CLINIC FOR CHILDREN WITH SOCIAL COMMUNICATION DISORDERS

Name: M /F
Address:
Landline:
Mobile:
Carer(s) present:
Mother Y /N
Father Y / N
Other
Parents’ ethnicity/country of birth:
Languages spoken at home: / Date:
Date of birth:
Age:
Nursery/School: Start date:
GP:
Referred by:
Community Consultant Paediatrician:
Others present:
REASON FOR REFERRAL
PARENTS’ PERCEPTION OF THE PROBLEM:
OTHER PROFESSIONALS INVOLVED:
HV / SLT / EP
Clin. Psychol. / Portage / SENCO
Other / Other / Other
MANAGEMENT SO FAR
Health
Education (CoP Stage)
BACKGROUND INFORMATION AND MEDICAL HISTORY
Family and Social History (including mood/MH problems)
Birth History Gestation:
Medical History:
Hearing – was the child ever thought to be deaf?
Investigation results: Chroms/Fra X
EEG
Anxiety/mood/sleep:
Bowel function:
What was your first concern about your child and when was that?
Early Development
  • What was she/he like as a baby? Happy, responsive, sociable, interested in people and the environment
  • Social interaction – pointing/joint attention
  • Feeding
  • Motor milestones
  • Early language – was he/she a quiet baby
Babble
Jargon
What were the first words/when
Phrases
  • Early play/imaginative play/imitation
History of loss of skills (or plateauing)
COMMUNICATION SKILLS
Concerns now or in the past
Interest in communication
How does your child tell/show you what s/he wants?
  • Use your hand as a tool?
  • Get things for self?
  • Point to request?(CHAT 18-24 months)
  • Point to share interest? (CHAT 18-24 months)
  • Follow a pointed finger?
  • Initiate communication spontaneously
  • Bring toys or books to show you or share?
  • Can your child request help?
  • How?
/
Comprehension
Can your child
  • Respond to his/her name?
  • Understand situations?
  • Follow simple instruction?
  • Do you need to simplify your language
  • Literal understanding?
  • Understanding of humour?

Expressive language
  • What can s/he say: single words, phrases
  • Can you have a conversation?
  • Does it make sense?
  • Is it varied or repetitive?
  • Can hour child answer questions?
  • Echolalia – delayed
  • – immediate
  • Learned phrases
  • Pronoun reversal
/
Speech production
  • Can you understand what s/he says?
  • Does s/he make sounds?
  • Babble,jargon
  • Voice, tone, speed, volume, intonation patterns
  • Ever use unusual accents
  • Does s/he make unusual noises

Non-verbal Communication
Does your child:
  • Use gestures? Nod/shake head
  • Respond to facial expressions?
  • Respond to tone of voice?
  • Can you tell how s/he feels from his/her face?
/
Signing
  • Does your child understand/use signs?

SOCIAL INTERACTION
Concerns now or in the past
Eye contact:
  • Is it easy to get your child to look at you?
  • Brief glances or too long?
Does your child:
  • Show preference for main carers? Greet them after absence?
  • Come to you for a cuddle?
  • Like rough and tumble games?
How does your child respond to people:
  • Family members?
  • Others – Adults?
- Children?
Does your child initiate:
  • Interactions/conversations?
  • Mutual sharing?
  • Does your child have a friend?
  • What do they do together?
  • Does you child conform to/show
interest in peer fashions?
  • Has your child ever been bullied?
  • Does you child know how to behave in familiar situations?
  • Is your child over friendly?
  • How does your child respond if s/he is hurt?
  • What does your child do if someone else is upset?
  • What does your child do when someone else is happy?
  • Does your child want to share interests with other people?
PLAY AND IMAGINATIVE ACTIVITIES
Concerns now or in the past
What does yourchild like to play with?
Does or did your child ever use your hand to help him e.g., play with a toy?
Imaginative activities: does/did your child
  • Play with toys (e.g., interest in cars, train, dolls)
  • Play with household equipment
(e.g., using it for real purpose)
  • Hold dolls, toy animals as if real and hugs or kisses it?
  • Follow simple sequences of play with toys (CHAT 18-24 months)
  • Pour out and gives other person cup of tea spontaneously (CHAT example)
  • Follow and extend longer sequences of play
Imitation skills: does/did you child
  • Like to copy what you or others do? Clapping, making faces?
  • Wave bye-bye at 2 years?
  • Initiate daily activities at home?
Does your child show interest in other children
  • Like to play games of pretence with other children, not just imitating or putting on the clothes?
Does your child engage in role play
  • Alone
  • Copy other children or videos
Does your child like music? /









NURSERY/SCHOOL
  • Activities and progress
  • Learning new skills
  • Reading, comprehension, inference
  • Fine motor skills
  • Practical skills
  • Interactions, adults, peers
  • Compliance
  • Motivation
  • Socialisation

INTERESTS, ACTIVITIES AND BEHAVIOUR
Overall pattern of activities
What does your child do if left to choose?
  • Engage only in repetitive activities
  • Has some varied interests but repetitive activities are a prominent part of child’s repertoire when not led by others
  • Activities variable and flexible when not directed
/

ATTENTION, ACTIVITY LEVEL, BEHAVIOUR
  • Attention span
  • Motor activity
  • Impulsivity
  • Temper tantrums
  • Noisiness
  • Aggression, destructiveness
  • Throwing objects
  • Variation with setting

ROUTINE AND RESISTANCE TO CHANGE
Does your child
  • Get upset if routines are changed?
  • Have any special objects s/he likes?
  • Is your child interested in a special thing? e.g., lights, switches, wheels?
  • Are there any particular or unusual fears, anxieties?
/
SENSORY RESPONSES
Are there any unusual responses to:
  • Sounds e.g., loud noises or fascination with sounds?
  • Visual e.g., bright lights, spinning wheels, twisting objects?
  • Mouthing or smelling objects?
  • Scratching, tapping, breaking objects?
/
UNUSUAL BODY MOVEMENTS
  • Jumping, flapping
  • Rocking, spinning
  • Tip-toe walking
/
MOBILITY
  • Walking, climbing
  • Riding a bike
  • Playing ball

INDEPENDENCE SKILLS
  • Eating
  • Toilet training
  • Washing
  • Dressing
  • Sleep
  • Awareness of danger

LEVEL OF INDEPENDENCE
Need for / extent of supervision
  • At home
  • Outside the home
  • Shopping
  • Approach/response to unfamiliar adults
  • In nursery/school
/
COGNITIVE ASSESSMENT
Source of info:
  • Development level
  • Assessment used
  • To be arranged

PHYSICAL EXAMINATION
  • Date performed
  • Doctor
  • To be arranged
/
VISION
  • Any concerns?
  • Referral to be arranged

HEARING
  • Any concerns?
  • Date of assessment
  • Referral to be arranged

OBSERVTIONS DURING THE COMMUNICATION CLINIC: Name:

Date:

Communication and Language: to include
Response to name
Gestures
Initiation of Communication
Prosodic features
Language samples
SOCIAL INTERACTION: to include
Reciprocal smile
Eye contact
Turn taking/sharing
PLAY AND EXPLORATION OF THE ENVIRONMENT: to include
Interest in toys
Imaginative play
Sharing a book
Drawing
Solitary play
BEHAVIOUR: examples of
Repetitive behaviours
Unusual body movemtns and motor mannerisms
ATTENTION AND ACTIVITY LEVEL
Fleeting
Rigid attention to own choice of activity
Single chanelled
Integrated attention for a short time
Integrated attention – well controlled
GENERAL COMMENTS
Passivity aloofness
Appearance
Level of co-operation

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