SPEECH-LANGUAGE PATHOLOGY

COMPREHENSIVE EXAMS

SPRING SEMESTER 2008

MORNING QUESTIONS

8:00 A.M – 11:30 A.M.

INSTRUCTIONS

  1. Put your Z ID number in the header of each page
  2. Do NOT put your name of the exam
  3. SAVE YOUR WORK FREQUENTLYto the desktop of the computer you are on
  4. When you have finished, upload your document to the appropriate assignment in blackboard

ADV PRAC: EDUC S L P SECTION 1. (There may be more than one person reading your answers).

  1. An ! should appear in the grade book to indicate the file was uploaded.
  2. Delete files off desktop.
  3. You must earn 75% on each question in order to pass.
  4. LEAVE THIS PACKET WITH THE PROCTOR BEFORE LEAVING THE ROOM.

Child Scenarios

Over the last two years, you have worked for a placement agency that contracts with clinics and schools that provide services to children. Some of the children you have or will see include

  1. Clinic -- Jason (3;9)
  2. School -- Zachary (6;6)
  3. Early Intervention -- Johnny (2;3)

Please answer the following questions about these patients.

#1 Fluency (65 points)

According to his mother, Jason G., a 3 year 9 month old male is stuttering. Jason reportedly began stuttering at two years of age. Jason has been evaluated at “The We-Fix-Em Speech and Hearing Clinic.” During this evaluation you have the opportunity to observe Jason and his mother interacting for about 15 minutes. In addition, you observe a 30-minute interview with Mrs. G and spend an additional 60-minutes watching Dr. Schwartz evaluate Jason.

During the 15 minute interaction with Mrs. G., Jason produced 300 syllables of conversational speech and exhibited 9 sound/syllable repetitions, 12 sound prolongations, 10 phrase repetitions and 20 multi-syllabic whole-word repetitions. During your observation you noted that the mother provided her son with enough time to respond to her questions and did not interrupt her son during conversation.

Upon completion of your initial observation, you spend some time interviewing Mrs. G. The mother provided a lot of information although only the highlights will be presented. Mrs. G. stated that there is a family history of stuttering. Reportedly, Jason’s maternal grandfather and paternal uncle stuttered when they were younger and continue to stutter. The mom stated that Jason’s stuttering is not always there and actually disappeared for a period of time. However, when his stuttering came back, he was getting stuck more and making “weird facial expressions” when compared to when the problem first started. Mom noted that her daughter Julie age 10, produces a lot of ums, y’knows, and often sounds disfluent. Reportedly, Jill and Jennifer, age 14 try to help their brother by completing his sentences and filling in words when he “gets stuck.” Motor development, speech and language development and medical history appear unremarkable.

When Dr. Schwartz conversed with Jason, you noted 18 sound/syllable repetitions, 21 sound prolongations, 36 multi-syllabic whole-word repetitions, and 12 phrase repetitions. The aforementioned observations occurred during a 300-syllable conversation sample.

  1. List all of the objective (including calculations) and subjective information that you will use to determine if Jason has a stuttering problem. Remember, in addition to individual calculations made while observing at a specific time, you need to report the summary data to the parents from the entire evaluation. (25 points)

Objective Info.

  • Frequency of occurrence of stuttering with mom: 7%
  • Frequency of occurrence of stuttering with clinician: 13%
  • Average frequency of occurrence of stuttering: 10%
  • SPI with mom: 57%
  • SPI with clinician: 54%
  • AverageSPI: 56%
  • Frequency of occurrence of between-word disfluency with mom: 10%
  • Frequency of occurrence of between-word disfluency with clinician: 16%
  • Average frequency of occurrence of between-word disfluency: 13%

Subjective Info.

  • Fam Hx (grandfather and uncle) of no recovery from stuttering
  • Time since onset is 1 year 9 months
  • the mother provided her son with enough time to respond to her questions and did not interrupt her son during conversation
  • Facial grimaces = associated behavior = problem more chronic
  • Mother reports the problem is getting worse, periods of fluency are shorter = PROBLEM MORE CHRONIC
  • Potential Environmental Demands for Communication – Sharing Daily Experiences.
  • Communicative demands when conversing with his sister

2. Mom says “Does my son really have a stuttering problem?” Please provide your reply as you would explain it to the mom. (10 points)

After taking the time today to speak with you and evaluate Jason, I have been able to make some decisions regarding the concerns you have with Jason’s speech. Throughout the evaluation, I kept track of the different types of disfluencies that I noticed in his speech. Some of these disfluencies that I noticed are actually disfluencies that are considered normal between word disfluencies. For example, when Jason repeats multisyllabic words and phrasesthese are normal disfluencies and do not contribute to the differentiation of children who stutter and those with normal disfluency. However, on average Jason has 13% of these between word disfluencies which is high compared to the average of 4 to 6% between word disfluencies(Yairi 2004). The other disfluencies that I noticed in Jason’s speech are unique because they actually break up his words. Jason is breaking up a word by repeating a sound in a word such as g-g-g-going or prolonging a sound in a word such as mmmmommy. Throughout the session today, Jason had an average of ten stuttering disfluencies out of every 100 syllables spoken. Normally fluent children exhibit approximately one or less stuttering like disfluencies per 100 syllables. So, at the evaluation today we have found that Jason does stutter and he stutters more often than typical fluent speakers.

3. Mom says “Jason is really young, do you think he will grow out of the problem?” How will you answer this question and what information will you use to justify your decision? Be specific (10 points)

In regards to your question whether or not Jason will outgrow the problem, I can not give you a definite answer. However, there are many factors to take into consideration in regards to him outgrowing the problem. One prognostic indicator to consider is how long Jason has been stuttering and within this time period if there’s been a change in the frequency of stuttering. Yairi observed that a decrease in the frequency of stuttering from 7 months post onset to one year post onset is a major prognostic indicator for recovery.Jason’s frequency of stuttering has increased over the past two years. Therefore, Jason has a decreased chance of natural recovery. Additionally, it has been found that girls recover sooner than boys which is a negative factor concerning Jason’s recovery. Another factor to consider in regards to whether or not an individual will outgrow stuttering is a positive or negative family history of recovery from stuttering. A biological link existsbetween stuttering and its recovery. You mentioned that Jason’s grandfather and uncle still exhibit disfluencies in their speech. Although these disfluencies may not be a high frequency, they still indicate that there’s a family history of no recovery from stuttering. I also found in the evaluation today that Jason produces sound prolongations (i.e. mmmmommy) slightly over half of the time he stutters (56%). A higher occurrence of sound prolongations is a negative prognostic indicator. Due to all of these negative prognostic factors, it is my clinical judgment that Jason will not outgrow stuttering without therapy.

4. What is your management plan for Jason? Provide a rationale for your decision. (20 points)

Jason G, is a 4-year old who has been stuttering for the past two years. In therapy, I would use a Fluency shaping behavioral approach to stuttering treatment. By the end of this program, Jason’s ultimate goal is spontaneous fluency.

Throughout the fluency shaping model, fluency is the major focus of therapy. At the beginning of therapy, a set of skills will assist Jason to reduce oral tension and overall increase his fluency. These fluency shaping skills include: initiating speech in a slow smooth manner, phrasing, connecting across word boundaries, and increasing vowel duration (Schwartz, 1999). Skills will be introduced to Jason one at a time. The clinician will have to use his or her clinical judgment to determine if specific skills work better for Jason and possibly focus therapy on those. Each skill will be practiced beginning with short utterances while describing pictures and gradually increasing each utterance in length and complexity all the way to conversation (Ryan, 1974). It is important in these early stages of therapy that Jason understands how and when to use the fluency skills so that he becomes responsible for his own fluency (Schwartz, 1999). In order to help Jason reach the goal of normal sounding fluent speech, it will be important for the clinician to focus not only on the fluency skills but also to be aware of Jason’s loudness, rhythm, and intonation (Neilson & Andrews, 1993). The fluency shaping behavioral approach views stuttering as a learned behavior and thus one can unlearn it through a set of positive reinforcement and negative feedback (Ingham, 1999). The clinician will begin by using continuous reinforcement and towards the middle to end of therapy use intermittent reinforcement. According to Ingham, extensive research has established that behavior maintained on intermittent schedules of reinforcement are more durable and more likely to generalize than behavior maintained on continuous reinforcement schedules (92). Also, as early as the first day of therapy, Jason will be given home assignments that reflect what was worked on in the therapy session.

Once Jason has an understanding of the set of skills to facilitate his fluency, the middle stages of therapy will work on applying these skills and shaping his speech from a slow rate to a natural rhythm. Activities in the middle stage of therapy will include longer picture descriptions (three to five sentences), monologues (30 seconds to two minutes), and short conversations (five to ten minutes). Throughout therapy, it is important that Jason takes control of his speech and become his own clinician accepting responsibility for any changes in his speech. Ingham states that the more control an individual has over more components of treatment, then the treatment has the potential of transferring outside the clinic (97). One way to approach self-control with Jason is to create a rating system of fluent speechand have him rate his speech. Jason can also take control over therapy by bringing in a favorite storybook for a picture description task. The fluency shaping approach views stuttering, no matter how severe, as failure. As Jason’s fluency increases, any associated behaviors should begin to decrease.

Towards the end of therapy, once Jason has reached a level of controlled fluency at the conversational level within the clinic, Jason may bring in his parents or siblings to converse/play with and practice his fluency skills. This will help Jason begin totransfer his skills by talking to individuals other than the clinician. If Jason brings in his siblings, this would be a good opportunity for the clinician to educate them on allowing them to provide Jason with sufficient time to complete his thoughts. After Jason experiences fluency with familiar listeners inside the therapy room, goals will target fluency with unfamiliar listeners. To continue transferring Jason’s skills to outside the therapy room, his homework assignments will reflect speaking situations with which he used to experience disfluency (i.e. speaking with siblings, friends, etc.). The clinician can start with having him set aside 10 minutes a day to have a conversation with his mom in which he controls his fluency. This should not be too stressing of a task for Jason since he appears to feel more comfortable talking to his mom. Homework assignments will then progress to situations where he feels least comfortable. The goal is for the controlled fluency to be practiced so much that it is maintained as spontaneous fluency across speaking situations. As Jason continues to practice his fluency at a conversational level inside and outside of the therapy room his maintenance should increase. As a level of spontaneous fluency is reached, any fears that Jason previously had associated with talking to his clients or teaching a class should be eliminated. He should no longer be fearful of his students thinking that he won’t know the information if he’s stuttering because he should not be stuttering by the time he leaves therapy. Additionally, as Jason becomes spontaneously fluent any emotional perspectives or reactions he had towards his stuttering should disappear since his stuttering is no longer present.

Goals: Beginning: Jason will demonstrate the fluency skill of elongating vowels in one sentence picture descriptions with 100% fluency. Middle: Jason will produce a one minute monologue with 99% fluency across 3 consecutive sessions.End: Jason will speak for 10 minutes in front of a group of 15 individuals in a classroom setting with 99% fluency across 5 consecutive sessions.

#2School service delivery (40 points)

Zachary is 6;6 and just started first grade. Academically, he is functioning as expected for his age. He has a history of ear infections with tubes inserted at 14 months and then again at 4 years. He spoke his first words at age two. Recent testing of his receptive language skills indicated he is functioning within normal limits. Expressive language testing results were inconclusive, because he continues to produce many sound errors that affect his intelligibility. An analysis of his speech indicated that he uses simplified syllable structures and produced very few consonant clusters.

In order to meet the No Child Left Behind requirements, the school district recently implemented benchmark testing on phonemic awareness. Zachary scored at the expected benchmarks for Letter Naming Fluency (quickly naming letters) and Letter Sound Fluency (quickly saying the sound letters make). He scored below expected benchmarks on Phoneme Segmentation Fluency (segment sounds in a word) and Nonsense Word Fluency (read nonsense words).

1. Write a timeline that take you, the student, and the team, from the parent’s written consent to the team decision to enroll in therapy. (6 points total)

The first procedure that would need to be accomplished to meet IDEA requirements would be to provide a written notification to Zach’s parents regarding the speech and language evaluation. I would evaluate him and have 60 days until the IEP meeting. I have 60 days to complete the assessment process and develop an IEP if warranted. After the assessment the IEP team meeting takes place. The parents must be informed of this meeting a minimum of 10 days prior. At the meeting the team discusses the decision to enroll Zach in therapy. If the team agreed to therapy, my timeline for implementing the IEP would be 30 days after the IEP meeting. However, Adam’s parents would have ten days following the IEP meeting to refute the IEP and deny services.

  1. Write two semester (4 month) therapy objectives for Zachary that will address his identified difficulties. (10 points total)
  2. What are two appropriate therapy approaches that will address Zachary’s identified communication difficulties (2 points each)? Describe each approach (5 points each) and explain why that approach is appropriate for Zachary. (4 points for each) (22 points total)
  3. What service delivery model/s will you choose for this student? (2 points)

The range of service delivery options for any student eligible for speech-language services includes:

From least to most restrictive:

1)Monitor: Monitoring requires the SLP to “check in” on their student’s progress. The student would be placed on the SLP’s caseload, to ensure adequate time. Monitoring would be used to ensure that the student has not lost a skill. This is the least restrictive service delivery option.

2)Integrate: This model requires the SLP to integrate therapy into the child’s daily environment. For example, the child may be working on greetings and the SLP may be conveniently on “bus duty” to integrate the greetings goal into a natural environment.

3)collaborative consultation: This service delivery option implements collaboration and consultation amongst professionals. The SLP would collaborate with the classroom teacher in a variety of ways such as team teaching lessons or 1 teach and 1 floats, to ensure students are understanding concepts.

4)pullout: This requires the SLP to pull the child out of class to receive therapy, either individually or in a small group. The child presents with a speech or language disorder, which is best served outside of the classroom (i.e. possibly beginning treatment of fluency in Adam’s case).

5)instructional: This service delivery model presents itself in the form of a self-contained classroom, where the student receives instruction all day. The SLP may be teaching lessons with the teacher. This is the most restrictive service delivery option.

#3Child Language (40 points)