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Application of Dynamic Assessment of Narratives in an English Language Learner

a is incorrect. The DA framework considers change from pretest to posttest, posttesting results, and observations of both modifiability and clinical judgment to make a diagnosis of LI, but not standardized test scores.

c is incorrect. If a child uses a language in which a clinician is not proficient, a translator may be necessary for assessment. Valuable information may st ill be obtained by conducting the mediation in English if a child is using English functionally and is well on their way to using English in the academic setting.

3. What is the best practice to assess HV’s language abilities?

a) Test in English since that is the language HV will eventu-

ally be using more of in school.

b) Test in Spanish using an interpreter if necessary because

HV uses Spanish more than English.

c) Test in both languages using an interpreter as necessary

to determine HV’s overall language ability.

Answer: c is correct. The goal of assessing language skills is to gain information about communicative competence including the languages a child uses to function across diﬀerent contexts. In HV’s case, we are considering the languages needed at home and school. For a child who is learning English, we expect errors during the process of learning a second language or errors in a first language if not given suﬃcient exposure to develop these skills. Errors in either language can be mistaken for LI, and competency in both languages must be determined.

a is incorrect. Although important to determine HV’s proficiency in English, this information alone does not provide a complete profile of HV’s communication ability across the contexts in which he uses language.

b is incorrect. HV spends more time using Spanish than English. Although he is in the process of learning English, he receives significant input in English and it is necessary to determine how his skills are developing in both languages. If the clinician only speaks English, an interpreter may be needed to elicit a story as well as transcribe and review the language sample.

4. For a child learning English at school and using English func-

tionally to communicate, but who speaks another language at home, what are the available options for conducting MLE? a) The mediation could be conducted in either language if

both languages are used functionally.

b) The mediation should only be conducted in the language

that the child has more experience with.

c) The mediation should never be conducted in the language

that the child has less experience with.

Answer: a is correct. For children who are learning English and using the language functionally, mediation in English may be a p ossibility as well as mediation in the child ’shomelanguage if the clinician is bilingual or an interpreter is availab le. There is a shortage of bilingual clinicians, and information gained from the mediation may be informative. For example, HV is using English more than 20% of the time during a typical week. He produced a simple story in English at pretest by generati ng sentences and drawing on his English lexicon. During mediation, the clinician would ensure th at input was comprehensible, and make provisi ons for improving the child’sabilities in English while providing individualized inst r uct ion. A bilingual child should be u sing English funct ionally in daily contexts for English mediation to be appropriate. Peña et al.

reported that, by providing mediation in English to bilingual children in their less familiar language, they were still able to accurately classify children with and without LI. They did so by observing modifiability and substantial diﬀerences in learning behaviors during the MLE. Children in the process of learning E nglish as a sec ond l anguage may demonstrate grammatical errors related to f irst language influence. However, these children should show good productivity in word production and be able to include most story elements even in the context of limited vocabulary.

b is incorrect. The clinician could still gain valuable information by conducting the mediation in the child’s less proficient language.

c is incorrect and follows the same reasoning as the above choice.

6.5 Description of Disorder and Recommended Treatment

It is important to note that both HV’s parents and teacher indicated concerns about his language abilities. HV’s teacher likely compared HV to other bilingual f irst graders and noticed that he was not using either Spanish or English as competently as his peers. Likewise, HV’s parents also noticed that he was not using Spanish in a manner that was consistent with their home and community expectations. For bilingual children, parents and teachers often provide reliable ratings of language performance. HV did not make much improvement from pretest to posttest in his inclusion of narrative components. Using only pretest measures may introduce bias into the assessment process for children from CLD backgrounds not familiar with an assessment task. Posttest measures following practice and mediation may better reflect language learning ability. his bilingual first- and second-grade peers (n =24) who also received mediation in English including NDW, TNW, and TNU as compared to peer measures: NDW M = 44.6 ± SD = 19.6; TNW M = 124.3 ± SD= 70.9; TNU M = 20.8 ± SD =9.1. In Spanish, HV’s inclusion of story compo- nents and his MLU were ≥ 1 SD below his peers on story components M = 10.1 ± SD = 0.9 and MLU M = 5.7 ± SD = 0.9. At posttest, HV’s performance was below his peers (more than 1 SD below the norm) in both languages on narrative and productivity measures. Specifically, HV’s total narrative score, story components, and measures of productivity, including TNW and MLU, were all below the performance of his bilingual peers: English total scores M = 30 ± SD = 7.9; Spanish M = 29.7 ± SD = 7.6; English story components M = 11.2 ± SD = 2.3; Spanish M = 11.4 ± SD = 3.1; English TNW M =139.4 ± SD = 57.4; Spanish M =132.3 ± SD= 50.1; English MLU = M = 6.2 ± SD = 1.2; Spanish M = 6.1 ± SD = 1.3. In English HV’s story ideas and language were greater than 1 SD below his peers (M = 14.5 ± SD = 4.9), although in Spanish, his inclusion of mental state verbs improved and thus his score on this measure was comparable to peers. HV did not appear to benefit from two sessions of mediation to improve narrative skills, while his typically developing peers improved. HV’s performance at posttest was consistent with both parent

and teacher concerns about his language.

Evidence from the story transcripts indicated that

especially when children are

HV’s performance at pretest was ≥ 1 SD below that of

on measures of productivity,

Application of Dynamic Assessment of Narratives in an English Language Learner

With respect to modifiability, observations of HV’s learning indicated diﬃculties predictive of LI (▶ Table 6.2). Diﬃculties with metacognition, flexibility, and task orientation are areas of modifiability that, with posttest measures, significantly increased correct classification of bilingual and CLD children

with and without LI.

In terms of grammaticality, both pretest and posttest transcripts revealed high ungrammaticality in English and some ungrammatical utterances in Spanish. Grammatical errors in English included diﬃculty with third person, present tense, and copula and auxiliary omission “to be.” In Spanish, HV’s errors included gender and subject and verb number agreement, and omission of the auxiliary verb “estar.”

The remediation plan for HV included bilingual intervention.

ity, the use of words to mark the order of events and inclusion of causal information should be targeted. For example, targeting sentences that use “because” or “porque” to include causal information and relative clauses to give more detail about setting or character stimulate HV to use more complex utterances. Furthermore, HV did not use advanced or specific vocabulary. The inclusion of more detail when retelling stories should also help HV produce utterances with more specific vocabulary and more propositions. Grammatically, copula and auxiliary forms should be targets in both languages. HV was beginning to use past tense in Spanish and should be introduced to the past tense “ed” in English and contrasting that with the third person

present form “s” morpheme. Information gleaned from the MLE regarding HV’s language learning should be employed to develop cognitive strategies for awareness and error recognition. In order to maximize progress in both languages, targets should be chosen to transfer across languages and improve language ability in both Spanish and English. Targets in both languages should include story grammar components of characters and setting with more description, the inclusion of initiating events, character plans to solve a problem, and attempts and outcomes to improve episode structure. To further improve story cohesion and sentence complex-

Table 6.2 Modifiability scores from MLE 1 and MLE 2

MLE components Target MLE 1 MLE 2

Score Description Score Description

Internal social-emotional (affect)

Cognitive arousal Task orientation 2 Mostly understands

Cognitive elaboration Problem solving 2 Organized, but some-

External social-emotional (behavior)

MLE, mediated learning experience.

Anxiety 1 Calm, little to no

Motivation 3 Ambivalent, unsure

Tolerance to frustration

Meta-cognition 2 Aware of most errors

Nonverbal self-reward 1 Positive response to

Verbal mediation 3 Talks occasionally 3 Talks occasionally

Flexibility 3 Some evidence of

Responsiveness to feedback

Attention 2 Focused, but distracti-

Compliance 1 Cooperative 1 Cooperative

1 Persistent, wants to

2 Positive but hesitant,

6.6 Key Points

●

Pretest and posttest in both languages can assess patterns in both languages.

●

Observations during MLE should be incorporated into the treatment plan .

●

Results from narrative assessment can guide intervention targeting grammar as well as vocabulary.

soothing required

about tasks

continue despite difficulty

tasks (75%)

(75%)

task regardless of difficulty

what inefficient (< 25% off task)

more than one strategy and occasionally utilizes them

requires some feedback

ble at times

1 Calm, little to no

2 Curious, shows

1 Persistent, wants to

3 Understands tasks

3 Aware of some errors

1 Positive response to

3 Sketchy plan, trial and

3 Some evidence of

1 Very positive, main-

2 Focused, but

soothing required

interest

continue despite difficulty

some of the time (50%)

(50%)

task regardless of difficulty

error

more than one strategy and occasionally utilizes them

tains enthusiasm

distractible at times

Application of Dynamic Assessment of Narratives in an English Language Learner

Suggested Readings

[1] Miller J, Chapman RS. SALT for Windows-Research version 7.0. Madison, WI:

Language Analysis Laboratory, Waisman Center, University of WisconsinMadison; 2002

[2] Miller J, Iglesias A. Systematic Analysis of English and Spanish Language

Transcripts. Madison, WI: Language Analysis Laboratory, Waisman Center, University of Wisconsin-Madison; 2002–2004

[3] Squires KE, Lugo-Neris MJ, Peña ED, Bedore LM, Bohman TM, Gillam RB. Story

retelling by bilingual children with language impairments and typically-developing controls. Int J Lang Commun Disord . 2014; 49:60–74

References

[1] Miller L, Gillam RB, Peña ED. Dynamic Assessment and Intervention: Improv-

ing Children’s Narrative Skills. Austin, TX: Pro-Ed; 2001

[2] Peña ED, Gillam RB, Malek M, et al. Dynamic assessment of school-age child-

ren’s narrative ability: an experimental investigation of classification accuracy. J Speech Lang Hear Res. 2006; 49(5):1037–1057

[3] Peña ED, Reséndiz M, Gillam RB. The role of clinical judgments of modifiabil-

ity in the diagnosis of language impairment. Adv Speech Lang Pathol. 2007; 9:332–345

[4] Fiestas CE. The Dynamic Assessment of Narratives: A Bilingual Study. [doctor-

al dissertation]. 2008. Available at: http://www.lib.utexas.edu/etd/d/2008/fiestasc36454/fiestasc3645.pdf

[5] Peña ED, Gillam RB, Bedore LM. Dynamic assessment of narrative ability in

English accurately identifies language impairment in English language learners. J Speech Lang Hear Res. 2014; 57(6):2208–2220

[6] Bedore LM, Pena ED, Joyner D, Macken C. Parent and teacher rating of bilin-

gual language proficiency and language development concerns. Int J Biling Educ Biling. 2011; 14(5):489–511

Stuttering in Young Children

7 Stuttering in Young Children

John A. Tetnowski

7.1 Introduction

The evaluation and management of stuttering is complex and several salient issues emerge. Primarily, parents frequently express uncertainty when a child begins to stutter and are unsure whether this speech pattern represents normal development or whether it warrants intervention. And upon the diagnosis of stuttering, parents are not sure whether they should intervene immediately, or wait to see whether the stuttering resolves over time. Finally, when parents wish to initiate treatment, they cannot find a “specialist” in their geographic area.

7.2 Clinical History and Description

GC was 2.5 years old and had been stuttering with “moderateto-severe disfluencies” for 7 months according to his mother. She stated that he was advanced with “verbal expression,” but she and her husband were quite concerned. Since there were no fluency specialists (FS) in her area, she reached out to an FS in another state and to a closed listserv associated with the Special Interest Group (SIG) on Fluency and Fluency Disorders in the American Speech-Language-Hearing Association. Through this outreach, GC’s mother connected with the author for consultation via email and telephone. As an initial step, it was recommended that the mom record GC in several speaking conditions for review. Within 1 month, several short samples were made available to determine whether a complete assessment was indicated. In addition, GC’s mother was also queried regarding his fluency. GC was an only child with an unremarkable birth and developmental history. He had one paternal uncle with a brief history of stuttering and recovery at a young age. In addition, GC’s mother reported that GC is sometimes “stubborn” and has a “reactive temperament” (e.g., he is quick to get upset and slow to calm). In addition, GC’s stuttering began just prior to his second birthday and although it varied since onset, GC’s mother reported that his speech progressively worsened (“more bumpy” in his mother’s words). GC had not received any previous therapy and was not particularly concerned by his stuttering. However, both parents expressed marked concern regarding his speech fluency.

7.3 Clinical Testing

As a result of the initial interactions, formal evaluation was recommended. GC and his mother drove approximately 3 hours for an evaluation of his speech and communication skills. GC cooperated completely. As suggested by his mother, his language was quite precocious for his age. GC interacted readily and completed all tasks. His articulation, voice, and language

skills were subject ively judged to be within normal limits or

even a bit advanced. As part of the assessment process, his

speech was evaluated in several diﬀerent settings and levels of

linguistic demand. This information was elicited during a clini-

cal assessment that included the use of several age-appropriate

toys, pictures, and standardized tools. Tasks included naming

and repetition tasks across various levels of length and linguis-

tic complexity. The results of this assessment are presented in

▶ Table 7.1.

In addition to speech samples, a weighted stuttering-like disfluency (W-SLD) score, a formal stuttering assessment, specifically the Stuttering Severity Instrument-4 (SSI-4), interview with GC’s mother W-SLD score of 35, an SSI-4 score of 24, which places him in the moderate severity range, and the interview revealed that both parents were greatly concerned about his stuttering and that they “wanted the ‘best’” therapy for him. They also indicated that they did not know what to do when he stuttered and t ried to not call it to his attention. Both parents were willing to “do whatever it takes” to get him through this period.

were completed. GC obtained a

and an

7.4 Questions and Answers for Reader

1. Based on the results of the clinical evaluation, this child’s

speech is: a) Normal for his age. b) Indicative of stuttering. c) Indicative of “normal” disfluencies. d) Unclear as to whether it is normal or abnormal.

Answer: a is incorrect. Stuttering frequencies in the range of 10% to 25% are abnormal. It is important to note that almost all of his nonfluencies are stuttering in nature. In some cases, a child may exhibit a large number of nonfluencies that are not stuttering. Almost all of GC’s nonfluencies are st uttering. For example, the 25% level of stuttering at the one-syllable naming task is also the same as the overall level of nonfluency (also 25%). Thus, none of his nonfluencies were in the disfluency category.

b is correct. Stuttering is defined by the use of part-word repetitions, prolongations, blocks, and single-syllable word repetitions. High levels of stuttering across tasks (10%, 25%, etc.) are indicative of true stuttering. Distinction between stuttering and disfluency is critical.

c is incorrect . The clinician must diﬀerentiate between stuttering and disfluency. Disfluencies consist of multisyllable word repetitions, phrase repetitions, interjections, revisions, incomplete phrases, and broken words.

disincorrect.Thischild’s speech is marked by true stutter- ing. The levels of stuttering are indeed outs ide of the normal range.

Stuttering in Young Children

Table 7.1 Results of clinical testing for a 2.7-year-old child suspected of stuttering

Task %SS %nf Dur Type

Single-syllable word naming

Single-syllable word repetition

Multisyllable word naming

Multisyllable word repetition

Dialogue with SLP

Dialogue with parent

Dur, duration of most typical stuttering; %nf, % of all nonfluencies (stuttered and nonstuttered types); %SS, % stuttered syllables; PR, phrase repetition; PWR, part-word repetition; SLP, speech-language pathologist; type, type of nonfluency.

25 25 2 s PWR

10 10 1 s PWR

10 12 2 s PWR PR

5 5 2 s PWR

8.6 8.8 3 s PWR PR

7.6 8.0 3 s PWR PR

2. Should therapy begin now or should the clinician oﬀer an alternate choice? a) Begin direct treatment now. b) Begin indirect treatment now. c) Postpone treatment until age 3 years. d) Postpone treatment until he begins school.

Answer: a is correct. The child has been stuttering for over 6 months. Although it is possible that the child may spontaneously recover, the trend of “stuttering getting worse over time” indicates that persistent stuttering is a strong possibility.

b is incorrect . Although this answer is partially correct, in terms of beginning therapy now, early-intervention programs for young children like the Lidcombe Program, family-focused therapy, and parent–child interaction therapy are eﬀective and eﬃcacious. All of these programs use direct intervention strategies rather than simply modifying the environment as the primary means of treatment.

c is incorrect. This child has been st uttering for over 6 months and his stuttering is getting worse; these findings justify initiating treatment.

d is incorrect. This child has been stuttering for over 6 months and his stuttering is getting worse; these findings justify initiating treatment.

3. Which of the following are risk factors for “persistent” stut-

tering? a) He is an only child. b) He is male. c) He has an uncle who also stuttered. d) He has not been in previous therapy.

Answer: b is correct. Males are between 2 and 12 times more likely to stutter than females.

c is correct. A genetic history of stuttering is a risk factor for stuttering; this link does not have to be a sibling, but can be a parent, grandparent , or other relative.

a is incorrect. No evidence suggests that an “only child” is more likely to stutter than children with siblings.

d is incorrect. There is no evidence that being in previous therapy (or not) puts a child at a higher (or lower) risk for persistent stuttering.

4. If therapy is recommended, what is the best and most eﬃ-

cient type of intervention and in what format should it be administered?

a) Indirect treatment from a local speech-language patholo-

gist who is not an FS.

b) Direct treatment from a local speech-language patholo-

gist who is not an FS.

c) Direct treatment from a distant speech-language patholo-

gist who is an FS that the parent can drive the child to for therapy.

d) Direct treatment from a distant speech-language patholo-

gist who is an FS and is willing to provide distance therapy through video/teleconferencing.

Answer: d is correct. Recent research, specifically on the Lidcombe Program, suggests that distance intervention (e.g., webcam delivery) can be as eﬀective and eﬃcient as face-to-face therapy for young children who stutter.

a is incorrect. Indirect therapy has not been shown to be as eﬀective as direct therapy for young children with persistent stuttering.

b is incorrect. The mother was not comfortable with the local options since none of them were board-certified specialists in fluency disorders.

c is incorrect. This is not the best answer. For this parent, the nearest board-certified FS was 3 hours of driving time away.

7.5 Description of Disorder and Recommended Treatment

GC presented with stuttering. Furthermore, positive “risk factors” for persistent stuttering included (1) significant stuttering across settings greater than 3%, (2) a high W-SLD score of 35, (3) male, (4) stuttering progressively worse for more than 6 months, (5) a reactive temperament, (6) a relative who stuttered, and (7) parental concern.

Since GC lived almost 3 hours away from an FS, it was recommended that the Lidcombe Program for Early Stuttering implemented via webcam. The Lidcombe Program for Early Stuttering is a behaviorally based intervention program that targets the elimination of stuttered speech through appropriate reinforcement for fluent speech. Much of this program is carried out by a parent trained by a speech-language pathologist. This program has been shown to be highly eﬃcacious through multiple randomized control trials. The treating speech-language pathologist was trained through the Lidcombe Training Consortium. Recent evidence suggests that the Lidcombe Program has suﬃcient eﬃcacy when implemented in this manner

(i.e., through a webcam).

Treatment was scheduled for weekly sessions with daily practice at home to be mediated by GC’s mother. Daily text messages were employed to track progress as well as address any problems or questions. Daily severity ratings (SRs) were also texted based on the level of complexity and demand of the assigned task(s). An SR was assigned to each task on a 10-point scale, with a score of 1 indicating no stuttering and a score of 10 indicating very significant stuttering.GC’s

Stuttering in Young Children

parents were trained on this method to ensure agreement between the therapist and mother. As therapy continued, GC’s love for books emerged and many therapeutic activities revolved around books and other enjoyable activities. One of the primary concepts underlying the Lidcombe Program is that therapy must be enjoyable and, after a short time, it was apparent that GC greatly enjoyed the individual time with his mother that often involved shared reading and interaction experiences.

Table 7.2 Results during “free conversation” task

Date SR(Mom) SR(SLP) %SS

6/21/2016 9.8

6/28/2016 5 5 5.8

7/12/2016 6 5 4.9

7/19/2016 4 4 4.2

7/26/2016 6 6 6.8

8/2/2016 5 4 4.5

8/10/2016 3 2 2.2

8/23/2016 2 2 2.3

8/30/2016 2 2 2.3

9/6/2016 2 2 2.6

9/13/2016 2 3 2.4

9/20/2016 2 2 2.1

9/27/2016 1 1 1

10/4/2016 1 1 1

10/11/2016 1 1 0.9

10/18/2016 1 1 1

11/3/2016 1 1 1.15

11/8/2016 2 2 1.7

11/22/2016 1 1 0.17

%SS, % stuttered syllables; SR(Mom), severity rating by mom; SR(SLP), severity rating by speech-language pathologist.

7.6 Outcome

Over 18 sessions across 5 months, GC’s stuttering decreased from 8.6% in dialogue to under 0.2%. The 18 sessions were approximately 1 week apart until success was apparent, and visits were then scheduled at biweekly intervals and eventually reduced to monthly. Therapeutic tasks were based on the level at which GC could interact and receive significant verbal rewards for “unambiguously stutter-free speech.” These tasks and proper reinforcement were demonstrated for GC’s mom to implement daily at home. The initial activity was a one-sentence, carrier-sentence completion task (e.g., This is a _________). As shown ▶ Fig. 7.1, GC maintained SR levels of 2 or less within a short time and maintained this level over extended periods.

GC progressed through two- and three-sentence tasks in a similar fashion and more online activities were eventually implemented. These activities included games, but as noted earlier, often revolved around shared-reading activities. These tasks included asking questions about a book after it was read to him and eventually progressed to GC telling a story about a book independently. Of note, books were never read verbatim to GC, but were paraphrased as he followed the pictures. In that regard, his storytelling was never memorization, but rather his interpretation of the story. He initially obtained an SR score of 3 and eventually progressed until he had 22 consecutive days with an SR of 1. In addition to SR scores, the percentage of stuttered syllables (%SS) was calculated during free conversation at the beginning of each session. The results are shown in

▶ Table 7.2, along with the SR score provided by both the treat-

ing speech-language pathologist and GC’s mom.

Fig. 7.1 Daily Severity Ratings (SR) over the course of treatment. SR of 1 indicates no stuttering and a score of 10 indicates very significant stuttering.

Stuttering in Young Children

7.7 Key Points

●

The risk for persistent stuttering is based on published risk factors.

●

The awareness of the parents and their willingness to participate in treatment are critical to therapeutic success.

●

A distance model of intervention may be eﬀective when inperson sessions are infeasible.

Suggested Readings

[1] Bernstein Ratner N, Guitar B. Treatment of very early stuttering and parent-

administered therapy: the state of the art. In: Bernstein Ratner N, Tetnowski JA, Eds. Current Issues in Stuttering Research and Treatment. Mahwah, NJ: Lawrence Erlbaum Associates; 2006:99–124

[2] Goodhue R, Onslow M, Quine S, O’Brian S, Hearne A. The Lidcombe Program

of early stuttering intervention: mothers’ experiences. J Fluency Disord. 2010; 35(1):70–84

[3] Ambrose NG, Yairi E. Normative disfluency data for early childhood

stuttering. J Speech Lang Hear Res. 1999; 42(4):895–909

References

[1] Riley GD. Stuttering Severity Instrument 4th ed. Austin, TX: Pro-Ed; 2009. [2] Westby CE. Ethnographic interviewing: asking the right questions to the right

people in the right ways. J Child Com Dis. 1990; 13:101–112

[3] Packman A, Onslow M, Webber M, et al. The Lidcombe Program treatment

guide. 2014 Available at: https://sydney.edu.au/health-sciences/asrc/docs/ lp_treatment_guide_0314.pdf.

[4] Bridgman K, Onslow M, O’Brian S, Jones M, Block S. Lidcombe Program web-

cam treatment for early stuttering: a randomized controlled trial. J Speech Lang Hear Res. 2016; 59(5):932–939

Evaluation & Intervention for a Young Child with Severe Intellectual Disability

8 Evaluation and Intervention for a Young Child with Severe Intellectual Disability

Billy T. Ogletree

8.1 Introduction

This case describes a communication evaluation and intervention sequence for BT, a 3-year-old boy with severe intellectual disabilities. BT’s communication disorder is consistent with significant delay associated with severe intellectual impairment. Critical features of communication-based services are featured. Children with severe intellectual disabilities benefit from early intervention with a broad therapeutic focus on partners and environments.

8.2 Clinical History and Description

BT was delivered via cesarean section at 27-week gestation and presented as “small for date” with a familial history significant for intellectual disabilities. BT participated in a developmental follow-up clinic after an 8-week neonatal intensive care stay. He was initially identified as “low” tone and moderately hearing impaired. In addition, BT’s extremely slow emergence of developmental milestones resulted in a team (including a speech-language pathologist [SLP]) diagnosis of severe intellectual disability at 8 months. Impaired vision was also suspected at that time.

BT received home-based early intervention conducted by an early interventionist working in conjunction with his parents. Eﬀorts emphasized general development throughout much of BT’s second year. The SLP involved in BT’s initial diagnosis consulted with the early intervention specialist throughout this treatment. At 18 months, BT was rolling over, sitting, and reaching for objects with both hands. He was also wearing bilateral hearing aids and corrective glasses. BT looked at the faces of others and at objects of interest. By 24 months, he was reaching for objects with persistence and repairing failed communication attempts by adding vocalizations without consonants (primarily vowelized squeals). By 36 months, BT was standing and communicating to request and protest with reaches, vocalizations, and some aberrant behaviors. He received direct speech and language intervention services for 12 months and was referred for testing to create his Individualized Education Plan.

8.3 Clinical Testing

BT’s assessment was tri-focused.1This framework pursued assessment targets relating to the child, his communicative partners, and relevant environments. BT’s early care was coordinated by the early intervention provider network (IDEA Part C). On his third birthday, BT participated in a complete developmental/educational team evaluation conducted through his local school district. The team considered all areas of develop-

ment including emergent communication. SLP evaluation was initiated by a review of BT’s general records and consulting with team partners with respect to BT’s sensory impairments. A preevaluation staﬃng with BT and his parents was then initiated. Specifically, BT’s parents were questioned regarding communication goals. BT was also informally observed, and his parents agreed to attend and participate in communication testing by assisting with sampling and through some limited test administration. His parents also requested that information be shared as testing progressed. A questionnaire regarding BT’s emergent language and general health and development was administered. BT’s parents were also provided with the words and gesture form from the MacArthur Communicative Development Inventories (CDI) prior to BT’s formal evaluation.

BT’s evaluation occurred in his home with his parents present. BT’s hearing aids were confirmed to be in working order, and BT wore his glasses throughout the duration of the evaluation. BT’s parents were instructed to initiate play in a typical manner. BT’s parents brought favorite toys from BT’s room and introduced them in a variety of games and routines. During these activities, BT and his parents were observed and data specific to expression of communicative intent, coordinated attention, aﬀect, and play were recorded. Partner targets such as parent responsiveness to his emergent communication were also observed. After approximately 10 minutes, the SLP joined play and gradually introduced communicative temptations and play probes from the Communication and Symbolic Behavior Scales (CSBS). temptation tasks, and data regarding learner and partner assessment targets were collected. The Communication Matrix and the Communication Complexity Scale (CCI)5were completed. As materials were gathered and put away, the SLP shared observations from the assessment session and sought parental confirmation or clarification about their perceptions of BT’s abilities as well as routine environments and parental perceptions of communication opportunities as a function of these settings.

BT’s CSBS assessment (learner findings) revealed that he was an intentional nonsymbolic communicator who requested and protested with gestural forms (e.g., reaches) accompanied by vocalizations without consonants. He occasionally used behavior (e.g., pushes) to protest. His CCI scores ranged from 7 to 9, indicating the presence of triadic gaze and the use of communicative vocalizations and object reaching and oﬀering. BT’s Communication Matrix administration revealed level IV behaviors characterized by requests for objects with conventional communicative forms consistent with CSBS and CCI results.

Assessment of BT’s partners revealed that some did not respond to his nonsymbolic communication attempts. BT’s environmental assessment identified potential environmental modifications to increase communication opportunities.

with the instruction to complete the form

BT’s mother periodically assisted with

Evaluation & Intervention for a Young Child with Severe Intellectual Disability

8.4 Questions to the Reader

1. A tri-focused framework was implemented in this case. One clear benefit of this framework is that: a) It is immediately more cost-eﬃcient. b) It addresses assessment from a broad-based inclusive

perspective.

c) It only provides objective data points for intervention

planning.

d) It only provides subjective data points for intervention

planning.

Answer: b is correct. A tri-focused framework broadens the SLP’s view of BT’s communication by providing objective and subjective data on BT’s learning abilities, the competence of his partners, and the communicative-friendliness of his environments. Data in each of these domains allow for a comprehensive intervention that is likely to result in intervention gains.

a is incorrect. Tri-focused assessment is likely to result in long-term savings but will be more immediately labor-intensive for BT’s SLP.

c and d are incorrect. Tri-focused assessment generates both objective and subject ive data.

2. Implementing a preassessment staﬃng provided:

a) The opportunity to discuss parental involvement in the

assessment process while making some early observations

of BT. b) Time for the initiation of standardized testing. c) Specific information regarding BT’s sensory status. d) Team members the opportunity to meet BT and his family.

Answer: a is correct. Preassessment staﬃng allowed for the determination of the aspirational expectations of the assessment process. It also provided a platform for the discussion of assessment roles for the parents and an opportunity to observe BT.

b is incorrect. No testing is conducted during preassessment staﬃng, rather it is a time for assessment planning and some initial observations.

c is incorrect. Although informal observations may assist with a better understanding of BT’s sensory status, specific information would require testing or record review.

d is incorrect. The SLP conducted the preassessment staﬃng by herself with BT and his parents.

3. The MacArthur Communicative Development Inventories

(CDI) a) An informant tool for parents to complete form specific to

emergent communicative abilities.

b) A structured communication sampling sequence for use

by the SLP. c) An instrument for assessing emerging grammar. d) An instrument for a comparing play stages to emergent

communication abilities.

Answer: a is correct. The CDI is an assessment instrument that allows parents to record emergent gestures, words, and early phrases.

b is incorrect. The CDI does not include a specific sampling sequence but instead allows parents to observe and record early communicative forms.

c is incorrect. Although the CDI allows for recording of emer-

gent phrases, it does not target more advanced grammar.

d is incorrect. The CDI does not address emergent play.

4. Both the Communication and Symbolic Behavior Scales

Answer: c is correct. Both measures were designed to assess presymbolic to emergent symbolic communication.

assess the specific communication abilities of persons with severe disabilities.

Scales includes clinician-directed communication sampling.

Scales specifically assesses emergent play.

and the Communication Matrix4were administered.

(CSBS) These two measure are similar in that:

a) They were specifically designed for children presenting

with severe intellectual deficits. b) They involve clinician-directed communication sampling. c) They were designed for children communicating at the

presymbolic to emergent symbolic levels. d) They assess play.

a is incorrect. The Communication Matrix was designed to

b is incorrect. The Communication and Symbolic Behavior

d is incorrect. The Communication and Symbolic Behavior

8.5 Description of Disorder and Recommended Treatment

Initially, BT presented as a child with a significant developmental delay possibly attributed to his shortened gestation and small presentation at birth (i.e., Intrauterine Growth Restric-

BT’s diagnosis became more clear with the familial pres-

tion). ence of intellectual impairment and as the gap in his developmental status and chronological age widened. His dual sensory impairment also provided diagnostic clarity. In sum, the most appropriate diagnosis for BT was severe intellectual disability. This diagnosis occurs under neurodevelopmental disorders in DSM-5 and is used when significant measured intellectual and adaptive deficits are present within the developmental period.

Prelinguistic Milieu Teaching (PMT) with parent responsivity

training strategy. PMT ut ilizes turn-taking within typical routines. As expectancy is established, routine interruptions are interjected to create communicative opportunities, and prompt sequences are employed to solicit intentional communicative acts. Given BT’s use of requests and protests, initial treatment eﬀorts focused on expansion of communicative behaviors to include comments and/or greetings. BT’s occasional use of behaviors communicatively could also be addressed through PMT. That is, conventional communicative means such as gestures or vocal behaviors could be targeted as replacements for any aberrant forms.

into nonsymbolic intentional communication. support for children with intellectual disabilities, and its eﬀectiveness can be enhanced with parental involvement. case, parental training included a focus on routine creation and milieu instructional strategies as well as emphasis on recognizing and responding to nonsymbolic communication. Parental involvement within everyday environments makes PMT a trifocused friendly intervention option.

was determined to be an appropriate therapeutic

PMT is a preferred treatment choice for children emerging

It has empirical

In BT’s

Evaluation & Intervention for a Young Child with Severe Intellectual Disability

8.6 Outcome

After 6 months of intervention, BT had expanded his intentional communication to include nonsymbolic commenting and greeting expressed through distal gestures (e.g., points and waves). This broadened his communicative repertory and provided increased social opportunities. BT also had replaced existing aberrant behaviors previously used to communicate (pushes) with a more appropriate head nod paired with vocalizations. BT’s treatment would now shift to expanding his requesting behavior vertically through the introduction of symbol forms such as objects and photographs. Objects and photographs will also now be used in schedules to assist with daily transitions.

Finally, in this same time frame, BT’s parents and other stakeholders participated in the creation of gesture dictionaries to assist with the recognition of nonsymbolic forms. Communication opportunities had also been infused into most of his daily life environments creating practice for nonsymbolic communicative behavior.

8.7 Key Points

●

Evidence supports posit ive outcomes for young children with disability who receive early intervention services.

11–13

Of course, these services are most eﬀective when utilizing evidenced-based practices.

●

The larger focus on partners and environments provided a broad platform for intervention likely to promote meaningful change.

●

The ability to communicate for more purposes will make BT a more successful communicator and will contribute a more positive perception of his communicative competence.