SpeechandLanguageEvaluation
November4th, 20xx
Client:JjjjjPppp
DateofBirth:May23rd, 20xx. C.A. 2 years, 5 months
Address:405 Main Street, Anytown, VT.05401
Phone:xxx-xxx-xxxx
Parent:Ms. DddPppp
Referral Sources:FamilyPediatric Group Graduate Clinicians:BbbbCcc,B.A.,FfffHhhh, B.A. Clinical Faculty: MarySpeech, M.S., CCC-SLP
DiagnosisandCode:315.32 Receptive-ExpressiveLanguageDisorder (mixed)
Referral Questions:
Jjjjwas referred to theEleanor M.Luse Center bytheFamilyPediatric Group.Acomprehensive speech and languageevaluationwas requested, to determine the 1)nature, severityand duration ofa speech and/or languageimpairment;and 2) functional limitations related to thespeechand/or languageimpairment.
Thespecificreferral questions areas follows:
1. Does Jjjjjdemonstrate aspeech sound or phonological disorder, which impacts on speech intelligibilityand imposes functional limitations on his abilityto communicate?
2. Does Jjjjjdemonstrate avoice and/or fluencydisorder, which impacts on voicequality and/or speech fluencyand imposes functional limitations on hisabilityto communicate?
3. Does Jjjjjdemonstrate areceptiveand/or expressivelanguagedisorder, which impacts on the comprehensionand/or useof spokenand/or written language, and imposes functional limitations on hisabilityto communicate?
Background:
JjjjjPpppis an energetictwoyear, fivemonth old boyliving athome withhis mother and seven- year-old sisterin Anytown, VT.Hewas accompanied to today’sevaluationbyhis motherMs. Pppp, his cousin Bbbb, and familyfriend Fred. Jjjjjwas referredforaspeechand language evaluation fromFamilyPediatricGroupafter Ms.Ppppsought services forJjjjj’s behavior through Vermont’s HeadStart Program.
Ms. Pppp reported that her pregnancywas unremarkable. Jjjjjwas born full-term weighingover
8 pounds and 5 ounces. She reported thatJjjjjwasbornwith one kidneyhowever,therehave been no associated complications.Inaddition,Jjjjj’s medical historyis significant for recurring ear infections (morethanfive sincetheystarted),asthma, ahospitalizationforbronchitis, and waxremoval. Ms.Pppp reported that his last ear infection was in Julyanditwas effectively
treated with antibiotics. Ms.Pppp reported that Jjjjjdoes not take anymedicationsbut does use a nebulizer when hehasacold to help with wheezing.
Ms. Pppp reported that Jjjjjsaid his first word at approximatelyone-year ofage and that his vocabularycontinues to grow.Jjjjj’s speech and languagedevelopment was characterized byMs. Pppp to have expanded significantlyover thesummermonths. Some examples ofwords heuses at home are:mama, dad,Jojo, sissy,me, Jjjjj, no, pushup, crabby, and help. Ms. Ppppreported that Jjjjjunderstands everythingthat is said to him and is easilyunderstood byothers.It was reported that Jjjjjboth vocalizes andusesgesturesto makewants and needsknown; however sometimes heuses his behavior morethan words to express himself. Ms.Pppp, Bbb, andFred characterized Jjjjj’s behavior as problematic and that itresults in him kicking, hitting,and knockingthings over. Ms.Pppp reported that thesebehaviors occurboth whenJjjjjis told “no” and spontaneouslythroughout theday. Shereported that his behavior is difficultto manage, as she does not know what is causingit.
Accordingto thepediatric casemanager report from VisitingNurseAssociation (VNA) of MonroeBlock Counties, therewere concerns regardingJjjjj’sfamilystability, familial isolation, and the cognitive/mental status of his primarycaregiver.Theseenvironmental factors placeachild at risk foradevelopmental languagedelay.
Assessment:
Formal and informal assessment measures wereused in today’s evaluation to assessJjjjj’s
speech and languageskills.
HearingScreening:
Otoscopic visualization was conducted to assess tissuehealth, overallappearanceof theear canals and tympanicmembranes (eardrums). Theleft tympanicmembranewas partially visualized as the ear canal was partlyoccluded with wax. Both tympanicmembranes were unremarkable forsigns of infection.
Tympanometrywas conducted to assess ear canalvolume, tympanicmembrane compliance and middle ear pressure. Results indicated an ear canal volume within normal limits in both ears and compliance and middle ear pressureexceedingnormal limits in the right ear. No compliance within the middle ear spaceof theleft ear was obtained.Lack of compliancewithin the middle ear spaceis indicativeoffluid behind the tympanicmembrane.
A pure-tone threshold hearingscreeningacross allfrequencies (250Hz, 500Hz, 1000Hz, 2000Hz,
3000Hz, 4000Hz, and 8000Hz) at 20dBwasconducted usingsoundfield testingandconditioned playaudiometry.Jjjjjpassed the hearingscreening.
Oral Speech Mechanism ScreeningExamination
An examination of Jjjjj’soral structures, speech motor function, and swallowingabilities was completed byparent report and observation during today’sevaluation. Anattemptwasmadeto examine function “on command”; howeverJjjjjwas shyand did notwant to follow the directions.Itwas observed however that heperformed several of thesetasks spontaneously throughout the evaluation.
Initial observation of Jjjjj’sfacial structures revealed symmetryat rest.Jjjjjis characterized as a nosebreather, whichwasapparent based on his closedmouth posture. Hecoughed intermittently
throughout the evaluation; however no signs of congestion werenoted. Jjjjjwas asked, on command, to open his mouth and stick outhis tonguegiven verbal and visual cues from the clinician. Followingseveral attempts bythe clinician,Jjjjjopened his mouth forhis mother wherehis oral structureswerepartiallyvisualized. Adequate rangeof motion, normal smooth movement of the jaw, symmetryof lips and jaw in both open and closedmouth postures were observed. His dentition was not visualized; however, Ms.Pppp reported that he has all of his teeth. Jjjjjwas asked on command to protrudehis tongue.Jjjjj’s tonguesurfacecolor and size appeared normal, wellhydrated, and symmetrical. Duringplayactivities with bubbles,Jjjjj spontaneouslysmiled, puckered lips, and puffed his cheeks. Symmetryof thesestructures, in both open and closed positions, was present and rangeof motion appeared adequate.Jjjjj’s hard and soft palatewerenotvisualized; however, his voicequality and resonance appeared to be typical for a child his age. Neithersigns of hyper norhyponasalitywerenoted. Duringabreak in the evaluation, Jjjjjtookadrink from the fountain and awater bottle. Therewas no observation ofliquid escapingwhenJjjjjwas drinking, indicating good bilabial closure.Ms.Ppppreported that Jjjjjexperiences no difficultychewingand swallowing.
Severalcomponents ofthespeech mechanismwere assessed todaythroughthe spontaneityof speech functions. Thestrength of Jjjjj’s lips, tongue, and jawappeared to bewithin normal limits.Visualization ofthehard and soft palate, tonsils, faucial pillars, uvula, and oropharynx could notbe assessedand thereforearenot reported. Based on parental report and observations duringtoday’s evaluation,Jjjjj’s oral structures and oral articulatorfunction appeared to be adequate to support speech.
LanguageAssessments
The Preschool LanguageScale– Fourth Edition (PLS-4)assesses both auditorycomprehension and expressive communication for children between birth and6years, 11months of age. This test is designed to examinea child’s level of languageunderstanding as wellas expressive communication strengths and difficulties.
Jjjjj’s standard scoreof102forthe AuditoryComprehension portion of this particular assessment iswithin the averagestandard score for his agegroup.The PLS-4Auditory Comprehension component includes tasks that assess understandingspatial concepts, pronouns, and followingtwo-step related commands in the absenceofcues. Jjjjjwas ableto successfully complete allAuditoryComprehension Tasks within the PLS-4forhis agegroup of24 to 29 months.
The calculated standard score forJjjjj’sExpressiveCommunication is slightlybelow the mean of his agegroup. Jjjjj’s standard scoreof 97from theExpressiveCommunication component of the PLS-4 falls between 0and-0.5 standard deviations of themean standard score forindividuals of Jjjjj’sage. Jjjjjdemonstrated the abilityto successfullyname objects within photographs,
request assistance, and toansweryes/no questions;alltasks within the 24 to 29-month age range for ExpressiveCommunication. Jjjjjdid notdisplaytheuse consonant-vowel-consonant sound combinations in spontaneous speech or during clinician-elicited languageactivities. This expressivelanguage abilityfalls within or below thelanguageexpectations of Jjjjj’sagegroup accordingto the PLS-4.
Jjjjj’s Total LanguageStandard Score of100, (acombination ofhis AuditoryComprehension and ExpressiveCommunication abilities),is within the averagerangefor his agegroup. Accordingto the PLS-4,Jjjjj’sexpressive and receptivelanguageskills areconsidered typical for
his ageand developmental level.
Table 1 – Jjjjj’sPreschool LanguageScale – Fourth EditionResults
Norm-Referenced ScoresRaw
Score / Standard
Score
(SS) / SS
Confidence
Band(at
95%level) / Percentile
Rank
(PR) / PRs forSS
Confidence Band Values
Auditory
Comprehension / 31 / 102 / 93 to 111 / 55 / 32 to 76
Expressive
Communication / 32 / 97 / 89 to 105 / 42 / 24 to 62
Total Language
Score / 63 / 100 / 92 to 108 / 50 / 29 to 71
Throughout today’sevaluation, Jjjjjproduced accurate productions or close approximations of fifty-fivewords. This findingis consistent with parental report regarding Jjjjj’sexpressive vocabularyconsistingofmorethan fiftywords. The expressivevocabularywords verbalized by Jjjjjduringtoday’s session arelistedin Table 2.
Table 2 – Jjjjj’s observedexpressive vocabularyas of November 4, 2010
ExpressiveVocabularyNouns / Pronouns / Verbs / Greetingsand
Valedictions
Negation and
Affirmation
Yeah
No
Articles
The
Adjectives / Adverbs / QuestionWords
Big
Blue Green One Ready Right Two / Here
There / What
Prepositions
At
Up
Jjjjj’s mean length of utterance(MLU) in morphemeswas calculated based on a conversational speech sample obtained from the observation ofparent-child interaction. The expected MLU for a child between the ages of two and threeyears is approximately2-3 morphemes per utterance. Jjjjjdisplayedan MLU of 2.07duringspontaneous speech.
Sections of TheRossetti Infant-Toddler LanguageScale wereusedto informallyassessJjjjj’sgestures, play, interaction-attachment, pragmatics, language comprehension, and language expression. Thesesections were analyzed to provide moreinformation intoJjjjj’s overall languagedevelopment.Information wasgatheredusingparental report, observation, and elicitation duringtheassessment.
Results of theRosettiindicate thatJjjjj’s level of interaction-attachment (e.g., requestsassistance from an adult) and pragmatics (e.g., uses words to protest) areage-appropriate. Both playand gesturesections wereunable tobefullyassessed,as therewerelimited opportunities to observe, elicit, and receive parental report duringtheevaluation; however,Jjjjjdiddemonstrate appropriate useofgestures (e.g., slaps palmin responseto “give me five”)and play(e.g.,
chooses toys selectively).Jjjjj’s languagecomprehension was evaluated asage-appropriate, within the rangeof 21-30months and each item (e.g., responds to simplequestions, follows novel commands)was observed, elicited, or reported bytheparent.Jjjjj’s language expression best fitwithin the appropriate agerange; however,hedid notreceive fullcreditforusingthree- word phrases frequentlyor referringto self bypronoun consistently. Accordingto theRossetti, theseskills aretypicallydeveloped within the24-27 month and 27-30 month rangerespectively. Table 3 liststhe items observed, elicited, or reported duringthe evaluation.
Table 3 -Sections from TheRossetti Infant-Toddler LanguageScale
AgeinMonthsSections / 15-18 / 21-24 / 24-27 / 27-30
Interaction-
Attachment / -Playsawayfrom
familiarpeople
-Requestsassistance fromanadult
-Retreatsto caregiverwhenan unfamiliaradult approaches / Noitemstoevaluate
atthisagelevel / Noitemstoevaluate
atthisagelevel / Noitemstoevaluate
atthisagelevel
Pragmatics / -Pointsto, shows,or
givesobjects
-Controlsthe behaviorofselfand others
-Useswordsto protest / Noitemstoevaluate
atthisagelevel / Noitemstoevaluate
atthisagelevel / Noitemstoevaluate
atthisagelevel
Gesture / Noitemstoevaluate
atthisagelevel / -Gesturestorequest
action
-Pretendstopour froma container / -Wipeshandsand
face
-Slapspalmin responseto“giveme five” / Noitemstoevaluate
atthisagelevel
Play / Didnotevaluate / -Putsawaytoyson
request
- Attemptstorepair brokentoys
-Stacksand assemblestoysand objects / -Performsmany
relatedactivities duringplay
-Choosestoys selectively
-Usesmosttoys appropriately / Unabletoassess–no
peerpresent
Language
Comprehension / Didnotevaluate / -Choosesoneobject
froma groupoffive uponverbalrequest
-Followsnovel commands
-Followsa two-step / -Pointstofour
actionwordsin pictures
-Recognizesfamily membernames
-Understandsthe / -Respondsto simple
questions
-Identifiesfour objectsbyfunction
-Understands locationphrases
relatedcommand
-Understandsnew wordsrapidly / conceptofone
-Understandssize concepts
Language
Expression / Didnotevaluate / -Usestwo-word
phrasesfrequently
-Uses50different words
-Usesnewwords regularly
-Relatespersonal experiences
-Usesthree-word phrasesoccasionally
-Refersto selfby
name
-Usesearly pronouns occasionally / -Imitatestwo
numbersor unrelated wordsuponrequest
- Asks forassistance withpersonalneeds
-Usesactionwords
-Usesameanlength of1.5-2.0 morphemesper utterance / -Namesonecolor
-Respondsto greetings consistently
-Usesnegation
-Usestwosentence types,(declaratives andinterrogativesi.e. “No,thisfit,”“Need help,”“Shoesgo
righthere,”and
“Whatthis?”)
-Usesameanlength of2.0-2.5 morphemesper utterance
Note. No items wereevaluated at 18-21 Months
Speech Assessment andIntelligibility
Jjjjjand his mother engaged in playduringthis diagnosticevaluation. Clinicians gathered information regardingJjjjj’s speech based on thisparent-child interaction. Jjjjj’s speech is characterized bythe consistent use of consonant-vowel (CV) and CVCV syllable productions. Twounfamiliar listenersrated theintelligibilitylevel ofJjjjj’sconversationalspeech during parent-child play. His speech intelligibilitywascalculated to be 49.5%based on the analyses of an individual 100-word speech sample. The expected intelligibilityofa childinJjjjj’sagerange (28-30 months) is66-74% (Weiss, 1980). TheWeissintelligibilityscoreguidelines arenormed percentagevalues that havebeenagreed upon byBernthalBankson(2004). Such guidelines areaccepted criteria within thespeech and languagepathologyprofessionand thereforecomply with Vermont Department of Educationguidelinesfor evaluatingindividuals between birthand threeyears of age.
Jjjjjproduced sixteen consonant sounds, ten singularvowels, and threediphthongvowel sounds throughout today’sevaluation. Jjjjj’s vowel and consonant repertoires alongwith examplesfrom his speech areincludedwithinTables 4 and 5 below.
Table 4 – Consonant phonemes withinJjjjj’sexpressivelanguage repertoire
Consonant RepertoireConsonant / Example fromDiagnostic Evaluation
/b/ / “bee”
/d/ / CV vocalization– approximation of“this”
/f/ / “feet”
/ɡ/ / “go”
/ʤ/ / “Jojo” (name of familyfriend)
/h/ / “here”
/j/ / “yeah”
/k/ / CV vocalization
/m/ / “mama”
/n/ / “no”
/p/ / “pick”
/s/ / “sit”
/st/ blend / CV vocalization
/ʃ/ / “shoe”
/t/ / “toolbox”
/w/ / “we”
Table 5 – Vowel phonemes withinJjjjj’sexpressivelanguage repertoire
Vowel RepertoireVowel / Example fromDiagnostic Evaluation
/ʌ/ and /ǝ/ / CV vocalization
/i/ / “feet”
/ɪ/ / “this”
/e/ / “yay”
/ɛ/ / “there”
/ӕ/ / “hat”
/ɑ/ / “mama”
/o/ / “no”
/ʊ/ / “put”
/u/ / “shoe”
/aɪ/ / “right”
/aʊ/ / “mouth”
/oʊ/ / CV vocalization
Jjjjjdisplays a varietyofphonologicalerrorpatterns within his speech. The clinicians observed final consonant deletion,glidingof liquids, vocalization ofliquids, and stoppingthroughout Jjjjj’s speech. Table 6 depicts the errorpatternsproduced byJjjjjas wellas examples from this diagnostic evaluation.
Table 6 – Phonological error patterns withinJjjjj’s verbal speech output
Phonological ErrorPatternsTargetFinal
Consonant / Target Word / Target
Production / Jjjjj’s
Production
Final Consonant Deletion / /k/ / “pick” / /pɪk/ / [pi-]
/ks/ / “toolbox” / /tulbɑks/ / [tubɑ-]
/p/ / “up” / /ʌp/ / [ʌ-]
/s/ / “this” / /ðɪs/ / [dɪ-]
/t/ / “right” / /raɪt/ / [waɪ-]
“hat” / /hӕt/ / [hӕ-]
“feet” / /fit/ / [fi-]
/z/ / “shoes” / /ʃuz/ / [ʃu-]
Gliding / /l/ / “help” / /hɛlp/ / [hɛʊ]
/r/ / “there” / /ðɛr/ / [dɛʊ]
“right” / /raɪt/ / [waɪ]
Omissionof
Liquids / /l/ / “eyeball” / /aɪbɑl/ / [aɪbo]
“toolbox” / /tulbɑks/ / [tubɑ]
Stopping / /ð/ / “this” / /ðɪs/ / [dɪ]
Summary:
JjjjjPpppis an engaging and energeticyoungboywho cooperated throughout the evaluation. Dueto his chronologicaland developmentalage, formal and informal assessment tools were usedin today’s evaluation.
Jjjjj’s hearingwas screened as a resultof recurring ear infections. Both tympanic membranes werepartiallyvisualized dueto waxobstruction and no signs of infection werenoted.The tympanogram obtained in his left ear is consistentwithfluid in the middleear space. Ms.Pppp was informed ofour findings andencouraged to follow-up with his primarycarephysician to monitor his recurringearinfections.Jjjjjpassed today’s hearingscreening.
Theoral mechanismexamination was attempted in thetypical format asan“on command task”; howeverJjjjjwas shyand did notcomply. His oral structures wereobserved spontaneously through play. Typical voicequalityand resonancefora child his agewas noted throughout the evaluation. Jjjjj’s oral structures appeared to be functioningnormallyto support speech.
Jjjjj’sexpressive and receptivelanguageabilities, as evaluated bythe Preschool LanguageScale
– Fourth Edition, fallwithin the expected rangefor children of his chronological and developmental age. His expressive communication abilities resulted in a slightlylower standard score ascompared to his receptivelanguageabilities. Jjjjj’sAuditoryComprehensionscoreisat the 55thpercentile rank and ExpressiveCommunication at the42ndpercentile. With a95%level of confidence, Jjjjj’sreceptive and expressive languageskillsas wellas hiscompositescoreof both AuditoryComprehension and ExpressiveCommunicationindicate thatJjjjj’sexpressive
and receptivelanguageabilities areconsistent with typicallydeveloping children of his age
groupaccordingto the PLS-4.
TheRossetti Infant-Toddler LanguageScalewas used to provide information of Jjjjj’s overall languagedevelopment.Items were elicited, observed, orreported byMs.Pppp.Levels of interaction-attachment, pragmatics,gestures, play,and languagecomprehension wereall considered to beage-appropriate. Theresults fromthe languageexpression subtest of the Rosetti indicate thatJjjjjhas metmanybut notallof the expressivelanguagemilestones often exhibited bychildren his age. Specifically, hedid notuse three-word phrases frequentlynor consistently refer to himself usingapronoun.
Jjjjj’s phonological errorpatterns contributeto a level of speech intelligibilitythat isbelow
average forhisagegroup. Gliding, as a phonological errorpattern, is considered developmentallyappropriate for children up to 5years, 5 months ofage. Vocalization ofliquids is appropriate for individuals of4years, 11 monthsand stoppingis considered acceptable for children as old as 4years,5 months of age. Finalconsonant deletion, as aphonological pattern, is expected to ceasepriorto threeyears ofage. Thephonological errorpatternsobservedare considered developmentallyappropriate for achildofJjjjj’schronological age.
Jjjjj’s speech intelligibilityis below the level expected forhis agegroup.Although the above mentioned phonological error patterns areage appropriate, theircombinationsignificantlyaffects Jjjjj’s overallintelligibility. Theconsistent consonant-vowel structureof Jjjjj’s utterances particularlyreflectshispattern of finalconsonantdeletion. The below averageintelligibility rating (49.5% compared to age-expected 66-74%intelligibilityrating) as judged byunfamiliar listeners has negative implications forsuccessin educational settings as wellas within one’s community. Without adequate speech and languagestimulation, itis possible thatJjjjjmayfall behind his same-agepeers in terms ofspeech sound development, as his speecharticulation has been judged as below average.
Jjjjjpresents with no indications of a fluencyor voicedisorder. Additionally,Jjjjjdoes not present with an expressiveor receptivelanguagedisorderbased on theinformation obtained duringthis evaluation. Comprehensive analyses of the TheRosetti Infant-Toddler LanguageScale, Preschool LanguageScale-Fourth Edition,and parent interview, in addition to informal observations indicate thatJjjjj’sauditorycomprehensionand expressivelanguageskills are consistent with typically-developingindividuals ofhis age.
Accordingto the VermontSpecial Education Rules, adevelopmental delayis present whena child is demonstratinga40%delayin skills(as measured bycomparison of age equivalencyon standardized tests and chronological age)orwhosestandardized score fallsgreater than two standard deviations below themean on at least one measure. Based on thescores obtained in today’sevaluation,Jjjjjdoes not presentwith adevelopmental delay. His speechhowever is characterized byphonological processessuch asfinal consonant deletionthatcontributeto an intelligibilityscorethat is consideredbelow average,as comparedto peersofthe same age (expected intelligibilityrange of66-74%). Jjjjj’sintelligibilitylevel of 49.5%negativelyaffects his abilityto successfullycommunicatewith unfamiliar listeners. Earlyspeech interventionmay remediate theexistenceof this developmental delayin communication.
Recommendations:
Based on the findingsfrom today’sevaluation, thefollowingitems are recommended:
1.Parental trainingin theHanenapproachforincreased communication opportunities is recommended toensurecontinued speechand languagedevelopment.
2. Ifthe parents would liketo pursueindividualized speech therapyto work on increasing speech intelligibilitythrough work on final consonant deletion, that therapycan be arranged at theLuseCenteror alternativenames of speech languagepathologists canbe provided. Therapyshould beheld at least two times perweek for 20 minutes either in the home orin his daycare.
Prognosis:
Theprognosis forimproved speech intelligibilityis good based on parental interest and client
willingness to learn skillsto promotespeech language effectiveness.
Ifthereare anyquestionsor concerns regardingthis report orthe information contained within it, please contact theEleanor M.LuseCenterat 656-3861.
BbbbCccc, B.A.Ffff Hhhh,B.A. Graduate ClinicianGraduate Clinician
MarySpeech, M.S., CCC-SLP Speech-LanguagePathologist
Cc:
Ms. DddPppp
405 Main Street
Anytown, VT 05401
FamilyPediatric Group
155 Highway10 Suite22A Anytown, VT 05401