conventional communication level characterized by pointing, nodding or shaking his head, waving, or looking from a person to a desired object. These behaviors were emerging, but not yet mastered. Behaviors at this level are typically employed to intentionally communicate.

On the PPVT-IV, JZ obtained a raw score of 12, indicating he correctly responded to 12 pictures. His standard score was 20 (average range: 85–105) and percentile rank was 0.1. The CCS describes three levels of communication. The first level is preintentional communication (scores 2–5). Communication at this level includes changing behaviors in response to toys or activities. For example, an individual might look at an object or reach toward the object. The second level is intentional nonsymbolic

communication (scores 6–10). Communication at this level consists of behaviors that clearly refer to an object or event and are directed to a communication partner. For example, an individual might try to open a jar of bubbles, but then hand the bubbles to someone to request help. The third level is intentional symbolic communication (scores 11 and 12). Communication at this level consists of speech, signs, or symbols used via an augmentative communication device. JZ’s top three scores across 12 diﬀerent activities were 9, 9, and 8. When averaged together, the three top scores resulted in an overall score of 8.67. This score indicated that JZ communicated intentionally with a variety of gestures and vocalizations, but was not yet using symbolic communication such as words, signs, or symbols.

38.4 Questions and Answers for the Reader

1. A child sees a toy they want that is out of reach. The child looks at the toy, then at their mom, and back at the toy while vocalizing. What kind of communicative act is this?

a) Preintentional communication. b) Intentional nonsymbolic communication. c) Intentional symbolic communication. d) Augmentative and alternative communication (AAC).

Answer: b is correct. Triadic eye gaze with vocalization is intentional communication with a communication partner, but it is not yet symbolic because it does involve spoken or augmentative language.

a is incorrect. Preintentional communication involves behaviors

that are purposeful, but not directed toward another person.

c is incorrect. Intentional symbolic communication includes

the use of words, either spoken verbally or with AAC.

d is incorrect. AAC involves the use of communication methods such as pictures, gestures, sign, and speech-generating devices that supplement spoken speech.

2. A 7-year-old boy with a diagnosis of autism is new on your

caseload. His mom and teacher report that he is able to have short conversations with adults and peers about preferred topics. His mother’s main concerns are that her son is not making friends and is not keeping up with his peers in school.

Which of these assessmentswould you use for this student? a) The CCS. b) The social communication questionnaire (SCQ). c) The communication matrix. d) A language sample.

Answer: d is correct. A language sample allows you to look at the mean length of utterance, total number of words, and number of diﬀerent words. The CCS and communication matrix are appropriate for individuals who are minimally verbal, meaning they have 30 or fewer spoken words. The SCQ is an autism screener, and this student already has a diagnosis of ASD.

142

Language Assessment in a Child with Minimal Verbal Skills

a is incorrect. The CCS is appropriate for individuals who are

minimally verbal, meaning they have 30 or fewer spoken words.

b is incorrect. The SCQ is an autism screener, and this student

already has a diagnosis of ASD.

c is incorrect. The communication matrix is appropriate for individuals who are minimally verbal, meaning they have 30 or fewer spoken words.

3. You are evaluating a 10-year-oldgirl with cerebral palsy who

communicates using AAC software on her iPad. Her mother reports that she uses the iPad to communicate at home and in the community and can say about 15 diﬀerent words. What additional assessment would you use if you wanted to learn more about how and why this girl communicates at home? a) The communication matrix. b) The Mullen Scales of Early Learning. c) The PPVT-IV. d) The Goldman–Fristoe Test of Articulation.

Answer: a is correct. The communication matrix is a parent report that would allow you to see how she communicates in diﬀerent settings.

b is incorrect. The Mullen Scales of Early Learning is a standardized assessment that examines early intellectual development. A caregiver questionnaire would provide more information about naturalistic communication in the home.

c is incorrect. The PPVT-IV is a standardized receptive language assessment. This would provide information of word knowledge, but not about their communication at home.

d is incorrect. The Goldman–Fristoe Test of Articulation is an articulation assessment and would not provide information about naturalistic communication at home.

4. A child and teacher are playing with a ball toy. The teacher

puts a ball in the ball toy and the child looks at the ball toy, then looks at the teacher, and vocalizes while clapping her hands. What is the function of this communication act? a) Behavior regulation. b) Joint attention. c) Asking a question. d) Refusing.

Answer: b is correct. This behavior is joint attention, because the child is making a social exchange with the teacher as if to say “this is fun.” The child is not requesting or rejecting, which would be behavior regulation.

a is incorrect. Communication acts that involve requesting or rejecting an item or activity are behavior regulation acts. This act is a social exchange rather than a request or protest.

c is incorrect. This communication act is shared social enjoyment, rather than asking a question.

d is incorrect. This communication act is shared social enjoyment, rather than refusing an object or activity.

38.5 Description of Disorder and Recommended Treatment

Based on the assessment, JZ primarily used intentional nonsymbolic communication (e.g., gestures, eye gaze, vocalizations) to express wants and needs. These communication acts were directed at a communication partner, but may be more diﬃcult for partners to interpret than symbolic communication (i.e., speech, signs, or symbols). For example, communicating with unfamiliar communication partners or creating novel utterances is typically facilitated with symbolic communication. Therefore, one goal for JZ was to increase potential communicative eﬀectiveness by introducing symbolic forms of communication. A second goal was to continue to encourage his use of nonsymbolic communication in appropriate contexts such as with family and caregivers.

The focus of treatment was functional communication by building upon JZ’s existing skills and teaching symbolic communication with an AAC device. Communication partners were prompted to reinforce his verbal and sign communication acts by honoring his requests (e.g., if he signs more, give him more or if he says “no,” then stop the activity) and providing verbal or gestural praise (e.g., nice job telling me “no,” high five, or thumbs up). New AAC skills were taught by providing core vocabulary words and modeling their use to request, comment, protest, and ask questions. Incidental teaching strategies were used to promote communication opportunities in natural contexts. For example, favorite toys were placed on a shelf that he could not reach. When he requested the toy with gestures or vocalizations, communication partners modeled a symbolic request by selecting the toy on his AAC device. Intervention was provided in multiple settings (e.g., classroom, lunchroom, home, community) to optimize generalizat ion. Family members, teachers, and paraprofessionals were coached on how to support communication goals throughout his day.

38.6 Outcome

Over time, JZ began to make independent requests and comments using his AAC device and/or speech. His device was updated regularly as his vocabulary expanded and environments changed. Five months after the initial assessment, his communication was reassessed using the CCS and communication matrix. JZ’s top three scores on the CCS were 9, 11, and 11. When averaged together, the three top scores resulted in an overall score of

10.33. JZ’s communication matrix profile indicated that he consistently communicated at the conventional communication level and had emerging skills at the concrete symbol level. These scores were suggestive of significant progress in therapy and the emergence of more symbolic communication.

143

Language Assessment in a Child with Minimal Verbal Skills

38.7 Key Points

●

Early, preverbal communication can be measured with assessments such as the CCS and the communication matrix.

●

Individuals who are minimally verbal communicate using preintentional and intentional presymbolic communication acts, such as eye gaze, gestures, and vocalizations.

●

Intervention goals include progressing to more advanced forms of communication including symbolic communication and promoting communication across environments.

Suggested Readings

[1] Abbeduto L, Brady N, Kover ST. Language development and fragile X syndro-

me: profiles, syndrome-specificity, and within-syndrome diﬀerences. Ment Retard Dev Disabil Res Rev.2007; 13(1):36–46

[2] Brady N. Augmentative and alternative communication for children with

Down syndrome or fragile X syndrome. In: Roberts J, Chapman R, Warren S, Eds. Speech and Language Development and Intervention in Down Syndrome and Fragile X Syndrome. Baltimore, MD: Paul H. Brookes; 2008:255–274

[3] Brady NC, Fleming K, Thiemann-Bourque K, et al. Development of the com-

munication complexity scale. Am J Speech Lang Pathol. 2012; 21(1):16–28

[4] Rowland C, Fried-Oken M. Communication matrix: a clinical and research

assessment tool targeting children with severe communication disorders. J Pediatr Rehab Med. 2010; 3:319–329

144

A Profound Phonological Disorder in a Preschooler

39 A Profound Phonological Disorder in a Preschooler

Jennifer St. Clair

39.1 Introduction

Children with profound phonological disorders are unintelligible to both familiar and unfamiliar listeners. These children typically produce speech containing only a few vowels and consonants. They often have diﬃculty producing multiple classes of sounds and regularly omit parts of syllable/word shapes.

39.2 Clinical History and Description

BM was a 4-year, 2-month-old male. Pregnancy and his birth history were remarkable for delivery at 35 weeks via cesarean section. He weighed 5 lb, 5 oz, but was not hospitalized following birth. BM crawled at 5 months, walked at 11 months, and ran at 15 months. His first word was noted at 19 months. At the time of testing, BM’s parents reported that he combined words “rarely” and usually used “one word at a time.” His parents reported that BM understood “almost all” of what was said to him. He typically used gestures and “grunting” to communicate his needs and wants. He had a reported vocabulary of 15 words and he was only 50% intelligible.

39.3 Clinical Testing

Assessment was completed in a university clinic setting and conducted by graduate student clinicians under the supervision of a speech-language pathologist. The assessment included parent interview, oral-motor examination, and administration of the Preschool Language Scales-5 (PLS-5) and Hodson Assessment of Phonological Patterns-3 (HAPP-3) as well as a spontaneous language sample.

Oral-motor examination revealed no abnormalities. BM obtained an average standard score of 102 on the Auditory Comprehension subtest of the PLS-5. The Expressive Communication subtest was attempted, but aborted due to increased frustration exhibited by BM. For example, after one, typically unintelligible attempt at answering a given item, he refused to repeat his response. Testing was ceased on this subtest because the examiners felt the score would be influenced by BM’s unintelligibility; his scores would not be representative of his ability. The HAPP-3 revealed >40% occurrence in the following areas: consonant sequences/clusters (115%), postvocalic singletons (94%), liquids (100%), stridents (100%), and velars (100%). These scores were consistent with a severity rating of “profound.”

A spontaneous language sample revealed a mean length of utterance of 1.2, with an estimated 20% intelligibility to unfamiliar listeners. His phonemic inventory consisted of the vowels /i/, /o/, /ɪ/, and /ʌ/ and the consonants /h/, /m/, /t/, and /p/. He was able to follow all age-appropriate verbal directions and appeared to understand all that was said to him by both the examiners and his parents. He exhibited immediate frustration

when the listener failed to understand what he said or when he was asked to repeat himself.

39.4 Questions and Answers for the Reader

1. What diagnosis is most appropriate for BM? a) Expressive language disorder. b) Phonological disorder. c) Childhood apraxia of speech (CAS). d) Receptive language disorder.

Answer: b is correct. He exhibited diﬃculties with classes of sounds that aﬀect word shape and intelligibility.

a is incorrect. Although an expressive language disorder cannot be ruled out at this point, there is not enough evidence to support this diagnosis. He was unable to complete the expressive portion of the PLS-4 due to frustration and unintelligibility. Expressive language should be reassessed at a later time when intelligibility has increased and frustration decreased.

c is incorrect. He exhibited none of the hallmarks of CAS. He did not exhibit groping, inconsistency, or significant diﬃculty with vowels.

d is incorrect. His scores were within the average range for auditory comprehension. In addition, at no time did his parents or evaluators indicate diﬃculty with receptive language.

2. What type of therapy would be most appropriate?

a) Hodson’s cycles approach. b) Traditional articulation approach. c) Core vocabulary approach. d) All of the above.

Answer: a is correct. Expressive language disorder is correct because of the severity and number of potential targets. A Hodson’s cycles approach would target multiple sounds at a time by targeting the missing classes of sounds. Syllable shape would also be potential targets. Targets would be rotated on a weekly basis, which would lead to greater overall intelligibility at a more rapid pace than targeting one phoneme at a time.

b is incorrect. A traditional articulation approach would target each individual phoneme until mastery, which would be a very slow approach, given the number of potential targets and his level of frustration.

c is incorrect. Core vocabulary approach is typically used for clients with inconsistent errors. BM’s errors are consistent, so this would not be appropriate for him.

d is incorrect. For the reasons listed above for answer b and c.

3. What two targets should be addressed first?

a) Liquids and velars. b) Velars and stridents. c) Final consonant deletion (FCD) and liquids. d) FCD and consonant sequences/clusters.

145

A Profound Phonological Disorder in a Preschooler

Answer: d is correct. Targeting these two first will create the greatest change in intelligibility. Since he exhibited frustration quickly, giving him success quickly is paramount. intelligibility increases the most if the word/syllable shape is correct, even if the phonemes are produced incorrectly.

b is incorrect. Velars and stridents will not impact intelligibil-

ity as eﬀectively as FCD and consonant sequences/clusters.

c is incorrect. Liquids are not appropriate targets for his age. a is incorrect. Liquids are not appropriate targets for his age.

4. Are familiar or unfamiliar listeners more valuable when determining intelligibility? a) Familiar listener percentage is more valuable. b) Unfamiliar listener percentage is more valuable. c) They are both equally important. d) Neither is important; the test scores are the only impor-

tant aspect.

Answer: c is correct. One is not more important than the other. They both give valuable information in determining the diagnosis and severity. Both scores provide a more accurate picture of actual severit y. These scores also help when showing progress.

a is incorrect. If the percentage for familiar listeners was the only one taken into consideration, the outcomes are typically skewed toward more intelligible.

b is incorrect. If the percentage for unfamiliar listeners was the only one taken into consideration, the outcomes are typically skewed toward less intelligible.

d is incorrect. Test scores alone should never be considered. Additional information must be considered to accurately capture performance.

39.5 Description of Problem and Recommended Treatment

BM was found to have a profound phonological disorder characterized by diﬃculty in the word/syllable shapes, containing final consonants and consonant sequences/clusters as well as the classes of liquids, velars, and stridents. He was 50% intelligible to familiar listeners and 20% intelligible to unfamiliar listeners. His phonemic inventory consisted of the vowels /i/, /o/,

/ɪ/, and /ʌ/ and the consonants /h/, /m/, /t/, and /p/. Frustration was high when listeners did not understand him. No evidence of receptive or expressive language disorders was observed.

It was recommended that BM receive 90 minutes of therapy per week. A Hodson’s cycles approach (minimum of 3, 10-week cycles) was recommended in a small group setting.

39.6 Outcome

BM received five cycles (10 weeks each) following a modified Hodson’s cyc les approac h. Every week a diﬀerent target (e.g., consonant sequences/clusters, FCD, liquids, velars, and stridents) was addressed. These targets were rotated based on previous testing. On the 10th week of each cycle, the HAPP-3 was adminis tered to asses s progress and determine targets for the followin g cycle(see ▶ Table 39.1). The pe rcentage of occurrence refle cting progress acros s the five cycles is reflected in.

Therapy was child-directed, following a modified Hodson’s cycles approach. Each session followed the following schedule:

●

Listening time (BM listened, through amplification, to a list of target words).

●

Pretest (assessment of BM’s productions of the target words).

●

Activity time (BM-directed therapy using age-appropriate toys, working with the target words as much as possible).

●

Phonological awareness focus (group reading from a book containing multiple examples of BM’s target).

●

Listening time (BM listened, through amplification, to a list of target words).

●

Posttest (assessment of BM’s product ions of the target words).

At the end of therapy, at the age of 5 years, 8 months, BM was 90% intelligible to unfamiliar listeners and 100% intelligible to familiar listeners. He had no expressive or receptive language diﬃculties. The PLS-5 was readministered at 5 years, 6 months and BM achieved scores in the average range in auditory comprehension (standard score [SS] = 108) and expressive communication (SS = 98). At discharge from therapy, BM had residual errors on /r/ and /l/.

Table 39.1

Percentages of occurrence

Dates of administration 10/6

Consonant sequences/clusters

Postvocalic singletons (FCD) 94 90 80 50 30 10

Liquids 100 100 100 80 75 60

Velars 100 90 95 80 60 25

Stridents 100 95 80 60 45 20

Severity rating Profound Profound Severe Severe Moderate Mild

Performance on HAPP-3 at the end of each 10-week cycle.

Pretherapy

115 104 104 84 55 38

12/5 End of cycle 1

3/2 End of cycle 2

6/3 End of cycle 3

8/26 End of cycle 4

12/4 End of cycle 5

146

A Profound Phonological Disorder in a Preschooler

39.7 Key Points

●

Poor expressive language scores in phonologically disordered children are not always indicative of an expressive language disorder.

●

When picking targets, it is important to focus on what will make the biggest impact on intelligibility.

●

Upon reaching 100% intelligibility, children who were severely phonologically impaired may still have residual errors on /r/ and /l/.