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Social Communication Intervention for a Child with Autism Spectrum Disorder

17 Social Communication Intervention for a Child with Autism Spectrum Disorder

Amy L. Donaldson

17.1 Introduction

Social communication challenges are a core feature of autism spectrum disorder (ASD). such skills have the potential to significantly impact the quality of life for children with ASD and their families.

Eﬀective interventions targeting

17.2 Clinical History and Description

GM was a 4-year, 4-month-old girl with autism. GM attended a developmental preschool program 3 days per week for 4 hours. GM was referred for assessment and intervention by her parents based on concerns regarding her social communication skills and engagement with others. GM was first diagnosed on the spectrum at 3 years, 5 months and received speech-language and early intervention preschool services since diagnosis. Her medical history was otherwise unremarkable with no previous diagnosis of known genetic syndromes, reports of serious medical or neurological conditions (e.g., encephalitis, concussion, seizure disorder, diabetes, congenital heart disease), sensory impairments such as vision or hearing loss, and/or serious motor impairment.

17.3 Clinical Testing

The Autism Diagnostic Observation Schedule–2 (ADOS-2)2was administered to confirm diagnosis and gain information regarding GM’s social communication and interaction skills. Throughout administration of the ADOS-2, GM demonstrated limited initiation of communication bids, limited responsiveness to her name, delayed and immediate echolalia, and lack of coordination of nonverbal and verbal communication. In addition, GM repeatedly regarded herself in the mirror throughout the assessment, particularly when manipulating a play object.

In addition, a sample of GM’s expressive language use was

analyzed using the Systematic Analysis of Language Transcripts

(SALT). complexity of her expressive language. She demonstrated a mean length of utterance (MLU) of 2.93. MLU is a measure of the number of words per utterance, as well as the number of morphemes used in that utterance. Children of GM’s age typically demonstrate an MLU in words of 4.08. Her spontaneous language comprised primarily requests for action/object and an occasional comment. Her language sample was notable for periods of “self-talk” (delayed echolalia of TV scripts), which did not appear to be directed toward the clinician or related to the play context. Finally, the Auditory Comprehension subscale of the Preschool Language Scale–5(PLS-5) GM’s receptive language skills. She achieved a standard score of 67 (mean = 50; standard deviation = 15).

Results of this analysis yielded information about the

was administered to assess

17.4 Questions and Answers for the Reader

1. Would further assessment be valuable to examine GM’s

social communication and interaction skills? If so, what kind?

a) No further assessment is needed. The ADOS-2 provides

adequate information regarding social communication skills.

b) No further assessment is needed. Speech-language path-

ologists (SLPs) are best suited to target language and speech production skills. Social communication and interaction is the domain of school psychologists.

c) Yes, further assessment is needed. Communication occurs

within social interaction; therefore, it is important to have multiple examples of communication within meaningful social contexts.

d) Yes, fur ther assessment is needed. However, not for social

communication. Examine GM’s expressive language (syntax, semantics, and morphology) through a normreferenced standardized measure to compare her performance to same-age peers.

Answer: c is correct. Given the decontextualized nature of most norm-referenced standardized measures, particularly those focusing on core language skills, social communication within meaningful social contexts is warranted. Although the ADOS-2 allows for observation of social communication and interaction skills within a semistructured environment, the primary communication partner within the assessment is an examiner unknown to the child. As such, observing a child’s performance within a familiar social context and/or with a known communication partner provides the examiner with the opportunity to observe a range of performance.

As such, in addition to the assessment described above, we observed GM and her neurotypical sibling HM (age 5 years, 5 months) within a 10-minute sibling interaction. They were provided with novel play materials (e.g., floor puzzle, play-dough) that were appropriate to their age and developmental level and that their parents had reported were objects/activities of high interest on a Play Interest Survey. support or instructions. We observed that GM rarely initiated social communication with HM and that when she did so, HM did not consistently respond. GM also demonstrated limited engagement in the play activity (block design toy), but rather manipulated a piece in her hands while engaging in “self-talk.” HM appeared to “guard” the materials, often blocking GM’s access to the activity with her body. One main diﬀerence noted between the ADOS-2 administration and this observation was GM’s overall decrease in initiations toward her communication partner. We hypothesized that GM’s reduction may be due, in part, to the lack of responsiveness by her sister, HM, whereas,

further assessment of GM’s

The clinician provided no

Social Communication Intervention for a Child with Autism Spectrum Disorder

during the individual assessment, the clinician was prompt in responding to all GM’s communication bids.

a is incorrect. Although the ADOS-2 can provide information regarding a child’s social communication skills, including initiation and response to communication bids and various types of communicative functions, the semistr uctured format may not provide adequate opportunities to assess particular behaviors of interest. An ADOS-2 contributes valuable information to a comprehensive evaluation of an individual for diagnostic purposes.

b is incorrect. Social communication might be best conceptualized as use of communication within social contexts and for interacting with others. As such, there is rarely a time when one does not employ their social communication skills. While speech-language therapy with children often focuses on the “appropriateness” of communication (i.e., correct use of mor- phology, phonology, syntax, and/or semantics), one cannot do so to the exclusion of the “eﬀectiveness” of communication (i.e., successful use of communication skills for interaction). As such, assessment and intervention for social communication skills is

well within the realm of an SLP’s scope of practice

and should

be a regular part of any assessment protocol.

d is incorrect. As indicated above, the ADOS-2 in isolation is insuﬃcient to fully assess GM’s social communication skills. Her performance on the receptive language portion of the PLS-5 was within normal limits for her age. Given her MLU during the language sample, further testing of her expressive language skills using a norm-referenced standardized measure may have been warranted. However, social communication skills were the primary area of concern for the family and reason for referral.

2. What type(s) of intervention might support GM’s social com-

municationgrowth and facilitate interaction with others? a) A combination of evidence-based social communication

interventions that include a peer or sibling in targeted interactions.

b) Clinician-directed intervention that focuses on increasing

GM’s vocabulary skills. c) Extinguishing GM’s “self-talk”/delayed echolalia. d) Naturalistic intervention focusing on increasing speech

intelligibility.

Answer: a is correct. Based on the expanded assessment results demonstrating HM’s influence on both GM’s frequency and diversity of social communication bids and HM’s own patterns of decreased interaction and shielding of toys, the team (clinician and parents) discussed how to best approach increasing and improving the social engagement and social interactions of the siblings. The team agreed that both children could benefit from learning strategies to facilitate and improve their social interactions with each other. This approach considers both communication partners equally responsible for communicative and social success and creates an environment where both communication partners learn strategies to grow their skills. Two evidence-based practices for targeting social communication skills were specifically selected for this sibling dyad: video modeling (VM) for supporting the skills of the child with ASD; and peer mediation (sibling mediation) for teaching social com-

munication strategies to the neurotypical sibling.

The intervention was implemented following a strengths-based model that capitalized on the children’s motivation as the context for

learning and maximized strengths to support areas of chal-

lenge.

(VM and peer mediation is described in more detail

below.)

b is incorrect. Increasing GM’s vocabulary was not the focus of her parents’ referral for services; improving her social communication as a core feature of ASD was their primary focus. To date, there has been no evidence of a clinician-driven vocabulary-specific intervention resulting in collateral benefits to social communication skills and/or social engagement for children with ASD.

c is incorrect. Although self-talk can disrupt social interactions and engagement with others, following principles of naturalistic developmental behavioral intervention, the team decided to address GM’s self-talk within the sibling dyad social communication intervention in the following manner: (1) incorporate use of highly preferred objects and activities as the teaching context to increase interactions and language related

to context

; and (2) coach LH in responding to all of GM’s communicative bids, even if they were self-talk, in an eﬀort to engage in ongoing interaction. We call this the “as if” principle —the communication partner responds “as if” the child was directing the communication to them and is context-appropriate. By responding, the communication partner opens up the opportunity for further interaction and ongoing communication.

d is incorrect. Speech intelligibility was not an area of con-

cern for GM.

3. Why should clinicians consider including siblings or peers

when targeting the social communication skills of children with ASD?

a) Because siblings and peers can be good teachers for chil-

dren with ASD—they can show them how to communicate.

b) Because eﬀec tive communication requires everyone’s

participation; therefore, both the child with ASD and peer/sibling can learn strategies to facilitate success and develop meaningful relationships.

c) Because families want peers and siblings to feel sorry for

children with ASD and help them at school.

d) Because children with ASD do not want friends; therefore,

it is the SLP’s job to establish friendships for them.

Answer: b is correct. Social communication skills are integral to

developing and sustaining peer relationships.

In addition,

social and communicative competence is considered key to

school success.

And, as children progress through school,

communicative and social expectations become increasingly

complex.

Although social communication skills are often the target of intervention, many children with ASD demonstrate diﬃculty with generalization of social communication skills to natural contexts, particularly within peer relationships. such, inclusion of peers and/or siblings in intervention is war-

ranted, not only to support generalization of skills, but also to facilitate development of meaningful relationships.

takes two people to eﬀectively communicate; as such, supporting the communication of both individuals promotes success and creates equity in relationships.

a is incorrect. While peers and siblings can certainly serve as models for each other and for children with ASD, a strengthsbased approach to intervention encourages equity in peer and

15,16

Further, it

Social Communication Intervention for a Child with Autism Spectrum Disorder

sibling relationships.10To build lasting relationships between children with disabilities and neurotypical children, it is important to maintain balance with regard to power and responsibil-

As such, in peer-inclusive or sibling-inclusive interven-

ity. tions, the author and her colleagues assist children in developing their own skills, rather than teaching others (except what would occur within a natural interaction).

c is incorrect. As indicated above, authentic relationships occur when children are provided natural and equitable opportunities for interaction. Recent research indicates that friendship may be an important context for development of communication, particularly production of diﬀerent types of communicative functions or speech acts. Bauminger-Zviely and col-

leagues strated greater frequency and variety of speech acts during conversation with friends as compared to nonfriend peers. In addition, they found these children demonstrated increased frequency and variety when engaged in conversation with neurotypical friends. They stated, “friendship may enable children to converse in a more socially complex and co-regulated way.”

ship, but may do so in a manner that diﬀers from neurotypical children. Although previous research has indicated that children with ASD may report fewer friendships and challenges maintaining friendships, children with ASD report levels of friendship satisfaction similar to neurotypical peers.

found that preschool-age children with ASD demon-

d is incorrect. Children with ASD seek interaction and friend-

other research has indicated that

17.5 Description of Disorder and Recommended Treatment

With an understanding of the range of GM’s social communication skills and how her communication partner’s responsiveness potentially impacts her performance, we employed a twoelement intervention that involved both GM and her sibling. For 10 weeks (two times per week for 50 minutes), the family participated in “Socialsibs,” a social communication intervention that combines two methods: VM and peer mediation (in this case, sibling mediation).

VM is an intervention method that provides direct intervention to the child with ASD and has been identified as eﬀective for targeting social communication skills. with ASD watches a video of a peer and/or adult demonstrating a discrete skill/target behavior and then practices the skill.

Peer mediation (or in our case, sibling mediation) refers to direct coaching of a peer to elicit and facilitate the child with autism’s social communication skills a peer to increase their own initiations and responsiveness to the child with ASD. initiate interactions, maintain interactions, and prompt a variety of play, motor, and communicative behaviors in children with autism.

Using VM, GM targeted the following social communication behaviors with HM: (1) responding to communication bids; (2) requesting objects; and (3) turn taking. The procedure for VM included: (1) video recording of the target behavior as demonstrated by HM during an interaction with the clinician; (2) playback of video for GM, with discussion of target behavior; (3) clinician-supported practice of the target behavior using the

9,24

22,23

Peers have been successfully taught to

9,15,16,20

In VM, the child

and/or direct training of

same play materials from the video; and (4) fading support of the VM, as well as clinician prompts, as GM demonstrated increased accuracy in spontaneous production of the behavior.

We found it important to explain in age-appropriate, literal language the function of the behavior and why it is important, particularly when first introducing a target behavior. By pausing after the behavior was demonstrated within the VM and discussing these points, the child associated the model of the behavior with the intent. For example, when targeting responding to communication bids, the VM included at least three to five clear exemplars of the target behavior (with the sibling as the model). When the skill was first taught, after each demonstration of the behavior the video was paused and the clinician described the behavior (e.g., “I asked HM about her picture and she told me what she colored”) and identified its importance (e.g., “I didn’t know what she drew. I liked learning about her picture”).

The sibling-mediated intervention followed the model of Pierce and Schreibman based on Pivotal Response Training communication behaviors when interacting with GM. Based on family priorities, the age of the participants, and the length of the intervention (10 weeks), three strategies were selected for sibling mediation; they included (1) gaining attention; (2) responding to all communication bids; and (3) providing GM with a choice between two objects/activities.

To teach each strategy, the clinician brought HM into an individual treatment room (separate from GM) and explained the skill in developmentally appropriate and literal language. For example, when teaching the strategy of gaining attention, the clinician said, “Have you ever noticed that when you talk with GM it seems like she might not hear you? I have some ideas to help make sure that she is listening when you tell her something.” The clinician would then explain each component of the strategy in turn (often using age-appropriate visual supports), and role-play use of the skill with HM. This initial training of the strategy lasted approximately 10 minutes. HM then practiced using the strategy directly with GM, with facilitation and feedback from the clinician. The clinician provided graduated prompts from most to least support as needed to facilitate use of the strategy within play ac tivities. Also, the clinician provided verbal praise (e.g., “You did it!”) to reinforce HM’s performance of a target behavior. It can be tempting for the clinician to direct attention to the child with ASD in an eﬀort to facilitate interaction; however, this strategy can leave the sibling without a clear understanding of his/her performance. As such, we directly reinforced the sibling’s attempts at using the strategy, regardless of their success in eliciting the desired behavior from the child with ASD.

26,27

by teaching HM to use strategies

to change her own social

17.6 Outcome

Overall, GM increased all targeted social communication behaviors (i.e., responding to HM’s communication bids; requesting objects from HM; turn-taking) and maintained generalization of the first two skills at a 1-month follow-up. Although engagement was not a specifically targeted behavior, we also measured GM’s engagement with HM within sibling interactions over the course of intervention to see whether targeting specific social communication behaviors might have a more global

Social Communication Intervention for a Child with Autism Spectrum Disorder

impact on GM’s social engagement. She increased joint engagement (siblings are involved in activity or object together and GM coordinates attention between object and activity) and decreased object engagement (GM is involved solely in playing with object, not attending to HM) over the course of intervention. HM increased the use of attention-getting strategies and responded to GM’s communication bids more frequently than prior to intervention. However, she did not demonstrate an increase in oﬀering GM choices within play interactions.

Following intervention, the girls’ parents reported an increase in responsiveness and initiations by GM. In addition, they reported an increase in the frequency of social interactions between the siblings and noted a diﬀerence in the quality of the interactions, as characterized by increased spontaneous verbal interactions, imitation during play, and reciprocity since the start of intervention. The parents also reported that HM independently and spontaneously taught the children’s cousins the gaining attention strategy, which increased GM’s par ticipation in play during extended family visits in their home.

17.7 Key Points

●

Traditional norm-referenced standardized measures, even those intended to identify social communication and interaction challenges, may not provide adequate information for intervention planning. Assessment of skills within multiple social contexts and/or across communication partners will provide clinicians with a range of performance, as well as a starting place for intervention planning.

●

Siblings and peers are integral to social communication intervention for children with ASD and other social communication challenges. Successful social interaction requires two people and too often adult communication partners scaﬀold performance. Although this strategy may assist in acquiring new skills, it can be a detriment to generalization of skills and relationship building. As such, inclusion of peers and/or siblings in intervention promotes communication success and relationship equity.

Suggested Readings

[1] Sam A; AFIRM Team. Modeling. Chapel Hill, NC: National Professional Devel-

opment Center on Autism Spectrum Disorder, FPG Child Development Center, University of North Carolina. 2016. Available at: http://afirm.fpg.unc.edu/ modeling

[2] Sam A; AFIRM Team. Peer-Mediated Instruction and Intervention. Chapel Hill,

NC: National Professional Development Center on Autism Spectrum Disorder, FPG Child Development Center, University of North Carolina. 2015. Available at: http://afirm.fpg.unc.edu/peer-mediated-instruction-and-intervention

References

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

Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013

[2] Lord C, Rutter M, DiLavore PC, Risi S, Gotham K, Bishop S. Autism Diagnostic

Observation Schedule. 2nd ed. Los Angeles, CA: Western Psychological Services; 2012

[3] Miller JF, Chapman RS. Systematic Analysis of Language Transcripts (Version

6.1)#[Computer software]. Madison, WI: University of Wisconsin—Madison, Waisman Center, Language Analysis Laboratory; 2000

[4] Zimmerman IL, Steiner VG, Pond RE. Preschool Language Scales–5th ed. (PLS-

5). San Antonio, TX: The Psychological Corporation; 2011

[5] Donaldson AL, Olswang LB. Investigating requests for information in children

with autism spectrum disorders: Static versus dynamic assessment. Int J Speech Lang Pathol. 2007; 9(4):297–311

[6] Quill K. Do-Watch-Listen-Say. Baltimore, MD: Paul H. Brookes Publishing Co.;

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[7] Landa RJ. Assessment of social communication skills in preschoolers. Ment

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[8] Donaldson AL. Siblings of children with ASD: promoting social communica-

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[9] National Autism Center. Findings and Conclusions: National Standards Proj-

ect, Phase 2. Randolph, MA: National Autism Center; 2015

[10] Donaldson AL, Krejcha K, McMillin A. A strengths-based approach to autism:

neurodiversity and partnering with the autism community. Perspectives of the ASHA Special Interest Groups. 2017; 2:56. doi:10.1044/persp2.SIG1.56

[11] Baker MJ, Koegel RL, Koegel LK. Increasing the social behavior of young chil-

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[12] Rotheram-Fuller E, Kasari C. Peer relationships: challenges and interventions.

In: Hollander E, Kolevzon A, Koyle JT, Eds. Textbook of Autism Spectrum Disorders. Arlington, VA: American Psychiatric Publishing; 2011:555–564

[13] Zigler E, Gilliam WS, Jones SM. A Vision for Universal Preschool Education.

New York, NY: Cambridge University Press; 2006

[14] Brinton B, Fujiki M. Social development in children with specific language im-

pairment and profound hearing loss. In: Smith P, Craig H, Eds. Blackwell Handbook of Childhood Social Development. Malden, MA: Blackwell Publishing; 2002:588–603

[15] Ferraioli SJ, Harris SL. Treatments to increase social awareness and social

skills. In: Reichow B, Doehring P, Cicchetti DV, Volkmar FR, Eds. EvidenceBased Practices and Treatments for Children with Autism. New York, NY: Springer; 2011:171–196

[16] Schreiber C. Social skills interventions for children with high-functioning au-

tism spectrum disorders. J Posit Behav Interv. 2011; 13(1):49–62

[17] Bauminger-Zviely N, Golan-Itshaky A, Tubul-Lav G. Speech acts during

friends' and non-friends' spontaneous conversations in preschool dyads with high-functioning autism spectrum disorder versus typical development. J Autism Dev Disord. 2017; 47(5):1380–1390

[18] Kasari C, Locke J, Gulsrud A, Rotheram-Fuller E. Social networks and friend-

ships at school: comparing children with and without ASD. J Autism Dev Disord. 2011; 41(5):533–544

[19] Petrina N, Carter M, Stephenson J, Sweller N. Perceived friendship quality of

children with autism spectrum disorder as compared to their peers in mixed and non-mixed dyads. J Autism Dev Disord. 2016; 46(4):1334–1343

[20] Wang S, Chui Y, Parrila R. Examining the eﬀectiveness of peer-mediated and

video-modeling social skills interventions for children with autism spectrum disorders: a meta-analysis in single-case research using HLM. Res Autism Spectr Disord. 2011; 5(1):562–569

[21] Kuhn LR, Bodkin AE, Devlin SD, Doggett RA. Using pivotal response training

with peers in special education to facilitate play in two children with autism. Educ Train Dev Disabil. 2008; 43(1):37–45

[22] Goldstein H, Kaczmarek L, Pennington R, Shafer K. Peer-mediated interven-

tion: attending to, commenting on, and acknowledging the behavior of preschoolers with autism. J Appl Behav Anal. 1992; 25(2):289–305

[23] Strain PS, Odom SL. Peer social initiations: eﬀective intervention for social

skills development of exceptional children. Except Child. 1986; 52(6):543– 551

[24] Zhang J, Wheeler JJ. A meta-analysis of peer-mediated interventions for

oung children with autism spectrum disorders. Educ Train Autism Dev Dis-

abil. 2011; 46(1):62–77

[25] Shukla-Mehta S, Miller T, Callahan K. Evaluating the eﬀectiveness of video in-

struction on social and communication skills training for children with autism spectrum disorders: A review of the literature. Focus Autism Other Dev Disabil. 2010; 25(1):23–26

[26] Pierce K, Schreibman L. Increasing complex social behaviors in children with

autism: eﬀects of peer-implemented pivotal response training. J Appl Behav Anal. 1995; 28(3):285–295

[27] Pierce K, Schreibman L. Using peer trainers to promote social behavior in au-

tism: Are they eﬀective at enhancing multiple social modalities. Focus Autism Other Dev Disabil. 1997; 12(4):207–218

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Reading Comprehension in a School-Age Student

18 Reading Comprehension Diﬃculties in a School-Age Student

Anna Eva Hallin

18.1 Introduction

This case report describes comprehensive language and literacy assessment in a 10-year-old who scored poorly on the English Language Ar ts summative reading comprehension test at the end of fourth grade.

18.2 Clinical History and Description

SH was a healthy monolingual, English speaker with good hearing and vision. She reportedly started talking late, around age 2, and saw a speech-language pathologist (SLP) weekly between the ages of 3 and 4 years. She was then discharged as she was performing at age-expected levels. SH was described as quiet and kind. She functioned well socially and focused satisfactorily in the classroom, but rarely participated in class discussions. She had no diﬃculties with early reading and writing skills, and at the time of assessment, read fourth-grade texts fluently and accurately. However, her performance on reading comprehension tasks varied greatly depending on text, topic, and task. She particularly struggled with understanding social studies and science texts. Her writing was described as simple with occasional grammatical errors, but she used appropriate writing conventions and her spelling was within normal limits. SH met most standards in mathematics, but she often required support with word problems.

18.3 Clinical Testing

18.3.1 Standardized Testing

Conventional and comprehensive standardized tests of both oral and written language were administered. See ▶ Table 18.1 for a summary of results. SH did not have diﬃculties with the technical aspects of reading (e.g., word recognition/decoding, fluency, and accuracy). She had average oral expression scores but below average receptive skills, and below average comprehension when oral or written information was presented in paragraphs.

18.3.2 Curriculum-Based/Informal Tasks and Portfolio

In addition to standardized testing, materials from the classroom were employed to gain additional insight into SH’sdiﬃ- culties with reading comprehension. Two “think-aloud” tasks using fourth grade science/social studies texts were employed; SH had diﬃculty understanding central content words and her performance was not enhanced with morphological or context clues; she did not understand complex syntax, and struggled when asked to find the main idea of a paragraph, draw infer-

ences, and summarize content. When asked what she usually does when she does not understand text, SH replied that she “sometimes re-reads.” When SH was asked to retell a short narrative, she was fluent with all main elements of the story, indicating that narrative language was one of her strengths. SH used simple and repetitive sentence structure as well as limited and/or nonspecific vocabulary in written samples obtained from her classroom teachers. Her narrative texts were longer and more elaborate than expository texts, which were brief and contained more grammatical errors.

18.4 Questions and Answers for the Reader

1. One well-established model of reading comprehension is the Simple View of Reading, which states that to comprehend a text you need both good decoding/word recognition skills to be able to read fluently and accurately, and good language skills to understand the decoded text. In other words, reading comprehension can be expressed as the product between decoding and linguistic comprehension. Even though linguistic comprehension in this model is a complex construct, this model is a meaningful starting point when assessing reading comprehension diﬃculties. The following statements about the Simple View of Reading are true except one:

a) A student may have reading comprehension diﬃculties

weak decoding skills, due to weak linguistic comprehension skills, or both.

b) A student with reading comprehension diﬃculties due to

weak decoding skills only will typically understand the text if it is read to him/her.

c) A st udent with reading comprehension diﬃculties will

typically str uggle with understanding all types of texts.

d) A student with weak oral language skills will most likely

also have weak reading comprehension skills.

e) When assessing reading comprehension diﬃculties, both

decoding abilities and oral language abilities should be carefully mapped out.

Answer: a is true. A student with weak decoding skills but good linguistic comprehension skills has a specific reading disability (“dyslexia”), a student with good decoding skills but weak linguistic comprehension skills may have language impairment without phonological processing diﬃ culties (or, if linguistic difficulties are subclinical, they might be called “poor comprehenders”), and a student with weaknesses in both areas may have a language impairment with phonological processing diﬃculties.

b is true. For students with isolated decoding diﬃculties, listening to texts is a way to compensate for their decoding diﬃculties when learning about a topic.

d is true. Oral language skills are the foundation of written language skills.

Reading Comprehension in a School-Age Student

Table 18.1 Summary of a selection of SH’s oral and written standardized test results

Test Subtests/scales Percentile rank

Written language Test of Written Spelling: TWS-5 Spelling of single words 23

Test of Word Reading Efficiency: TOWRE-2

Gray Oral Reading Test: GORT-4 Rate 71

Clinical Evaluation of Language Fun-

Oral language Core language score 13

damentals: CELF-5

Peabody Picture Vocabulary Test: PPTV-4

Sight word efficiency 50

Phonetic decoding efficiency 63

Accuracy 37

Reading comprehension (oral) 15

Reading comprehension (silent) 9

Expressive language index 39

Receptive language index 10

Understanding spoken paragraphs 11

Receptive vocabulary 9

e is true. The intervention and accommodations for a student with reading comprehension diﬃculties due to weak decoding compared to a student with weak (oral) linguistic comprehension are very diﬀerent. Always assess both areas.

c is false. Texts vary significantly in their demands on both

decoding and linguistic comprehension skills.

2. SH’s case is an illustration of the common phenomenon typically referred to as “illusory recovery”—when children with developmental language disorders seem to catch up with their peers in later preschool years, but exhibit language processing diﬃculties at a later stage again. What is the most likely explanation of this phenomenon? a) Language processing demands increase throughout the

school years.

b) Language processing diﬃculties in children often worsen

over time.

c) Language processing diﬃculties often spontaneously

reappear following puberty.

d) Preschool language assessments typically fail to capture

language ability.

e) School-age language assessments are more sensitive than

preschool assessments.

Answer: a is correct. The introduction of reading and writing and the increasing academic and social demands in the schoolage years can lead to reemerging language diﬃculties when language processing demand exceeds a child’s language processing ability.

b and c are incorrect. The eﬀects of a developmental language disorder change over time, but internal processing does not typically worsen and, furthermore, is not associated with puberty.

d and e are incorrect. Although it is important to ensure that standardized tests are reliable and valid, no universal diﬀerences exist in tests for diﬀerent ages.

3. All of the following statements highlight the importance of

including curriculum- or classroom-based tasks in addition to standardized language assessment tools as a component of comprehensive language assessment in school-aged children except:

a) Curriculum-based tasks are essential when setting appro-

priate language goals.

b) Curriculum-based tasks will quantify a student’s language

skills compared to peers.

c) Curriculum-based tasks may capture subtle language

processing diﬃculties.

d) Curriculum-based tasks may guide language intervention

procedures.

e) Curriculum-based tasks reflect the language demands in

the student’s everyday life.

Answer: a is true. School-based SLPs must write language goals that are aligned with the curriculum and should focus on functional language and communication.

c is true. Curriculum-based tasks and texts might reveal both language processing diﬃculties and strengths that standardized tests might not capture due to the specific language demands of the academic curriculum.

d is true. A dynamic informal task may show what type of support and intervention strategies are most beneficial for the student.

e is true. Students spend most of their time in school, and it is important that the language assessment reflects the demands that the student must meet.

b is false. Although curriculum- and classroom-based tasks might give an indication of how a student is performing relative to grade or age benchmarks, standardized tests of language and literacy with an appropriate normative sample would be the appropriate quantitative comparison.

4. The complexity of text depends on many interacting factors,

such as word diﬃculty, syntactic complexity, text structure, discourse style, genre features, background knowledge of the reader, and level of reasoning and inferencing required, as well as text format, length, and layout. Given this information, which of the following statements is accurate:

a) Additional factors, such as ability to focus and areas of

interest are not important to take into account when assessing reading comprehension.

b) It is important to assess reading comprehension with a

range of texts and comprehension tasks.

wide

c) Texts that are diﬃcult for one reader will most likely be

diﬃcult for another reader of the same age.

d) The format of a reading comprehension task or a reading

test does not influence performance.

Reading Comprehension in a School-Age Student

e) Only a limited number of factors can be targeted in lan-

guage intervention to improve reading comprehension.

Answer: b is correct . Research has shown that diﬀerent reading comprehension tasks do not identify the same students as having reading comprehension diﬃculties. Several diﬀerent texts and tasks have to be used in assessment.

a is incorrect. Because of the complex process of comprehension, both text factors and reader factors are important to take into account in assessment and intervention.

c and d are incorrect. See explanation b above.

e is incorrect. Reading comprehension can be improved through targeting both micro and macro aspects of language as well as working with comprehension strategies and improving background knowledge of the reader.

18.5 Description of Disorder and Recommended Treatment

Assessment results with the knowledge that SH had a previous diagnosis of language impairment suggest that SH’s language processing diﬃ culties persist, but now primarily impact her ability to comprehend complex and academic texts. Students like SH, who have language impairments or subclinical linguistic diﬃculties without major deficits in oral and/or written phonological processing such as non-word repetition and decoding, are often referred to as poor comprehenders. These students often perform poorly in the classroom and run the risk of not being detected as readily as those students with expressive diﬃculties or decoding diﬃculties.

In this case, it was recommended that SH receive individual and small-group language treatment and support, both inside and outside the classroom. The main goal of treatment was to improve reading comprehension in social studies and science. These goals were written to align with the Common Core Standards (http://www.corestandards.org/). A secondary goal was to strengthen expository written language skills. Based on SH’s test profile, treatment initially focused on comprehension monitoring and strategies including note taking and activating background knowledge, strengthening of vocabular y skills with a subfocus on morphology, and structured work with complex syntax and embedded phrases. The starting point was materials from social studies, science, and math. Later targets included identifying and contrasting diﬀerent expository text structures.

18.6 Outcome

Midway through fifth grade and following SLP intervention for one semester, follow-up assessment was performed using a “think-aloud” protocol with curriculum-based texts. In addition, the specific reading comprehension strategies employed

by SH spontaneously in the classroom setting was assessed. SH identified the main idea in short paragraphs on four out of five occasions and demonstrated improved comprehension monitoring. SH stopped and commented on words she did not know and demonstrated the ability to use the context and her own background knowledge or morphology to infer the meaning of unfamiliar words. Her performance in the comprehension of complex sentence structures improved. In the classroom, she more readily asked for help and accepted more assistance from her peers when she had diﬃculty understanding a task or instructions. The teacher reported that SH performed better on homework assignments involving reading comprehension, but that her diﬃculties with writing expository texts were even increasingly prevalent given the academic demands in fifth grade. SH reported that she enjoyed reading her social studies textbook more than before and her parents reported that SH was more willing to do homework assignments than in previous years.

SH will likely require continued support in oral and written language throughout her school years. Ideally, however, the intensity of support will decrease over time as SH gains independence with the targeted comprehension strategies and with language knowledge gained through intervention.

18.7 Key Points

●

Speech and/or language impairment identified in the preschool years may appear to resolve, but as linguistic demands increase, significant language processing diﬃculties may reemerge. Students with good reading accuracy and fluency, but with significant diﬃculties with reading and listening comprehension, may go undetected.

●

Language diﬃculties categorized as mild to moderate based on standardized test scores may still have severe consequences for academic achievement, in addition to students’ wellbeing.

●

Reading comprehension is complex and challenging to quantify. Multiple complementary approaches must be employed including both well-constructed standardized tests of oral and written language as well as curriculum- and standardappropriate informal tasks to ensure language intervention goals are curriculum-based and functional for the student.

Suggested Readings

[1] Hogan TP, Adlof SM, Alonzo CN. On the importance of listening comprehen-

sion. Int J Speech-Language Pathol. 2014; 16(3):199–207

[2] Keenan JM, Meenan CE. Test diﬀerences in diagnosing reading comprehen-

sion deficits. J Learn Disabil. 2014; 47(2):125–135

[3] Wallach GP. Improving clinical practice: a school-age and school-based per-

spective. L ang Speech Hear Serv Sch. 2014; 45(2):127–136

Childhood Apraxia of Speech

19 Childhood Apraxia of Speech

Megan S. Overby and Katie Micco

19.1 Introduction

This case study discusses the diﬀerential diagnosis and treatment of a preschooler who presents with expressive language delay and suspected childhood apraxia of speech (CAS).

19.2 Clinical History and Description

KJ was a 3.5–year-old, nonverbal boy with reported “strong” receptive language skills and no signif icant family history of speech-language diﬃculties. Perinatal history included induction at 36 weeks due to maternal preeclampsia and a birth weight of 5.6 lb. According to parent report, KJ did not latch successfully during breastfeeding and presented with limited babbling and sound play in infancy, although developmental motor milestones were met. During his first 2 years, KJ produced occasional vowel-like productions with few attempts at consonant-vowel combinations; first words (“da” and “muh”) emerged at approximately 25 months of age but were “lost” shortly thereafter. He was reported to drool excessively until age 3. KJ demonstrated strong communicative intent and primarily communicated through leading/guiding, vocalizing, and gesturing, although he occasionally hit and bit others when frustrated. Socially, he was often withdrawn, especially with peers in preschool or with unfamiliar communication partners.

19.3 Clinical Testing

Pure-tone hearing screening indicated KJ responded to 500, 1,000, 2,000, and 4,000 Hz at 25 dB. Examination of oral mechanism structures and function revealed lips were symmetrical both at rest and when retracted. The hard and soft palates appeared normal in shape and color and the soft palate was observed to rise upon production of “ah.” Adequate voicing and breath support were demonstrated across three trials of sustained vowel phonation (mean length = 10 seconds), though nasal resonance was noted during one trial. On the Preschool Language Scale-5 , auditory comprehension = 97 (percentile rank = 42) and expressive language = 64 (percentile rank = 1). Because KJ presented with a highly limited sound repertoire and lack of functional speech, standardized assessment of speech-sound produc tion skills was not attempted.

Diadochokinetic (DDK) rates for alternating and sequencing oral movements were assessed. Given a clinician model, KJ demonstrated di ﬃ culty imitating single consonant (C)–vowel (V) productions of “puh,”“tuh,” and “kuh;” although placement of “puh” and “tuh” was obtainable, productions were inconsistent and contained voicing errors. Despite multiple attempts, KJ was unable to produce “kuh,” sound repetitions, or alternating phoneme sequences (i.e., “puhtuhk uh”).

Informal motor speech examination assessed KJ’s accuracy, timing, and smoothness when producing increasingly complex

KJ’s subscale performance was as follows:

syllable shapes. Given maximum cues (clinician verbal model, visual cues, gestural support, and verbal placement cues), he produced CV, VC, and C tions, KJ failed to mark the final consonant or segmented the production (e.g., /u-m/). He often simplified C segmented it to C

and C1VC2shapes to CV even when maximal cues were

1VC1

provided. His phonetic inventory across all syllable shapes was /m/, /b/, /d/, /n/, an approximation of /w/, and schwa vowel. He was not stimulable for any voiceless phonemes or other vowels, though vowel approximations were possible with manual cues.

V–C1V with equal lexical stress. KJ simplified

V syllables. In some VC combina-

1VC1

VtoCVor

1VC1

19.4 Questions and Answers for the Reader

1. A 4.5-year-old girl’s performance on the Diagnostic Evaluation of Articulation and Phonology score, articulation SS = 72 and phonology SS = 88. Speechsound errors included “fife,”“ive,” and “vie” for “five”; “shish” and “fi” for “five”; and “wain” and “yai” for “rain.” However, stimulability testing revealed she was able to correct many of her articulatory errors at the phoneme level when provided a slowed auditory model. Her DDK for “patty-cake” was within 1 standard deviation of her age mean. Paternal history was significant for speech delay because of errors on the /s/ sound. Based on these results, the most likely diagnosis is:

a) Dysarthria. b) Childhood apraxia of speech. c) Phonological disorder. d) Articulation disorder. e) Typical speech-sound development.

Answer: c is correct. Errors are primarily unsuppressed developmental phonological process errors (assimilation, gliding, and final consonant deletion) in the absence of neurological or motor speech movement/planning impairment.

a is incorrect. dysarthric speech-sound errors are typically predictable, regardless of speaking task, and are most commonly distortions and omissions, with distortions being the most prevalent.

b is incorrect. Although inconsistency and significant family history may occur in children with CAS, speech-sound errors are typically omissions and distortions with evidence of motor speech movement/planning deficits. Deficits may appear in the accuracy, timing, and smoothness of sound sequences and/or transitions between sounds, as well as disruptions in prosody at various linguistic levels. In this example, normal DDK rates imply normal motor speech movement gestures, though careful observation of such gestures is required. Additionally, in this case, most speech-sound errors are substitutions.

d is incorrect. Articulation errors are due to errors in the placement of the articulators, not motor movement/planning. Although a case could be made that this client demonstrates an articulation disorder as well as a phonological disorder, her

was 57% inconsistency

Childhood Apraxia of Speech

stimulability for phonemes suggests that any articulation disorder is mild and possibly resolving. Hence, phonological impairment is the better answer (although clinicians may wish to monitor the client's articulatory status).

e is incorrect. By age 3, consonant assimilation and final consonant deletion typically disappear, although gliding may st ill be present. Initial consonant deletion is atypical at any age.

2. A 6-year-old boy diagnosed with CAS has the following pho-

netic inventory: /b/, /d/, /m/, /n/, /s/, /schwa/, and “ah.” His syllable shape inventory includes CV, VC, C imitation and C clinician. His mother says he adores cars and trucks and also asks that her son learn to say the name of the family dog, “Snowflake.” What would you recommend as initial therapy goals? a) “on, mom, done, beep, see, nah, tuhtah!, Snowflake.” b) “no, yes, apple, baa-baa, mama, uh-oh.” c) /p/, /t/, /k/, /g/, /f/ in isolation, then in words, then in sen-

tences.

d) “all done, go, no, yes, me, mine, you, is, are, I, mommy,

daddy, home, eat, milk.”

e) “bun” vs. “fun;”“not” vs. “rot;”“sun” vs. “one.”

Answer: a is correct. For children with limited repertoires, create four to seven meaningful target words representing diﬀerent parts of speech (e.g., nouns, verbs, exclamations, adjectives) using primarily syllable shapes and phones within the child’s inventory. “Tuhtah!” introduces a voiceless phoneme, but the syllable shape and vowels are familiar; new vowel /i/ is a visible high front vowel in contrast to the central-low vowels produced. Prosody can be addressed with multisyllabic targets or monosyllables using rising and falling pitch contours to ask a question, demand attention, or “whine!”“Snowflake,” an important parent/child goal, introduces a new syllable shape, possibly achievable through forward chaining of /s/ and /n/ already in the inventory (e.g., “sn,”“sno,” snof,”“snofay,” and/or “snoflay,” and then possibly “snowflake”).

b is incorrect. These targets do not include sounds primarily in the child’s repertoire. “Baa-baa” is not particularly meaningful for this 6-year-old boy.

c is incorrect. A developmental “traditional” approach does not support the acquisition of gestures for motor speech movement/planning.

is incorrect. Although these meaningful targets can build

d syntax, they are not composed of sounds within the child’s phonetic inventory and include challenging new gestures for motor speech movement/planning.

e is incorrect. These maximal opposition pairs contrast the target to a sound within the inventory across several possible feature contrasts (e.g., place, nasality, manner, voicing). Such pairs may assist in overall system-wide phonological change in children with a phonologically based speech-sound disorder, but do not address deficits in motor speech movement/planning.

3. In treating a client with CAS, the clinician first identified the

level of cueing support (e.g., simultaneous production—direct imitation—delayed imitation) as well as the number and type of multisensory cues (clinician verbal model, visual cues, gestural support, and verbal placement cues) needed for

in simultaneous production with the

1VC1

V in direct

accurate, smooth, and appropriately timed movements/productions. For each target, the clinician shaped the client's independence for targeted speech-sound production by fading the number and type of multisensory cues. What therapy

strategy was used? a) Melodic intonation therapy. b) Cycles phonological approach. c) Vertical therapy. d) Core vocabulary approach. e) Dynamic temporal and tactile cueing (DTTC).

Answer: e is correct. DTTC is a type of integral stimulation (i.e., imitation tasks combined with motor learning principles) which the clinician shapes the child’s productions with multisensory cues to achieve accurate, well-timed, and smooth movement gestures in speech.

a is incorrect. In this therapy, the client intones simple twoto-three-syllable phrases containing high-frequency words or social phrases, tapping out each syllable as it is produced, while the clinician provides auditory models and visual cues.

b is incorrect. This linguistic approach addresses the gradual suppression of phonological processes through listening to correct speech-sound models and learning the kinesthetic and auditory feedback associated with correct target production.

c is incorrect. A vertical approach is an intense (often massed) practice on one or two targets until a specific level of mastery (typically conversational level) is attained, af ter which new targets are practiced.

d is incorrect. Although the child’s motor speech movement/ planning may be considered, this approach’s focus is consistent production of functional words selected with parent, child, and/or teacher input, and not necessarily incorporating the child’s phonetic repertoire.

19.5 Description of Disorder and Recommended Treatment

Although no standardized diagnostic markers for CAS exist, KJ’s characteristics were most consistent with a diagnosis of CAS. He demonstrated diﬃculty with consistent production of consonant and vowels combinations (e.g., VC, CV timing and production when transitioning between sounds, simplification of more complex syllable shapes, and disturbances in lexical prosody. Additional indicators of motor speech movement/planning deficits included a profoundly limited sound repertoire for consonants and vowels, vowel neutralization, and speech-sound production improvement with multisensory cues and imitative models. KJ’sdiﬃculties in breast- feeding and excessive drooling imply some early deficits with oral motor control/planning, a separate but sometimes comorbid condition with verbal motor control/planning diﬃculties. It is important to note that a diagnosis of CAS does not depend on any single deficit, but on a combination of diﬃculties suggesting motor speech movement/planning problems.

A DTTC approach was recommended. KJ’s family assisted in the development of the treatment plan so that goals were functional and meaningful. Treatment was scheduled for three times a week for 30 minutes.

1CV1

), accurate

Childhood Apraxia of Speech

Table 19.1 Cumulative percent correct for target “mama” across 30 treatment sessions.

Treatment session

1 2345678… 30

Daily data (no. of correct/total targets)

Daily percent correct 50 9 20 23 23 32 50 58 100

Cumulative data(no. of correct/total tar-

gets)

Cumulative percent correct

Calculate by dividing the number of targets correct each session by the total number of targets produced each session.

Calculate by dividing the total number of targets correct for all sessions by the total number of targets produced for all sessions.

5/10 1/11 4/20 5/22 6/26 8/25 13/26 15/26 25/25

5/10 6/21 10/41 15/63 21/89 29/114 42/140 57/166 624/780

50 29 24 24 24 25 30 34 80

19.6 Outcome

KJ’s initial therapy goals included the use of his current sound repertoire to produce functional words or approximations, expanding C and V repertoires, and improving prosody. Seven functional targets across various language functions were “dada,” “mama,”“whoa,”“beep,”“me,”“no,” and “do.” Three to four rep- etitions of targets (“mini-blocks”) were practiced in a distributed, variable manner. Initially, KJ required simultaneous productions, but transitioned to direct imitation given verbal placement, visual placement, and gestural cues. Clinician cues were faded with repetitive practice and KJ began to self-cue with gestural prompts. After 15 sessions, he was still unable to produce /p/ in the final position, but during a moment of frustration, spontaneously produced “oﬀ.” Because it could be elicited with verbal and visual placement cues in subsequent sessions, “oﬀ” was added as a target as were VC combinations “on” and “odd.”

Production of /i/ and /o/ was prompted with manual gestures using arm movements mimicking each vowel’s distinctive oral motor movement and mouth shape. Approximations of target words in isolation were obtained with limited carr yover in simple syllable shapes. Prosody using rising and falling intonation activities was achieved for “whoa.” Because cumulative percent correct is more useful in accounting for performance variability than daily percent correct, it was used to monitor progress for all targets. KJ achieved 80% cumulative percent correct (▶ Table 19.1) for accuracy (including appropriate lexical stress) for “mama” after 30 sessions.

19.7 Key Points

●

CAS presents as a complex symptom and cannot be identified by the presence or absence of any single deficit.

●

The family of the client should be actively involved in the development of the treatment plan.

●

Speech motor movement/planning gestures should be included using multisensory cues, fading cues as soon as possible.