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Child Client Final Therapy Report

SAN FRANCISCO STATE UNIVERSITY

1600 HOLLOWAY AVENUE, BH 114

SAN FRANCISCO, CA 94132

PHONE: 415.338.1001

FAX: 415.338.0916

 

SPEECH/LANGUAGE THERAPY REPORT

 By: Student Clinician, Brenna Gall 

       Supervisor, T.C., M.S., CCC-SLP 

DATE OF REPORT: April 21, 2010                         

 I.    BACKGROUND INFORMATION

B.W., a *-year, *-month-old male was referred to the San Francisco State University Communicative Disorders (SFSU CD) clinic by his mother, W.W., to strengthen his speech and language skills.  She expressed her main concern was that B.W. did not express his ideas clearly.  She reported B.W. uses verbal language, and if he cannot express his needs, he will pull her hand to point at an object.  B.W. lives at home with his father, mother and older brother, age 7.  B.W.'s brother stuttered as a preschooler, but no speech therapy was received.  English is the only language spoken in the home.  Per his mother's report, B.W. enjoys playing with cars, trains and planes.

B.W.'s mother reported that during gestation, she was put on bed rest at 20 weeks and given terbutaline to delay premature labor.  B.W. was born at 39 weeks at a healthy weight.  He suffered a cephalohematoma, a collection of blood under the tissue that lines the skull, as a complication of child birth.  No treatment was necessary and this resolved itself by one month of age.  His mother reported that during infancy, B.W. had an average amount of crying, sleep, activity, affection, and weight gain.  She also reports that B.W. met all developmental milestones at the appropriate ages.  He sat unsupported at seven months, crawled at 10 months, and walked unsupported at 14 months.  He has had no major illnesses or infections.  B.W.'s first word was "uh-oh" at 12 months, and he began putting two-word and three-word combinations together at age 3.  His last hearing test was done in July 2009 at the Hearing and Speech Center of Northern California and results were normal.

  B.W. attends the *** language and learning preschool three days a week, for three hours each day.  His mother reports he has limited social interactions with other children.  According to a speech-language report done by XXX, M.S., CCC-SLP, on Sept. 15, 2009, B.W. was diagnosed on Aug. 9, XXX with Autism at the XXX Clinic by XXX, Ph.D.  B.W. previously received private speech therapy from September 2009 through February 2010, when he then stopped these services and began receiving services at the SFSU CD clinic. 

Information and results for this report were determined through file review, parent interview, direct observation, standardized and informal assessment measures, and data collection. 

  II.         CURRENT SEMESTER'S ASSESSMENT

      The following assessment procedures were administered:

  • Clinical Evaluation of Language Fundamentals-Preschool, 2nd edition
  • MacArthur-Bates Communicative Development Inventories-Words and Sentences
  • Oral-Motor Examination
  • Speech and Language Sample
  • Probe for Requesting, Turn-Taking, and Imaginative Play

   A.      Standardized Testing

       Clinical Evaluation of Language Fundamentals-Preschool, 2nd edition

 

Standard Score

Percentile

Sentence Structure

5

5

Word Structure

9

84

Expressive Vocabulary

9

98

Core Language (TOTAL)

86

18

The Clinical Evaluation of Language Fundamentals-Preschool, 2nd edition (CELF-P2) is standardized and norm-referenced. Standardized test scores are noted with standard scores and percentiles. A standard score of 100 can be considered squarely in the average range, with 15 points above or beneath that score equal to one standard deviation, so a standard score of 85-115 is considered within the average range. Percentiles can be best understood as a number from one to 99, with a group of 100 students of the same age or grade standing in a row, from the lowest- to the highest-performing student. The 99th percentile represents the highest-achieving student.  For each of the subtests, a standard score of 10 is considered squarely in the average range, with three points above or below that score equal to one standard deviation, with a standard score of seven to 13 within the average range.

The CELF-P2 was given to determine B.W.'s expressive and receptive language skills.  Overall, B.W. scored in the 18th percentile with a standard score of 86, which is considered to be in the low-average range.  Three subtests were administered to obtain the core language score: sentence structure, word structure and expressive vocabulary.

Sentence Structure

The Sentence Structure subtest probes for understanding of differing sentence structures, such as verb tense, prepositional phrases, negation, passive structure, and relative clauses.  B.W.'s standard score of 5 placed him in the 5th percentile, which is below the average range.  When asked to point to the picture that represented "She is climbing and he is swinging," he chose the picture that depicted a boy climbing and a girl swinging.  Although it is not the purpose of this subtest, knowledge of pronouns is required to arrive at the correct answer.  B.W.'s difficulty with pronouns is a possible explanation for his below-average performance on this subtest.  However, B.W. also showed difficulty understanding age-appropriate sentence structures, such as verb tense and prepositions such as "in" and "under."

Word Structure

The Word Structure subtest examines the ability to verbally complete a sentence given visual representation, such as, "The boy is standing [while the clinician points to picture of boy standing].  This boy is…[while the clinician points to picture of a boy sitting]."  B.W. received a standard score of 9, placing him in the 84th percentile and within the average range.  He correctly used the prepositions "over" and "on" and the possessive -s.  B.W. had difficulty with irregular verbs such as "blew" and "fell."

 Expressive Vocabulary

The Expressive Vocabulary subtest is given to determine the amount of vocabulary B.W. knows and expresses.  Pictures of objects were shown, and B.W. was required to verbally identify each object.  B.W.'s standard score was 9, which placed him in the 98th percentile for his age range, and well above the average range.  He identified objects such as a wheelchair, calendar, branch, firefighter and a piano.  He did not identify telescope, binoculars, scale or a stamp.  Overall, B.W. performed extremely well on this subtest.

 B.      Non-Standardized Testing

       MacArthur-Bates Communicative Development Inventories-Words and Sentences

The MacArthur-Bates Communicative Development Inventories-Words and Sentences was given to B.W.'s mother to examine vocabulary production and beginning semantic and syntactic development at home.  This instrument is used only as a reference since it is normed on children up to 30 months.  Per his mother's report, B.W. produces 509 out of the 680 words listed in the checklist.  B.W. reportedly often produces long sentences, and some examples of recent sentences include "I will tell Daddy the seat belt is broken," "I want to play cars with you Mommy" and, "I don't want turkey in my sandwich."  B.W. uses some irregular verbs such as drove, bought and broke.  He also uses the plural -s, the possessive -s and the -ing ending.  His mother also reports B.W. sometimes talks about past and future events and objects that are not present.

 Oral-Motor Examination

An oral-motor examination was completed to rule out any structural or functional abnormalities of the speech mechanism that may contribute to a communicative disorder.  Evaluation of facial symmetry at rest appeared normal.  B.W. successfully protruded his tongue and moved it from side to side, showing normal tongue range of motion and strength.  He rounded his lips by blowing bubbles and pretending to give the mirror a kiss.  He smiled, frowned and puffed his cheeks full of air.  Findings after assessment of the hard and soft palate were normal.

Speech and Language Sample

A speech and language sample was attempted, but the number of utterances collected was insufficient for a thorough analysis of his speech and language skills.  Some examples of B.W.'s longest utterances at the beginning of the semester include, "Can I go ride on the elevator?" and "There is no keyhole."  B.W. repeated phrases and key words that the clinician said with some frequency, but more often created novel sentences.  Some examples of his speech from the end of the semester include, "Can we play with Guess Who? after silly magnet faces?" and, "That is my favorite game."

Probe for Requesting, Turn-Taking, and Imaginative Play

      Legos, cars and bubbles were used to elicit requesting, turn-taking and imaginative play.  When two Legos were withheld, B.W. requested, "I want the red one."  Throughout the session, B.W. requested objects he desired, such as cars or more bubbles.  He willingly took turns pushing a wind-up car back and forth across the table.  He seemed to enjoy this type of partner play.  B.W. was engaged and interacted well with the clinician, often making eye contact and giggling.  B.W. was asked to pretend the Lego was a car, and he successfully did this.  He pretended to drive the Lego around the table and up the wall.  Per his mother's report, B.W. has been engaging in imaginative play more often than before.

III.  INTERVENTION GOALS AND PROGRESS

Goal 1: B.W. will correctly answer yes/no questions when verbally prompted during structured activities with 80% accuracy.

      Baseline: B.W. correctly answered yes/no questions with 66% accuracy.  He did not attempt to self-correct after using yes or no inappropriately.  However, B.W. seemed to know the answer to the question if asked in a different way. 

      Progress: Goal met. B.W.'s use of yes and no improved during the course of the semester.  He successfully and consistently answered yes/no question more than 90% of the time.  Games such as Guess Who?, as well as picture cards were used to elicit answers to yes/no questions like, "Is he wearing a hat?"  B.W. would independently answer, "Yes, he is wearing a hat."  If B.W. used yes or no incorrectly, he would often self-correct and rephrase his sentence.  Giving B.W. sufficient time to process the question aided him in answering correctly.

[Incidental language learning refers to natural situations arising from child-directed interactions that allow for the child to learn from the adult in a natural setting.  This technique was used during child-directed play with games such as Guess Who?.  An article reviewing its efficacy and effectiveness can be found here: Warren, S.F., & Kaiser, A.P. (1986). Incidental language teaching: a critical review. Journal of Speech, Language, and Hearing Research, 51, 291-299. 

ASHA's Guidelines for Speech-Language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders Across the Life Span discusses the importance of child-centered therapy.]

 

Goal 2: B.W. will improve his expressive vocabulary by producing the pronouns "he" and "she" independently during structured activities with 80% accuracy.      

      Baseline: B.W. used the pronouns "he" and "she" during structured activities with 26% accuracy.  He often confused "he" and "she" and would replace one with the other.  He did not attempt to self-correct after making a mistake.  However, after modeling, B.W. did repeat the correct usage.

       Progress: Goal met.  The board game Guess Who? was modified to elicit the use of "he" and "she".  Mr. Potato Head was also used to elicit productions of "he" and "she".  During these activities, B.W. correctly used he and "she" with 96% percent accuracy.  When playing Guess Who?, B.W. was asked, "Does Frank have glasses?" and he would independently answer, "No, he does not have glasses."  During play with Mr. Potato Head, items were withheld and B.W. was required to say, "He needs [insert body part]."  On a few occasions, he would use "he" or "she" incorrectly, but would self-correct without cueing or prompting.  Overall, modeling and prompting was not necessary to elicit these productions.  B.W. made tremendous improvement using "he" and "she" correctly during the course of the semester.

[According to the book,  Born to Talk: An introduction to speech and language development  by Howard Hulit and Merle Howard (2005), children that are B.W.'s age should be using the pronouns "he" and "she."  This evidence-based research was the basis for the chosen goal.]

      Goal 3: B.W. will increase his expressive language by identifying and naming emotions in complex picture scenes with 80% accuracy.

       Baseline: B.W. identified emotions in a complex picture scene 16% of the time.  He had difficulty isolating specific characters' emotions and would often answer "happy" for all characters.

         Progress: B.W. continues to have difficulty with identifying emotions by looking at the faces of characters in a complex picture scene.  He successfully identified emotions in a complex picture scene with 74% accuracy.  B.W. needed extended time to answer questions like, "What is he feeling?"  Prompting such as, "Look at his mouth.  Is he smiling or frowning?"  was used to elicit B.W.'s correct responses.  Although this task was difficult for B.W., he identified emotions of characters standing independently of a scene with 100% accuracy. 

  IV.  IMPRESSIONS

      B.W. is a hard-working, caring and cheerful 4-year-old.  He has a sweet disposition and is always excited to work hard in therapy.  B.W. enjoyed routine and thrived playing many of the same games each week.  He transitioned well between activities and had no trouble when our plan deviated from what was expected.  Increased time to process tough tasks seemed to be an effective way for B.W. to be increasingly successful in therapy.  He often self-corrected if the clinician allowed sufficient time for him to process his incorrect answer.  Providing activities that required moving around the room were helpful to keep B.W. motivated.  He enjoyed playing the "freeze dance" and doing jumping jacks with the clinician.  B.W. is a quick learner who is very motivated when provided with fun activities and given sufficient time to process the task required of him.

 V.      RECOMMENDATIONS

B.W. would benefit from continued speech and language therapy at the SFSU Communicative Disorders clinic to improve his receptive, expressive and pragmatic language skills.  The following suggestions are recommended:

 1. Recommended Therapy Goals:

  • Continue to work on pronouns using increased task complexity
  • Increase accuracy of answers to "wh" questions
  • Assess B.W.'s production of vowels and model the appropriate pronunciation
  • Decrease repetitive utterances by requiring novel utterances

  2. Recommendations for the Home:

  • Play a modified version of Guess Who?, or other games depicting male and female characters, once a week to elicit yes/no and he/she responses in sentence form
  • Discuss emotions and feelings when they occur, and have B.W. express what he is feeling physically and emotionally to help B.W. understand his own feelings
  • Require B.W. to use he/she in a sentence at least three times each day
  • When B.W. uses yes/no or he/she incorrectly, require him to rephrase giving sufficient time for him to process his own mistake without prompting or modeling

Reflection: Child Client

B.W. was my very first client.  I had a range of emotions when walking into the clinic room that day: excited, scared, anxious, motivated.  Although I knew I had the academic training, I wondered how I would apply this knowledge to my clinical work.  The initial step was interviewing his mother.  As I began the interview, I was pleasantly surprised at how calm and collected I felt.  I had questions in mind I wanted answered, but I also knew I needed to give her time to share about her son.  I successfully built good rapport with the mother and it was time to begin my assessment of B.W.  Again, I was pleased at how well my academic training had prepared me for this step.  Information gathered from the CELF-P2, informal testing, parent interview, and chart review helped me glean an overall picture of B.W.  On B.W.'s second day back, his mother reported that he could not wait to come back to therapy, and he had asked everyday that week when it was time to see Ms. Brenna again!  With such a wonderful beginning to my clinical work, I gained confidence in myself and felt I had been well prepared for the challenges ahead.  With the assessment process underway, I began to fall in love with the process of diagnostics.  To me, diagnostics was like detective work.  I really enjoyed putting the pieces of assessment to together to glean a whole view of B.W.  Each piece was like a clue leading to an answer about the best way to help B.W.  Discovering B.W.'s strengths and areas of difficulty was challenging and rewarding for me.  Once I felt I had pinpointed the areas in which he needed the most help, I wrote measurable goals for B.W.  Carrying out these goals in therapy required flexibility and child-centered therapy.  I often let him lead the activity or choose a game and I would weave his goals into the game.  Although practicing truly child-centered therapy is still a challenge for me, I feel grateful that my program at SFSU has shown me the importance of child-centered therapy and gave me the opportunity to integrate into my clinical practice as early as possible.

My experience with B.W. allowed me think about not only what I did well, but also what I would like to change as I develop my own philosophy about speech and language pathology.  Upon reflection, I have set certain professional growth goals for myself.  First, I want to continue to use evidence-based practice (EBP) to make clinical decisions.  This includes keeping up to date on current information and research studies.  As I grow as a professional and I gain more experience in the field, I believe that my idea of EBP will also grow.  Because EBP includes using clinical experiences to make decisions about therapy, I want to be able to continually integrate my clinical experiences with current research.  Next, when working with children like B.W., I believe that a family-centered approach is the most effective way to provide therapy. I strive to continue to learn how to fully involve the parents and other family members in the therapy process.  I know that I may only spend a few hours a week with a child, but the family spends much more time with the child and can continue to work on goals at home making therapy much more efficient and effective.

 
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