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Assessment of a School-Aged Speech Sound Disorder

9 Assessment and Treatment of a School-Aged Speech Sound Disorder

Kelly Farquharson

9.1 Introduction

This case reviews the complex issues associated with persistent speech sound disorders in a child. In particular, this case highlights the importance of considering decoding and spelling skills while assessing and treating school-aged children with speech sound disorders.

9.2 Clinical History and Description

B is a 9-year-old boy who just began fourth grade. He has received school-based speech-language therapy services since kindergarten for remediation of a speech sound disorder. In kindergarten, many speech sounds were problematic, but he is now only targeting the /r/ sound. Recently, B’s fourth grade teacher reported that he has very poor spelling and will not read aloud in class. She initially thought B was shy, but now reports that he clearly has diﬃculty decoding words. Although B’s current speech therapy sessions focus only on /r/ sound production, this report from his teacher suggested that additional testing was indicated to determine whether his speech sound disorder impacted his literacy skills.

9.3 Clinical Testing

Clinical testing must go beyond traditional articulation testing. B’s assessment battery examined speech production (Goldman–Fristoe Test of Articulation, 3rd Edition [GFTA-3] speech sample), receptive and expressive language (Clinical Evaluation of Language Fundamentals, 5th Edition [CELF-5] word decoding (Woodcock Reading Mastery Test, 3rd Edition [WRMT-3] Edition [TWS-5] 100 with an average range of 85 to 115. Results of the standardized assessments are presented in ▶ Table 9.1.

B’s receptive and expressive language abilities were within normal limits. Interestingly, his GFTA-3 score was only slightly below normal limits as is often the case with older children with one speech sound error. B’s speech sample also revealed distortions and substitutions with the /r/ phoneme in all word positions. His /r/ error was quite obvious and, although intelligibility was not greatly impacted, it is clear that he is aware of, and embarrassed by, this aspect of his speech.

Two subtests from the WR M T-3 were administered: word identification and word attack. The word identif ication subtest requires reading of decontextualized real words that increase in complexity as the test advances. The word attack subtest requires phonemic decoding of nonwords. The

), and spelling abilities (Test of Written Spelling, 5th

). All measures have a mean standard score of

and

stimuli words follow the rules of English, but do not carry meaning. As such, this subtest examines the abilit y to apply knowledge of letter–sound correspondence. The results of the two subtests are combined to create an overall composite, which was below the average range in B’scase.B’sscoreon the word identif ication subtest indicated that he had some sight word skills, but he experienced diﬃculty decoding more complex word str uct ures. This finding was substantiated by the word attack subtest, which revealed moderate impairment in the use of letter–sound correspondence for decoding. This deficit is particularly relevant as B is in fourth grad e and interacts with novel and advanced vocabulary in most academic subjects.

Finally, the TWS-5 was administered to quantif y B’sspelling abilities. His score was below normal limits. In his written narrative, he produced multiple spelling errors as well as missing a nd incorrect punctuation and capitalization. His spelling er ro rs comprised 38% of his writing sample. Importantly, his errors were reflective of letter substitutions that mapped onto his current speech production errors (e.g., “w” written in place of “r,” or “r” omit ted in vocalic contexts). Additional errors reflec ted an immature knowledge of letter– sound correspondence (e.g., “wach” instead of “watch”), many phoneti c spellings (e.g., “educashun” instead of “education”), and homophone confusion (e.g., “two” vs. “to”). Collaboration with the teacher further corroborated that these types of errors are pervasive in B’s spelling on classroombased measures.

Table 9.1 Results of Brandon’s speech, language, and literacy assessments

Construct Assessment (subtest) Standard or scaled

Speech sound production

Receptive and expressive language

Word reading WRMT-3 80

Spelling TWS-5 77

CELF-5, Clinical Evaluation of Language Fundamentals, 5th Edition; GFTA-3, Goldman–Fristoe Test of Articulation, 3rd Edition; TWS-5, Test of Written Spelling, 5th Edition; WRMT-3, Woodcock Reading Mastery Test, 3rd Edition.

GFTA-3 83

CELF-5 103

Sentence comprehension

Word structure 11

Recalling sentences 10

Formulating sentences

Word identification 87

Word attack 76

score

Assessment of a School-Aged Speech Sound Disorder

9.4 Questions and Answers for the Reader

1. Should services be provided to a fourth grade student who has diﬃculty with only the /r/ sound? a) No, because this deficit does not adversely aﬀect educa-

tional performance. b) Yes, but only if the parent requests services. c) No, because if he cannot produce the sound by fourth

grade, he will likely never produce it. d) Yes, because it may be impacting educational perform-

ance and that will vary for each case.

Answer: d is correct. The American Speech Language Hearing Association (ASHA) and the U.S. Department of Education have clearly indicated that an adverse impact on educational performance should be determined on a case-by-case basis. Blanket policies that suggest that a single speech sound error does not create educational impact are not appropriate. As evidenced by this case, a connection between a speech sound disorder and literacy is common.

a is incorrect . The evidence in the case supports that B is experiencing diﬃculties within the classroom. Although his speech sound disorder may be considered “mild,” it has evolved into a disorder that is impacting his reading and spelling abilities.

b is incorrect. According to the Individuals with Disabilities Education Act (IDEA) as well as the ASHA Scope of Practice documents, children with communication impairments are entitled to services that can assist them in accessing the classroom curriculum.

c is incorrect. Children are able to make progress in speech sound production past the fourth grade. Certainly, for older children, it is more challenging for the child and the clinician to make a change in speech production. However, like any child, B deserves the opportunity to make this change and to acquire the necessary skills for classroom success.

2. Why might B be experiencing diﬃculties with spelling in

fourth grade? a) He has weak alphabet knowledge. b) He has not developed the appropriate phonological and

orthographic representations.

c) He was never taught letter–sound correspondence.

d) He has an underlying language impairment.

Answer: b is correct. It is very likely that B experienced limitations in the development of phonological representations, which leads to diﬃculty mapping sounds to letters. This deficit could be a result of a persistent speech sound disorder. However, causal directionality of this relation is unclear.

a is incorrect. As a fourth grader, B is able to identify letters of the alphabet, but is unable to complete the orthographic mapping necessary for accurate word decoding.

c is incorrect. we cannot assume that B was or was not taught any specific skill. We can only make clinical judgments based on his current performance on tasks.

d is incorrect. B’s language scores were normal.

3. Why is it important to test B’s receptiveand expressive lan- guage if there does not appear to be a weakness in those areas?

a) It is possible that, after years of a speech sound disorder,

language can become weak over time.

b) A language impairment would ensure he gets the services

that he needs.

c) It is not important to test receptive and expressive lan-

guage.

d) It is a common practice to test receptive and expressive

language.

Answer: a is correct. For some children with speech sound disorders, language is normal early in elementary school. However, over time, expansion of language skills in children with severe or persistent speech sound disorders may be reduced, particularly if literacy skills are impacted. This deficit is primarily related to an impaired phonological system; thus, the connection between phonemes and graphemes is a challenging concept. As that system progresses, problems with word reading and spelling are likely to evolve. The less a child reads or practices spelling, the likelihood of issues with semantics and morphosyntax skills is increased.

b is incorrect. Children should receive the services that they

need, regardless of the area of communication that is impacted.

c is incorrect. Language can become weakened over time in the presence of a speech sound disorder. Furthermore, as classroom demands increase, language requirements become more complex. As such, it is crucial to ensure that language abilities are age appropriate.

d is incorrect. There are theoretical and clinical reasons why testing language is important. Although it is a common aspect of a communication evaluation, the choice to test language should be clinically and empirically driven.

4. What is the recommendation for a speech-language patholo-

gist (SLP) who does not have access to standardized tests of reading and spelling?

a) Use clinical judgment to guess a child’s reading and spell-

ing skills.

b) Collaborate with a classroom teacher, reading specialist,

or school psychologist.

c) Examine the child’s

patterns of strength and weakness.

d) Both b and c.

Answer: d is correct. It is often the case that the appropriate test(s) are not available. Collaboration with relevant service providers is encouraged. It is also clinically meaningful to examine what the child has produced in the classroom. An analysis of decoding and spelling patterns can be determined using classroom materials and can also lend insight into how the student is functioning in the classroom.

a is incorrect. Although newer clinicians are being training in reading and spelling assessments and interventions, it is never appropriate to guess. Collecting data from the child, the teacher, the parent(s), and the environment are the best ways to make informed clinical decisions.

b alone is incorrect. Collaboration can be diﬃcult due to time constraints or the fluctuation of an itinerant clinician’s sched-

classroom tests and assignments for

Assessment of a School-Aged Speech Sound Disorder

ule. Although collaboration is strongly encouraged, the SLP should be able to supplement that information with his/her own assessment of the child’s classroom performance.

c alone is incorrect. Although this approach is an appropriate method to examine how a child is functioning within the classroom, it is best that the SLP is able to pair this information with other data from the classroom teacher or related service professionals.

9.5 Description of Disorder and Recommended Treatment

B’s diagnosis was persistent speech sound disorder, as evidenced by continued diﬃculty achieving appropriate articulation. In particular, B continued to exhibit diﬃculty with the production of the /r/ phoneme. Although B’s speech sound disorder was limited to one phoneme, the disorder impacted his literacy skills in the areas of decoding and spelling. Thus, he experienced diﬃculty accessing fourth grade curriculum as (1) his speech production was unclear and, although not unintelligible, certainly noticeable and distracting to his peers and teachers, (2) he was unwilling to read aloud in class due to social embarrassment related to a persistent speech sound disorder, (3) he was experiencing diﬃculty decoding words due to poor phonological and orthographic representations, and (4) he was experiencing diﬃculties in spelling because his letter– sound correspondence was aﬀected by the persistent speech sound disorder.

Treatment was altered to target both expressive (i.e., speech sound) and receptive (i.e., decoding and spelling) phonological skills. Specifically, sessions focused on not just phoneme production but also his knowledge of the linguistic use of those phonemes. Therapy materials included curriculum-based vocabulary and spelling words ranging in complexity from second to fourth grade levels. Where appropriate, B highlighted the /r/ phoneme within a word so that he could practice correct speech production skills on highly relevant words that he was likely to see in the classroom. Therapy activities included phonological awareness (e.g., rhyming, blending, and phoneme deletion), phonics (e.g., letter manipulation, orthographic knowledge), and morphologi cal awareness (e.g., explicit instruction of prefixes and suﬃxes). Tasks related to these three areas, employing vocabulary and spelling words from his cur-

riculum, provided repeated practice identifying sounds and letter similarities and diﬀerences. Importantly, therapy activities were contextualized (e.g., no flashcards) in hopes of generalizing speech production and letter–sound skills to decoding and spelling opportunities in other settings.

9.6 Key Points

●

In this case, the speech sound disorder appears to be more complex than diﬃculty with speech sound production.

●

Continued diﬃculty with speech sound production throughout a child’s academic experience is likely to lead to diﬃculties with literacy skills (e.g., decoding and spelling).

●

The connection between phonology and literacy is an intimate one; children with weak phonological representations often experience diﬃculty with mapping phonemes onto graphemes.

●

For all children with speech sound disorders, early phonological awareness and reading skills should be monitored to avoid persistent reading and spelling issues later in elementary and middle school.

Suggested Readings

[1] Foy JG, Mann VA. Speech production deficits in early readers: predictors of

risk. Read Writ. 2012; 25(4):799–830

[2] Lewis BA, Avrich AA, Freebairn LA, et al. Literacy outcomes of children with

early childhood speech sound disorders: impact of endophenotypes. J Speech Lang Hear Res. 2011; 54(6):1628–1643

[3] Lewis BA, Freebairn LA, Taylor HG. Correlates of spelling abilities in children

with early speech sound disorders. Read Writ. 2002; 15(3–4):389–407

[4] Raitano NA, Pennington BF, Tunick RA, Boada R, Shriberg LD. Pre-literacy

skills of subgroups of children with speech sound disorders. J Child Psychol Psychiatry. 2004; 45(4):821–835

References

[1] Goldman R, Fristoe M. Goldman–Fristoe Test of Articulation. 3rd ed. Circle

Pines, MN: Pearson; 2009

[2] Semel E, Wiig EH, Secord WA. Clinical Evaluation of Language Fundamentals.

5th ed. Circle Pines, MN: Pearson; 2013

[3] Woodcock R. Woodcock Reading Mastery Test. 3rd ed. Circle Pines, MN: Pear-

son; 2011

[4] Larsen SC, Hammill D, Moats L. Test of Written Spelling. 5th ed. Austin, TX:

Pro-Ed; 2013

Assessment and Treatment of Pediatric Dysphonia with a Complex Medical History

10 Assessment and Treatment of Pediatric Dysphonia with a Complex Medical Histor y

Abigail L. Rosenberg

10.1 Introduction

Dysphonia refers to “abnormal pitch, loudness, and/or vocal quality resulting from disordered laryngeal, respiratory, and/or vocal tract functioning”. pediatric population ranges from 1.4% to 6.0%.

The prevalence of dysphonia in the

10.2 Clinical History and Description

EB was an 8-year-old girl who presented with a breathy voice, low volume, and diﬃculty being heard at home and school. Vocal quality had been consistent since she began speaking. EB described feeling “winded” while speaking and needed to breathe every few words. She was adequately hydrated and rarely engaged in concerning vocal behaviors. EB’s medical history included extreme prematurity, prolonged intubation as an infant, chronic lung disease, repaired patent ductus arteriosus (PDA), and paralyzed right diaphragm status post plication.

10.3 Clinical Testing

Clinical testing was completed in conjunction with an otolaryngologist to assess lar yngeal function and voice quality. Flexible laryngoscopy revealed false vocal fold compression with phonation and mild arytenoid tilt. The true vocal folds were smooth and straight with no obvious immobility; however, due to false vocal fold squeeze, complete glottic closure could not be fully visualized. Microlaryngoscopy, bronchoscopy, and laryngeal electromyography (EMG) were then completed, revealing acquired grade I posterior subglottic stenosis and normal vocal fold innervation with full closure (▶ Fig. 10.1).

Acoustic analyses included fundamental frequency for sustained vowels and connected speech, pitch range, and maximum phonation time. Frequency measures were within the normal range for EB’s age/sex. Pitch range was restricted at the upper register (262.26–601.44 Hz), and maximum phonation time was significantly lower than anticipated (5.91 vs. 14–17 seconds).

Perceptual measures of voice quality were completed using the Consensus Auditory Perceptual Evaluation of Voice (CAPEV), which judges the voice on overall severity, roughness, breathiness, strain, pitch, and loudness (▶ Fig. 10.2). EB presented with a moderate rating for overall severity and breathiness and mild ratings for the remaining parameters. EB also participated in stimulability trials to test therapy techniques targeting enhanced vocal quality, reduced laryngeal tension, and improved breath support.

10.4 Questions and Answers for the Reader

1. Based on EB’s presentation, there was concern for vocal fold immobility, prompting completion of a laryngeal EMG. Which of the following cranial nerve branches would negatively impact vocal fold mobility if damaged, and what in EB’s medical history would cause concern for damage of this nerve?

a) Trigeminal nerve. b) Hypoglossal nerve. c) Recurrent laryngeal nerve (branch of vagus nerve). d) Pharyngeal branch of vagus nerve.

Answer: c is correct. The recurrent laryngeal nerve innervates all intrinsic laryngeal muscles except the cricothyroid. Damage to this nerve would weaken or paralyze the aﬀected side, resulting in breathiness, hoarseness, or weak vocal quality. EB’s medical history is significant for PDA repair, which is a cardiac surger y. The left r ecurrent lar y ngeal nerve loops under the aorta, making it vulnerable to injury during heart surgery.

a is incorrect. The trigeminal nerve innervates muscles related to jaw movement. Damage may impact articulation and chewing.

b is incorrect. The hypoglossal nerve innervates the majority of muscles in the tongue. Damage may cause tongue deviation and muscle wasting.

d is incorrect. The pharyngeal branch of the vagus nerve innervates many muscles of the pharynx and soft palate. Damage to this branch may negatively impact resonance and/or swallowing.

2. Voice disorders can negatively impact a child’s education.

What is one reason why this may be?

a) Children with voice disorders typically have co-occurring

learning impairments.

b) Children with voice disorders may have limited participa-

tion in classroom activities.

c) Children with voice disorders have frequent illnesses and

often miss school.

d) Children with voice disorders typically have co-occurring

hearing loss and so cannot hear classroom instructions.

Answer: b is correct. Spoken communication is crit ical to classroom learning. Children may self-limit class participation to hide their voice disorder, which may reduce the amount of practice or feedback they receive.

a is incorrect. While children with learning disabilities may also have voice disorders, the two are not directly correlated.

Assessment and Treatment of Pediatric Dysphonia with a Complex Medical History

Fig. 10.1 Microlaryngoscopy and bronchoscopy images (with permission of Karen B. Zur).

c is incorrect. While some voice disorders may have underlying medical influences, children with voice disorders are not more likely to miss school due to illness.

d is incorrect. It is possible that children with conductive hearing loss due to middle ear fluid may speak loudly, which could result in vocal fold damage. Generally, there is not a high co-occurrence of hearing loss and voice disorders.

3. Based on EB’s clinical presentation, which of the following

would be an appropriate treatment recommendation? a) Resonant voice therapy. b) Surgical intervention (for vocal folds). c) Pushing/pulling adduction exercises. d) Indirect intervention only, such as vocal hygiene.

Answer: a is correct. Resonant voice therapy aims to unload tension from the vocal folds, with emphasis on easy vibrations further up in the vocal tract such as the mouth and nose. Resonant voicing is often produced with “vocal folds that are barely touching or barely separated,” resulting in a stronger, clearer voice with minimal vocal fold impact stress. It also requires “the least amount of lung pressure to vibrate the vocal folds.” This is appropriate for EB, as it can help achieve an improved vocal quality while reducing strain and without requiring high lung volume.

b is incorrect. Microlaryngoscopy and laryngeal EMG revealed normal vocal fold innervation and normal laryngeal function and motion; therefore, surgical intervention for the vocal folds would be inappropriate.

c is incorrect. These exercises can be beneficial for individuals with weak vocal fold closure and quiet, breathy voice. However, they can also result in increased strain and tension. As EB presented with strain and false vocal fold squeeze with phonation, this would not be recommended.

d is incorrect. Vocal hygiene is an important component of voice intervention, as it helps create healthy voice habits and serves as a foundation for direct therapy. While it can be beneficial on its own, its eﬀectiveness is reduced compared to voice

hygiene plus direct voice therapy. As EB successfully achieved an improved vocal quality using trial techniques during the assessment and demonstrated few negative vocal behaviors, her treatment should not be limited to vocal hygiene alone.

10.5 Description of Disorder and Recommended Treatment

EB presented with moderate dysphonia characterized by breathiness, perceptual component of strain, reduced breath support, and low volume. She frequently spoke on inhalation, which negatively impacted her ability to be heard. Vocal quality was not appropriate for her age/sex. Voice therapy was recommended to address breath support, identification and use of appropriately timed breathing breaks within longer sentences or songs, and use of forward focus and resonant voicing to reduce strain. In addition to voice therapy, physical therapy was recommended to help increase trunk strength in relation to breath support.

Specific therapy techniques to target improved voice quality and strain reduction emphasized the use of forward focus voicing. EB used kazoos, noise makers, straw phonation, and humming to unload tension from her vocal folds and establish forward focus. These activities were motivating and brought attention to feelings of vibration around her nose and lips. They also provided immediate auditory and sometimes visual feedback as to whether successful voicing was achieved. For example, forward focus voicing created a fuller kazoo sound and increased airflow through the straw, which was used to move a tissue across the table. As EB became successful with these techniques, external materials were faded and she practiced producing words, phrases, and then sentences while still maintaining the targeted voice placement. Breath support and timing were addressed by establishing a consistent breathing pattern and pairing breathing exercises with motivating voice tasks including tongue twisters, jokes, and popular song lyrics.

Assessment and Treatment of Pediatric Dysphonia with a Complex Medical History

Fig. 10.2 Initial assessment CAPE-V results.

10.6 Outcome

EB participated in weekly voice therapy across several months and progressed toward achievement of all goals. Her breath suppor t improved with phrases and eventual carry-over to structured conversation. She also established appropriate breaks to reduce i nhaled phonation. She initially benefitted from reading passages and mark ing of appropriate breathing breaks; at completion of therapy, she appropriately timed breaks without cuing during structure d tasks in 80% of opportunities, with improvement noted during semi-structured tasks and conversation. EB participated in resonant voice therapy and use of forward focus. Gains were notable within structured tasks, with some carry-over to conversation given clinician cuing. She successfully maintained forward focus to produce sustained nasal syllables, to chant nasal syllables with changing intonation, to produce nasal phrases,andtoreadshortpassages.Shealsocompleted weekly home exercises regarding breath suppor t and vocal quality.

Reevaluation was completed following therapy. EB presented

with significantly improved, though persistent, mild-moderate

dysphonia. Pitch range was within expectations and CAPE-V measurements were improved for all parameters. EB demonstrated greatly improved breath support, including identification of more appropriate breathing breaks to reduce instances of inhaled phonation. EB’s parents and teachers reported that she was more easily heard. Some variability in volume and vocal quality persisted, particularly during extended conversations. She demonstrated the knowledge and skills required to achieve eﬃcient voicing with adequate loudness and breath support.

10.7 Key Points

●

Pediatric voice disorders are common and can negatively impact a child’s ability to be heard and understood.

●

Collaboration with an otolaryngologist is necessary to identify any underlying physical dysfunction related to a voice disorder, and to make appropriate recommendations.

●

Children can participate in direct voice therapy and should not be limited to indirect intervention, such as vocal hygiene, based on age alone.

Assessment and Treatment of Pediatric Dysphonia with a Complex Medical History

●

Treatment for voice disorders often includes a combination of techniques to address various symptoms and/or causes.

Suggested Readings

[1] National Center for Voice and Speech 1998. Available at: https://www.ncvs.

org/freebooks/vocologyguide.pdf

[2] Hooper CR. Treatment of voice disorders in children. Lang Speech Hear Serv

Sch. 2004; 35(4):320–326

AAC in a Child with Congenital Porencephaly

11 Augmentative and Alternative Communication in a Child with Congenital Porencephaly

Jill E. Senner

11.1 Introduction

Pediatric neurodevelopmental disorders can result in multiple impairments aﬀecting cognition, motor skills, hearing, and vision. In some cases, children may not be able to communicate using natural speech. Augmentative and alternative communication (AAC) can support these children with complex communication needs.

11.2 Clinical History and Description

JF was a 30-month-old boy referred for AAC evaluation to identify strategies and assistive technology to improve his ability to communicate. He had been receiving early intervention services, but his expressive communication remained limited to two sign approximations (more and eat) and making choices between objects presented in a field of three by reaching with his left hand.

Brain abnormalities were detected on a 20-week ultrasound and labor was induced at 37 weeks of gestation due to concerns about JF’s lack of growth. Labor was complicated by fetal heart rate decelerations and nuchal cord. At birth, JF was diagnosed with congenital porencephaly, which resulted in quadriplegic cerebral palsy (CP) and cortical visual impairment (CVI).

JF lived at home with his mother and father, although his paternal grandparents frequently assisted with his care. English was the only language spoken in the home. JF was not yet sitting alone or crawling. He was reportedly dependent on a caregiver for all activities of daily living. He had a Zippie IRIS manual wheelchair for mobility but was dependent on a care-giver to push it. Occupational therapy and physical therapy reports obtained noted that JF demonstrated decreased muscle strength and poor head control. He was reported to consistently attempt to use his left hand to play and assist in functional activities.

JF underwent surgery at 24 months to correct strabismus in both eyes; however, his left eye still turned inward. He had diagnoses of CVI, nystagmus in both eyes, and strabismic amblyopia in the left eye at the time of the assessment, and glasses were prescribed. JF’s hearing was within normal limits.

The report from his primary speech-language pathologist indicated that JF babbled using open-mouth vowel sounds, bilabials /m/ and /w/, and sometimes /g/. He demonstrated the ability to vary his intonation and pitch. He cried to protest or when upset.

11.3 Clinical Testing

Assessment occurred over two visits and included an AAC Intake Questionnaire, caregiver interview, observation, testing,

and device trials. During the evaluation sessions, JF was smiling and engaged. Upon arrival, he responded to a greeting by waving his left hand. When asked to follow commands within his motor capabilities (e.g., “look up”), he did so upon request. An open mouth posturewith intermittent drooling was noted at rest. During the sessions, JF produced an approximation of the sign for “eat” (he put his fist near his mouth) to request a snack and smiled while moving his head slightly upward (paired with a vocalization) to indicate acceptance of the food item oﬀered. His mother presented him with pureed and mechanical soft foods. She reported that he was unable to masticate crunchy or chewy foods. Some anterior loss of material was noted due to poor lip closure. JF reached toward toys presented with his left hand.

The Prelanguage Inventory from Evaluating Acquired Skills in Communication, Third Edition (EASIC-3, an inventory designed for children with developmental disabilities), was administered using a combination of testing, observation, review of records, and informant interview. JF’s mother and paternal grandfather served as informants. JF’s receptive skills were as follows: he turned his head to attempt to locate environmental sounds, turned his head and smiled in response to voice, consistently inhibited when told “no” in a normal voice, demonstrated comprehension of several common objects (e.g., cup, crayon and paper, toothbrush, toy car, tissue), responded to 4/4 commands (to show/give me) with gestures involving an object, responded to verbal commands with gestures, and demonstrated the ability to match 4/4 identical objects. Receptive skills were consistent with the 24-month developmental level. In addition, JF demonstrated appropriate symbolic play (e.g., he pretended to cook with toy pots and pans, tried to feed a baby doll) and he manipulated objects to achieve a desired outcome (e.g., he operated a variety of large-button and switch-adapted toys). Expressive communication was limited. JF produced a sign approximation (eat) to gain adult attention to obtain a desired food item out of reach, used eye gaze to get assistance (e.g., he stopped trying to open a container and looked at the evaluator for several seconds), produced a sign approximation of “more” (putting his hands together) to indicate recurrence, rejected items by shaking his head “no,” accepted items by smiling and looking upward, initiated a greeting by waving to his grandfather upon entry to the room, and reached for desired items. JF demonstrated diﬃculty indicating basic needs (e.g., he had no way to request “drink” so he refused food until a caregiver presented him with a drink, he cried to indicate physical discomfort) and was unable to request actions or objects out of his immediate reach. ▶ Table 11.1 provides a summary of JF’s nonverbal communication.

The Visual Identification section of the AAC Evaluation Genie iPad app was used to evaluate JF’s ability to visually track and identify a single icon from 5″ to 1″ in size. AAC Evaluation Genie is an informal diagnostic tool that is intended to assist with identifying skill areas that relate to the language representation

AAC in a Child with Congenital Porencephaly

Table 11.1 EASIC-3 functions of nonverbal communication

Score Function of commu-

nication

+ Requests for objects 24, 25 Reached toward

+ Requests of action 25, 26 Signed “more”

+ /E Calling/attention 13, 14 Signed “eat,” gazed

+ Rejection/negation 19, 20 Shook head “no,”

+ Affirmation 19 Smiled and looked

+ Recurrence 26 Signed “more”

+ Greeting 21 Smiled, waved

+ , present in spontaneous nonverbal communication; + /E,

spontaneous in elicited nonverbal communication.

methods commonly found on augmentative communication systems. On this informal probe, JF used the three middle fingers on his left hand to access the iPad. He was 50% accurate in selecting 5” buttons from a field of two using direct selection. His accuracy dropped to 25% in a field of four. Due to chance accuracy using direct selection with his left hand, alternate access methods were trialed using high-interest, low-cognitive demand activities (e.g., switch-accessible iPad and computer games). Eye gaze was attempted on an available SGD (speechgenerating device), but was not eﬀective likely due to his nystagmus. Similarly, optical head pointing was not accurate due to poor head control. Two-switch step-scanning was then attempted. In this access method, two switches were placed vertically, one to the right and one to the left of JF’s left hand. The green switch on the left was used to “move” between items presented and the red switch to the right of his hand was used to make selections on an iPad app. Following modeling, JF demonstrated emerging understanding of the functions of both switches; however, his accuracy was 50% from a field of 15.

Partner-assisted auditory and visual scanning was done on pages printed out from an SGD. During partner-assisted scanning, a communication partner points to (or holds up) each symbol while saying each word or phrase, “scanning” through the child’s choices. JF appropriately smiled to aﬃrm and occasionally shook his head “no” to reject items presented. During a play-based activity (bubbles), JF independently selected “go” several times as well as “more” and “want” at appropriate times during the activity.

Items Comments or

examples

desired toys

at evaluator for assistance

refused food (turned head away)

upward (occasionally included a vocalization)

11.4 Questions and Answers for the Reader

1. What conclusion can you draw about the appropriateness of

AAC interventions for this child based on the descr iption provided?

a) JF is unable to communicate using his natural speech

alone, therefore AAC is appropriate. b) JF is too cognitively impaired to use an AAC system. c) JF cannot point accurately and alternate access methods

are not mastered at this time, therefore JF is not an

appropriate candidate for AAC. d) JF cannot use an AAC system due to his visual

impairments.

Answer: a is correct. According to the National Joint Committee for the Communication Needs of Persons with Severe Disabilities (NJC), all individuals with severe expressive communication impairments that interfere with the development of oral language should have access to AAC systems or devices to promote eﬀective communication.

b, c, and d are incorrect. According to the NJC, “the currently accepted evidence in the literature suggests that no specific skills are prerequisite for successful use of AAC in the broadest sense.”

2. What therapeutic intervention strategies would be most

appropriate for JF at this time?

a) Use of partner-assisted scanning with a light tech paper-

based system.

b) Motor training to improve two-switch step-scanning

skills.

c) Use of a light tech paper-based communication system for

immediate communication needs plus motor training to more complex skills required for adaptive access.

d) AAC is not appropriate for this child.

Answer: c is correct. “A longitudinal program designed to meet the person’s immediate communication needs with a number of readily accessible approaches, which also ‘invests in the future’ through a systematic motor or speech therapy program to train more complex skills, may be fruitful and ultimately, more balanced”. intervention or parallel training."

a is incorrect. Although JF needs a system to meet his immediate communication needs, abandoning motorically complex options completely would not prepare JF for use of an SGD in the future.

b is incorrect. Although JF needs practice to improve his access, waiting to provide a means of communication until this is mastered would delay access to language opportunities.

d is incorrect. According to the NJC, all individuals with severe expressive communication impairments that interfere with the development of oral language should have access to AAC systems or devices to promote eﬀective communication.

3. What features would need to be present in an SGD for JF?

a) Auditory cues or previews. b) Indirect access methods. c) Core vocabulary. d) All of the above.

Answer: d is correct. JF required a system with a large amount of vocabulary to meet his current and developing language needs, as well as auditory cues due to his poor vision and alternate access (i.e., scanning) options due to his limited fine motor skills.

This is referred to as a "balanced approach to

AAC in a Child with Congenital Porencephaly

4. What type of training (if any) should JF’s caregivers receive? a) Caregivers do not require any special training. b) Caregivers should only be trained in operating the device

(e.g., turning it on/oﬀ, programming messages).

c) Caregivers should be trained in operating the device and

in modeling use of the device.

d) Caregivers should join an online group so they can ask other

parents of children using SGDs for advice when needed.

Answer: c is correct. Parents must have suﬃcient skills in oper- ating the communication system, the language of the device, and strategies for reinforcing communication (e.g., modeling and responding to children’s communication) to support children learning to use an AAC system.

a is incorrect. Recent analyses of communication partner training programs suggest that there is consistent evidence that communication partner inst ruction not only improves the skills of communication partners but also has a positive impact on the communication of people who use AAC. primary communication partners for their young children and they need training in operating the device as well as ways to integrate use of the device into naturally occurring activities.

b is incorrect. Parents do need to know how to operate the device; however, they also need to know how to support communication with the device.

d is incorrect. Parent and family support has been identified as a contributor to positive outcomes for individuals who use AAC; however, information from online groups may not be always accurate or relevant.

Parents are the

11.5 Description of Disorder and Recommended Treatment

JF’sCPaﬀected his oral motor skills for both feeding and com- munication. His phonemic repertoire was severely limited and he was unable to produce oral speech, characteristic of severe dysarthria. JF had receptive language skills at approximately the 24-month level, but his nonverbal expressive skills were limited. At 24 months, children typically have 200- to 300-word expressive vocabularies and are using short, incomplete sentences. In this case, a clear discrepancy evolved between what JF understood and what he could communicate.

A feature-matching process was completed in which JF’s skills were matched to features of available SGDs. JF required a system with dynamic display and a large amount of vocabulary to meet his current and developing language needs, as well as auditory cues due to his poor vision and alternate access (i.e., scanning) options due to his limited fine motor skills. Three devices with these features were trialed during the assessment sessions, and the most appropriate synthetic speech, dynamic display SGD was obtained through the state lending library for a 6-week trial period. A core vocabulary that included some phrase-based branches was selected that allowed for a balance of novel sentence construction and quick messages. Concurrently, a printout of the device screens provided JF an immediate means of communication when accessed via partner-assisted scanning and nonverbal yes and no responses. In addition, weekly diagnostic speech therapy commenced to (1) teach the language of the communication system, (2) improve JF’stwo-switchstepscan-

ning skills in a variety of high-interest, lower-cognitive demand iPad and computer games, and (3) instruct communication partners how to operate JF’s technology and to support his communication in the home environment. Communication progress was monitoredvia language sampling.

In therapy, JF par ticipated in a number of play-based activities designed to improve language skills using his book and SGD. During the trial period, JF smiled and vocalized excitedly when provided with opportunities to communicate using his book and device. Objective measures indicated that JF used his communication book to generate a number of action + object phrases to request objects and actions (e.g., “play music,”“eat yogurt,”“drink milk,”“go outside,”), used two-word combina- tions to greet communication partners (e.g., “good morning + mom”), terminated activities (e.g., “all done,”“stop”), and expressed feelings (e.g., “hungry,”“tired”).

Two-switch step-scanning training was provided throughout the trial period using a combination of high-interest, low-cognitive demand games as well as opportunities for operation of the SGD during play-based activities. JF’s accuracy increased to 60% in a field of 15 during the trial period. On the communication device, JF generated similar messages on occasion; however, they were often interspersed with unintended messages due to decreased accuracy.

The success of an interaction between a child using AAC and a communication partner depends heavily on the skills of the partner. Being an eﬀective communication partner of a child using AAC often requires parents to change long-established ways of communicating. Because JF spent most of his waking hours with his mother and grandfather, both caregivers were trained in operating the book and device and they also received instruction in partner-augmented input (PAI), a modeling strategy whereby communication partners use the child’s AAC system themselves by pointing to the symbols on the child’s communication board or device while simultaneously talking.

11.6 Outcome

Based on data collected during the 6-week trial period, the SGD was recommended for purchase. JF continued to benefit from weekly therapy to improve his language and use of two-switch step-scanning. An occupational therapist provided consultation regarding optimal switch placement to improve JF’s access, and JF’s grandfather fabricated a switch mount based on her recommendations (see ▶ Fig. 11.1).

Six months after the assessment, JF began a blended preschool program with both students with disabilities and neurotypical peers. School sta ﬀ were trained to provide PAI throughout JF’s day using an eight-step training model. tinued to be a multimodal communicator, using a combination of signs, vocalizations, a light tech book, and a synthetic speech, dynamic display SGD. He was a very social and engaging child who continued to eagerly expand his communication skills.

JF con-

11.7 Key Points

●

There are no specific prerequisites for AAC use.

●

Intervention that balances a child’s immediate communication needs with systematic therapy to teach more complex skills is appropriate for young children with CP.

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