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CONFIDENTIAL CONFIDENTIAL Diagnostic ReportName: AKClinicians:Jenna Didier, B.A.DOB:05/22/2004.Age: 8; 9Supervisor:Lynn Calvert, M.A., CCC-SLPAddress: XXXXXXDiagnosis:Asperger’ SyndromeXXXXXXX Phone: XXXXXXDate:March 1, 2013Background InformationReferral and Complaint AK, an 8-year, 9-month-old male, was evaluated at the Eastern Illinois University (EIU) Speech-Language Hearing Clinic (Clinic) on March 1, 2013. He was referred to the clinic by Ms. K, his mother. Ms. K’s concerns include recurrent behavior issues in the school setting, attention span, and social skills.Birth and Developmental History Mrs. K, AK’s mother, reported a premature pregnancy at 36 weeks with a normal delivery. At delivery AK weighed 3 pounds and 9 ounces, with precipitous saline and glucose levels. He experienced breathing difficulties and hypospadias, a malformation of the urinary system. He spent one week in the hospital after birth. AK experienced acute colic until the age of 18 months, which resulted in a soft gag reflex. Mrs. H reported that all of AK’s developmental milestones were reached within normal limits, except speech and language. AK was evaluated at 3 years of age by Eastern Illinois Area of Special Education (EIASE) who recommended that AK receive speech therapy. Mrs. K reported no other speech, language, or hearing problems in AK’s immediate family; however, he has one cousin with Asperger’s and attention deficit-hyperactivity disorder (ADHD). Mrs. K reported that AK is potty-trained; however, he still struggles with bedwetting. He has achieved up to two months of extended ‘dry periods’ with no wetting accidents, then wets the bed for up to two weeks consecutively. No other serious medical conditions were noted. Family and Medical HistoryReports regarding family history indicated that AK’s paternal cousin was diagnosed with Asperger’s syndrome and mild schizophrenia at the age of 13. No other family history was reported. Mrs. K reported ear infections at 9 months, ear drainage, and a minor head laceration in December 2005 which required stitches. AK also underwent surgery to repair his urinary system in 2005. In November 2012, Dr. P, AK’s pediatrician, suggested that AK may have attention deficit hyperactivity disorder (ADHD) and Asperger’s syndrome. A formal evaluation has not been conducted for the suspected disorders. AK is currently taking multi-vitamins with iron, fish oil tablets, and caffeine. He is currently not taking any prescribed medications. Academic History and ServicesAK received speech language services at Eastern Illinois University (EIU) Speech-Language-Hearing (Clinic) in the summers of 2009 and 2010. Therapy targeted articulation and all goals were met in summer of 2010.AK attended and repeated kindergarten at XXXX Elementary School in XXXX, Illinois. The family moved to XXXX, IL in 2011 where AK attended XX XXXX Elementary School for first grade. He is currently in second grade in a regular education classroom with an Individualized Education Plan (IEP) for speech and language impairment. AK receives speech therapy twice a week for 20 minutes each session. Pragmatic goals are the primary focus of intervention. Ms.P, AK’s school speech-language-pathologist, reported that AK is able to explain pragmatic situations and describe what action should be taken when “things go wrong,” but has difficulties with functional carryover. For example, Ms. P reported that one of AK’s past goals was saying “sorry” when appropriate. AK is able to say sorry for inappropriate behaviors, but he continues to display the same behaviors after recognizing that they are inappropriate. Ms. P also reported that AK often speaks off topic and talks about topics that are not of interest to most second graders. She stated that AK has a vast vocabulary and peers to not remain interested in conversations with him due to his vocabulary. Observations of AK’s impulsivity, inability to stop himself from talking out of turn, and staying on task were concerns expressed by Ms. P.During the second quarter, AK received an A in Mathematics, B’s for English and Science, and a C for Reading. He also received a rating of excellent for Art, good for Music and satisfactory for Physical Education. AK’s teacher, Mrs. M, stated that AK’s academic performance is average. She stated that his reading skills are good, but that he displays comprehension deficits. For example, when asked a comprehension question regarding a reading, he often changes the topic of the question and fixates on specific topics. AK sometimes discusses fantasy situations as being real.Social/BehavioralMs. K reported that AK is generally sociable, but prefers one-on-one interactions. AK becomes frustrated and aggressive when ideas of peers do not correlate to his ideas. During his emergent years, incidents of biting occurred during frustration; however this behavior has decreased. Ms. K reported that AK displays disruptive behavior at times in the home and has difficulties self-managing projects and tasks. Ms. K reported that at times AK has difficulty following two to three step directions, and forgetting tasks before completion. AK also displays situational anxiety and impulsivity. These behaviors are often seen when AK’s daily routine is interrupted. Ms. K reported that their daily morning and after school routine are consistent and if interrupted, AK will become upset, but usually copes with his frustration. Mrs. M indicated that similar behavioral issues have been observed in school. She described AK’s behavior as being impulsive and stated that AK requires additional one on one attention. AK sits on a sensory pad at school, but Mrs. M stated that she does not know if it is helpful because AK tends to play with it. Mrs. M stated that AK’s classroom behavior is socially inappropriate at times. For example, AK will blurt out socially inappropriate comments and tends to correct his teacher, peers, and others. However, he is sensitive when comments are directed toward him and becomes emotional. Mrs. M stated that AK follows their classroom routine, and adjusts with minimal support if the routine is altered. AK’s school progress report indicated that he experiences difficulties with social and emotional learning (e.g. respect of others, solving problems in a positive manner, following classroom rules, working without disturbing others, etc.). Also, the progress report noted that AK is frequently off task and that his behavior is impacting his academic environment.According to Ms. P, AK’s speech-language pathologist, he does not exhibit inappropriate attention behaviors during small group speech therapy sessions. However, she reported that AK frequently talks out of turn and talks over the adult that is teaching the material. Examination InformationA diagnostic evaluation of AK’s current overall language abilities was completed using a battery of formal assessments and informal observations. Results and observations are summarized in the following sections. Peabody Picture Vocabulary Test (PPVT-4)The Peabody Picture Vocabulary Test (PPVT-4) was administered to assess AK’s receptive vocabulary and one-word auditory comprehension. The PPVT-4 also provides a baseline of cognitive ability as it is highly correlated to intelligence quotient (IQ). Table 1: PPVT-4 ResultsRaw ScoreStandard ScorePercentileAge Equivalent 14610153rd9:1Mean = 100; Standard deviation = 15AK obtained a raw score of 146 that correlated to a standard score of 101, indicating average one-word receptive vocabulary and IQ. AK established a basal at the appropriate age level and reached a ceiling at a set above his age level. AK responded quickly to verbal stimulus items, and sustained attention and focus during the task. AK often repeated the words to himself before pointing to the stimulus item during the assessment, indicating self-talk skills. Also, AK provided additional information about stimulus items. For example, AK provided the names of the animals and instruments during the test. AK’s vocabulary serves as a strong foundation for continued learning, specifically in academic areas such as reading, writing, social studies, and language. Clinical Evaluation of Language Fundamentals-IVThe Clinical Evaluation of Language Fundamentals-Fourth Edition (CELF-IV) was administered to assess AK’s receptive and expressive language abilities. The CELF-IV is a comprehensive language assessment tool with subtests measuring sentence structure (syntax and morphology), word classes and word groups (semantics), understanding spoken paragraphs (comprehension), retrieval and repetition abilities (working memory). Results were as follows:Table 2: CELF-IV ResultsStandard ScoreScaled ScorePercentileConcepts & Following directions---937th Word Structure---825thRecalling Sentences---825thFormulated Sentences---716thSentence Structure---1163rd Word Classes-Total---1163rd Core Language88---21st Receptive Language101---53rd Expressive Language87---19th Mean Scaled Score = 10; Standard Deviation (SD) = 3; *>1SD below meanMean Standard Score = 100; Standard Deviation (SD) = 15The Receptive Language index is a comprehensive measure of listening and auditory comprehension. It is derived by summing the scaled scores of the following subtests: Concepts and Following Directions, Word Classes-Receptive, and Sentence Structure. AK received a Receptive Language score of 101, which places him in the average range of functioning. AK’s receptive language abilities were shown to be average on all subtests, suggesting he is able to listen and comprehend auditory stimulus. AK’s strengths included the ability to interpret spoken sentences of increasing length and complexity, as well as identify pictures that illustrate meaning of the spoken sentence. He was also able to identify two words that were related by semantic features. AK’s high score on this subtest can be attributed to the fact that he was not asked to formulate a verbal response, but instead only had to point to objects in order to complete each subtest. The Expressive Language index is an overall measure of expressive language skills. The subtests used to derive this score were the following: Word Structure, Recalling Sentences, and the Formulated Sentences. AK received an Expressive Language score of 87 which is considered low average. AK’s strengths were in the areas of syntax and morphology, as evidenced by his ability to listen to a spoken sentence of increasing length and complexity and repeat the sentence without changing word meaning, inflections, derivations or comparisons, or sentence structure. AK’s weakness on the Expressive Language index was on the Formulated Sentences subtest. During this subtest he was asked to formulate complete, semantically and grammatically correct spoken sentences with increasing length and complexity when given a word and an illustration. AK’s Expressive Language scores were lower because of his egocentric, off topic responses. Although many of his responses made sense and were grammatically correct, the test protocol did not allow full credit for many of AK’s responses. The Core Language index subtests measured AK’s general language ability which quantifies his overall language performance. The Core Language index is made up of both expressive and receptive language subtests. The subtests include: Concepts and Following Directions (9), Word Structure (8), Recalling Sentences (8), and Formulated Sentences (7). AK’s low average Core Language index score of 88 indicates that his overall language abilities are within normal limits for his age. This index is made up more heavily by the expressive subtests, which is why his overall Core Language index score was towards the lower range of average. AK’s average language skills are consistent with the language profile associated with Asperger’s syndrome (AS), as these individuals typically display normal to above average receptive and expressive language. Pragmatic LanguageThe Test of Pragmatic Language -2nd edition (TOPL-2) was administered to assess AK’s ability to interpret and react to social situations by analyzing, predicting, and solving problems. His results are as follows:Raw ScorePragmatic Language Usage IndexPercentile RankDescriptive Rating149025AverageTable 3: TOPL-2 ResultsMean = 100, Standard Deviation = 10, Average Range = 90 to 110AK achieved a pragmatic language usage index of 90, which is considered average. AK’s errors were a result of topic maintenance, pragmatic evaluation (i.e. justifying or giving rationale for a response), purpose (i.e. explaining, apologizing, persuading, and negotiating) and audience (i.e. tailoring his message to fit a different audience, and respective turn-taking between speaker and listener). For example, when AK was shown a picture of a girl upset at her friend because she told someone her secret, he responded by stating, “I’m sorry. I just couldn’t help myself. Sometimes secrets are secrets. I told them not to tell anyone.” When asked how he knew what the friend might say, he responded, “It’s just a stupid secret. What’s the big deal?” AK’s comments often reverted back to himself and how they related to his own life, instead of stating what the people might say in the specific illustration provided. Also, AK changed the topic when asked to interpret questions. For example, AK was shown a stimulus picture of a boy that upset a girl by telling her to hurry up. The correct response for this stimulus was for the boy to apologize. A second question was asked, “How do you know that what Matt says might work?” AK responded, “Because. It’s not the end of the world. Like, every time my friends build a Lego ship they never want to destroy it and I’m like, you can build it again. It’s not the end of the world.”Although AK’s score was within the average range on the TOPL-2, it should be taken into consideration that he has received previous speech therapy to target specific social situations. As previously stated, Ms. P reported that AK is able to explain scenarios, but displays difficulties transitioning the skill to functional situations. Executive Functioning Executive functions (EFs) reflect a cluster of metacognitive skills rooted in the prefrontal cortex of the frontal lobe, which form the foundation of metacognitive skills required for self-regulation and self-awareness. EFs include organization and planning, flexibility and adaptation, task initiation and persistence, and anticipation and prediction. EFs require a foundational development of attention, inhibition, and working memory. These foundational EF skills progress in a hierarchical manner, beginning with attention. When attention is impaired, inhibition and working memory are going to be impaired as well. Disordered development of executive functions contributes to ineffective problem solving and social interactions, disrupted language use, and overall diminished development of independence and self-regulation. The Behavioral Assessment of Dysexecutive Syndrome for Children (BADS-C) assessed AK’s executive functioning skills through six subtests. Scaled scores for the subtest on the BADS-C have a mean of 10 and a standard deviation of 3. Scaled scores ranging from 7 to 13 are considered average. The overall scaled score is comprised of all six subtests and has a mean of 100 with a standard deviation of 15. An overall scaled score ranging from 85 to 115 is considered to be average performance. Tables 4 and 5 below summarize test results. Table 4: BADS-C Subtest ResultsSubtestsRaw ScoreAge-Scaled ScorePlaying Cards Test34*Water Test 47Key Search Test210Zoo Map Test 1311Zoo Map Test 255*Six Part Test24**Below average scaled scoresTable 5: BADS-C Overall Test ResultsOverall ScoresResultsTotal Age-Scaled Score41Overall Scaled Score60Overall ClassificationImpairedThe six subtests that assessed executive functioning skills included the Playing Cards Test, Water Test, Key Search Test, Zoo Map Tests 1 and 2, and Six Part Test. The Playing Cards Test assessed AK’s cognitive flexibility by evaluating how well he could shift from one rule to another while naming cards. AK was required to say yes or no when presented with cards based on the provided rule. AK’s performance yielded a scaled score of 4, which was two standard deviations below the mean, depicting below average performance. Difficulty shifting between tasks could result in difficulties transitioning between class assignments and tasks. The Water Test assessed AK’s ability to formulate a plan of action in order to solve a novel problem. The clinician presented a set of objects to AK including water, a large beaker, a tall beaker, a wire, and a plastic tube with a screw top. AK was required to retrieve the cork from the tall beaker using the tools provided without touching the beakers with his fingers. AK obtained a scaled score of 7, which was within the mean, reflecting low average performance and rigid thinking. Problem solving difficulties and rigid thinking could result in the inability to independently create solutions or multiple solutions to common classroom problems. The Key Search Test assessed AK’s ability to plan a systematic and efficient search of a field. AK was given a piece of paper with a square drawing to represent the field and was given a color pencil to complete the search. AK was instructed to search the field until he was certain he could find the key no matter where it was. The Key Search Test required AK to monitor his own performance. AK obtained a scaled score of 10, which was the mean, indicating average performance. During this test, AK did not plan or develop a systematic drawing, however; he did search all quadrants of the square. Poor planning could result in decreased maximized potential with school work and homework. The Zoo Map Tests 1 and 2 assessed AK’s planning ability when given instructions regarding the specific animals to visit and rules regarding path usage (e.g., could only use white paths once and dotted paths as many times as needed). The Zoo Map Test 1 is a demanding open-ended task that provides little structure. AK was required to visit specific places within the zoo, but in any order of his choice. AK’s scaled score was 11, indicating average performance. The Zoo Map Test 2 is rule-governed. AK was required to visit specific places within the zoo and this time in a specific order. The Zoo Map Test 2 required increased organizing and planning in comparison to the Zoo Map Test 1. AK’s scaled score of 5 was more than one standard deviation below the mean, indicating below average performance. AK’s performance on the Zoo Map Test 2 further substantiated his lack of planning and organizing. The Six Part Test required AK to plan, schedule tasks, and monitor his performance. AK was given three different colored tasks with two parts each and was instructed to try to complete a portion of each of the six parts within a 5-minute time frame. Two rules were required; AK could not complete both parts of the same task consecutively, and he was required to work from each pile. AK’s performance yielded a scaled score of 4, which was two standard deviations below the mean, depicting below average performance. Although the directions were given and the rule that all stacks must be worked from was reiterated, AK was fixated and worked on one stack for the 5-minute time frame. The Six Part Test once again displayed planning, organizing, and self-monitoring deficits that may be problematic to AK’s functionality. AK’s performance throughout the BADS-C warranted an overall scaled score of 60, which was within one standard deviation below the mean and indicated impaired executive functioning skills. AK displayed difficulties with planning, impulsivity, anxiety, and self-monitoring during many of the subtests. He often started the test without listening to the directions in completion, without having a complete understanding, and without planning. Observations of AK’s behavior indicate possible difficulties with activities and school tasks that require shifting and organizing. For instance, instead of planning, AK impulsively began the Zoo Map Test 1 and 2. He also wanted to change the rules to fit his interest and desires. When attempting to solve the problem during the Water Test, he was unable to independently plan a course of action; instead he impulsively started picking up the tools and used them incorrectly. After becoming aware that his techniques were ineffective, he perseverated and continued the attempts. During the Six Part Test, AK perseverated on one part of one task for the entire 5-minutes (e.g., writing the names of the objects displayed on cards), which further illustrates AK’s inability to think flexibly and switch between cognitive thought processes. This behavior could affect AK’s ability at home and school when performing new tasks, changing tasks, or engaging in tasks of no interest. Behavior Rating Inventory of Executive FunctionThe Behavior Rating Inventory of Executive Function (BRIEF) was given to Mrs. H, and Mrs. M, and Ms. P. The BRIEF is a questionnaire and assesses executive functioning skills in natural environments (e.g., home and school) through the indirect measure of parent and teacher report. Responses to questionnaire items are used to calculate T-scores. Higher T scores indicate greater degrees of executive dysfunction. T-scores above 65 are considered clinically significant. T-scores between 50 and 65 are considered to be borderline significance. Ms. P reported that she was not confident in answering some of the questions asked on the BRIEF, which resulted in 13 questions left blank. Due to the incomplete responses, Ms. P’s BRIEF protocol could not be scored for analysis purposes.The BRIEF requires the rater to rank the frequency of observed occurrences of executive function skills, including: inhibition (i.e. controlling one’s impulses), shifting (i.e. switching between tasks), emotional control (i.e. regulating emotions), initiation (i.e. starting a task), working memory (i.e. holding on to information in order to manipulate it), planning/organization (i.e. organizing a plan), organization of materials (i.e. maintaining an orderly environment), and behavioral monitoring (i.e. evaluating one’s performance). BRIEF results are reported in three different areas. The Behavior Regulation Index (BRI) measures the ability to monitor and inhibit behaviors and emotions, and is composed of three component scores: Inhibit, Shift, and Emotional Control. The Metacognition Index (MI) assesses the ability to systematically solve problems, and includes: Initiation, Working Memory, Planning/Organization, Organization of Materials, and Monitoring. The global Executive Composite (GEC) combines the BRI and MI scores to summarize an overall executive function profile. T-scores of 65 or higher are considered clinically significant and in need of remediation; higher percentile scores reflect more impaired areas. Mrs. H completed the BRIEF Parent Form and Mrs. M completed the BRIEF Teacher Form. Results were as follows:Table 6: BRIEF Scoring SummaryScaleMrs. HMrs. MT-ScorePercentileT-ScorePercentile Inhibit78*9869*93 Shift71*9774*97 Emotional Control68*8175*95Behavioral Regulation Index (BRI)71*9674*96 Initiate69*9875*99 Working Memory80*9970*96 Plan/Organize73*9874*97 Organization of Materials649274*98 Monitor567970*96Metacognition Index (MI)74*9875*98Global Executive Composite (GEC=BRI+MI)74*9776*97*T-scores of 65 and above are statistically significant.Table 7: BRIEF Negativity and Inconsistency Scale ResultsScaleMrs. HMrs. MNegativityAcceptableAcceptableInconsistencyAcceptableAcceptableResponses met the Acceptable level for Inconsistency and Negativity for Teacher and Parent-Report ratings. These responses reflected that respondents answered similar questions in a consistent manner and that respondents were not unusually negative while answering select items. Both raters corresponded to clinically significant T-scores for the following subtests: Inhibit, Shift, Initiate, Working Memory, and Plan/Organize. Results indicate significant degrees of executive dysfunction with regard to these components. AK’s inability to inhibit a response is evident in his frequent outbursts and inappropriate comments. During informal observations and parent/teacher interviews, AK has a difficult time transitioning from one task to the next. His fixation with time also affects his ability to move from one activity to the next. Initiating events are difficult for AK. Both raters scored AK with an ‘often’ when asked if AK ‘needs to be told to begin a task,’ as well as ‘has trouble getting started on homework or chores.’ AK’s Working Memory and Plan/Organize scores correlate with his scores on the Zoo Map subtest within the BADS-C. On the BADS-C, AK was unable to accurately plan in order to complete a task. Both rater responses indicated a clinically significant T-score for the BRI, MI, and GEC composite scores, suggesting that AK has an overall executive dysfunction.Mrs. M did not rate AK within normal limits on any of the subtests. However, Mrs. H rated AK within the normal limits (T-score below 65) on the Organization of Materials subtest suggesting that he is able to maintain an orderly environment. However, Mrs. M’s T-score of 74 suggested that he is not able to maintain order in the classroom. All aspects of EF are important in the development of a child’s ability to manage behavior at home, school, and in the community, and to understand important social cues from external environment (Richard & Fahy, 2005). Overall, Mrs. H and Mrs. M’s BRIEF responses imply that AK’s degrees of executive dysfunctions are observed in both environments (home and school) and are consistent with other standardized assessments and clinical observations. Behavioral ObservationsAK is an active and intelligent boy. Various behaviors were noted on the day of the evaluation. AK was friendly and talkative and had good eye contact. He was eager to display his knowledge by sharing comments and correcting others. If the clinicians asked AK a question he would sometimes state “I already told you that.” Also, he displayed a fixated interest of animals and Beyblades. AK shared his snacks with the clinicians and interacted well with the clinicians. As difficulty of tasks increased, AK displayed an eye-roll and licked his lips repeatedly, indicative of nervousness and anxiety. Kowalski (2002) reported that 42% of children with AS experience anxiety and 26% are diagnosed with a comorbid tic disorder, such as AK’s eye-roll. Throughout the evaluation, AK fidgeted in his chair and stood up and moved side to side, but remained overall focused. During the assessments he often made additional comments about test items or strayed off topic. Also, AK displayed a lack of social reciprocity by relating several topics and test items to himself. Towards the end of testing, he requested several breaks (e.g. restroom, ate snacks, and drank juice) and frequently referred to the time and his interest in going to lunch. Taking breaks and racing the clinicians in the hallway seemed to release stress and anxiety for AK. Clinical Impressions Information obtained through parent interview, AK’s performance throughout the evaluation, and behavioral observations indicated a behavioral profile consistent with Asperger’s syndrome with Executive Dysfunction. The Diagnostic and Statistical Manual of Mental Disorders 4th Edition Text Revised (DSM-IV TR) defines Asperger’s syndrome as:Qualitative impairment in social interaction, as manifested by at least two of the following:Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction.Failure to develop peer relationships appropriate to developmental level.A lack of spontaneous seeking to share enjoyment, interests, or achievements with other people. Lack of social or emotional reciprocity. Restrictive, repetitive, and stereotyped patterns of behavior, interests, and activities, as manifested by at least one of the following:Encompassing preoccupation with one or more stereotyped and restricted patterns of interests that is abnormal in either intensity or focus.Apparently inflexible adherence to specific, nonfunctional routines or rituals.Stereotyped and repetitive motor mannerisms.Persistent preoccupation with parts or objects.The disturbance causes clinically significant impairment in social, occupational, or other important areas of functioning.No clinically significant general delay in language. No clinically significant delay in cognitive development or in the development of age-appropriate self-help skills, adaptive behavior (other than social interactions), and curiosity about the environment in childhood. Criteria are not met for another specific Pervasive Developmental Disorder or Schizophrenia. AK displayed multiple characteristics that support the diagnosis of Asperger’s syndrome. AK exhibited exaggerated oral expressions and impairments in lack of social reciprocity such as constantly relating topics to himself, as defined above in characteristic A-1 in the DSM-IV TR. Mrs. M and Ms. P reported AK to have an inability to form friendships with peers and prefers one-on-one and small group interactions (characteristic A-2). Mrs. H reported that during play time with peers, AK is uncooperative if his friends want to engage in an activity that is of noninterest to AK (characteristic A-3). Results of the BRIEF support significant impairments in social and emotional skills such as being able to take another individual’s perspective, negotiate conflicts in friendships, and support peers (characteristic A-4). AK displayed a fixated interest with animals, the time, and Beyblades (characteristic B-1). Mrs. M reported deficits in social understanding and the use of social language. This was also evidenced by results from the TOPL-2, which revealed an inability to stay on topic and relate pragmatic judgments to others (characteristic C). Deficits in executive functioning skills further impact AK’s functionality and social life, especially in school. AK’s inability to organize and shift between tasks requires additional attention from his teacher and family. AK’s outbursts and difficulty interacting with peers and others caused disruptions in class as reported by his teacher. AK experiences high anxiety likely due to impairments in social language and executive functioning skills. The DSM IV TR identifies those with Asperger’s syndrome as having “no significant general delay in language.” AK displayed average language skills in the areas of content, form, syntax and morphology as evidenced by results of the PPVT-4 and CELF-IV subtests. In addition to Asperger’s syndrome, AK demonstrated executive function difficulties as evidenced by results of the BADS-C, BRIEF, and informal observations. Executive Dysfunction involves impairment in metacognitive skills such as attention, planning, organizing, and regulating one’s behavior. Executive function deficits have been documented in several childhood disorders including autism and Asperger syndrome (Nyden, Gilberg, Hjelmquist, & Heiman, 1999).Recommendations Based on results from formal testing and informal observations, it is recommended that the following suggestions be implemented at home, school, and in speech-language therapy. Home RecommendationsAsperger’s syndrome is characterized by an awareness of differences and frustrations with the inability to know how to act in social situations. Mrs. H reported AK experiences increased anxiety. AK’s behavior should be carefully monitored and consultations with AK’s medical doctor should be scheduled to determine if medication (i.e., anti-anxiety or anti- depressant) becomes necessary as AK grows older. If left untreated, AK’s anxiety could hinder his ability to reach his full learning potential (Richard & Fahy, 2005). It would be beneficial to provide AK with a visual organizer or to-do list that allows him to check off completed tasks and have a visual reminder of remaining steps required to reach a final goal. For example, having a to-do list for AK’s morning and nightly routines may relieve frustration.In order to facilitate more age appropriate behavior, implement reward systems for desirable actions rather than punishing negative ones. Specifically state expectations to teach AK what to do in situations, rather than what not to do. For example, prior to playing outside with neighborhood friends, remind AK that if he plays nicely, he will earn video game time, or a snack. Enforce this system consistently (i.e., only provide the reward if expectations are met).Say things such as, “Get ready to listen,” or, “Are you ready to watch?” in order to gain AK’s attention before giving new instructions (Richard & Fahy, 2005). To eliminate misunderstanding, provide simple one to two-step directions when asking AK to complete tasks. Eliminating the amount of directions will enable AK to follow through with performing a task more accurately. Motor activity is known to reduce stress and anxiety. It may be beneficial to enroll AK in an exercise program. Exercise activities could include running, swimming, and playing outside. To enhance language development, it may be beneficial to play games that involve language in a fun, non-academic way, such as Catch Phrase, Scattegories, Apples to Apples, and Taboo. Games such as Guesstures could be utilized to promote awareness of nonverbal language.Speech-language services should continue to address pragmatic and executive functioning skills. School RecommendationsAK demonstrated difficulty organizing his thoughts and generating a sequence of steps to complete a task. It would be beneficial to provide AK with a visual organizer or to-do list that allows him to check off completed tasks and have a visual reminder of remaining steps required to reach the final goal.Instruct AK to repeat the directions to confirm his understanding before initiating an assignment or task. Discussing the steps necessary to reaching the intended outcome with AK could foster the development of efficient organizational skills. Allow AK to have purposeful, physical breaks throughout the school day. This will likely decrease AK’s restlessness and need to move about the classroom at inappropriate times (Brown, 2002). For example, allow him to take notes to the office, walk to the teacher’s desk with questions rather than raising hand during quiet work time, and standing quietly by his desk instead of sitting while the teacher instructs. Implement an incentive program to motivate AK to complete his work accurately and independently. For example, if AK finishes his work in a timely manner, he may earn computer time or other desired activities. A verbal phrase such as “Get ready to listen,” or “Are you ready to watch?” should be given in order to gain AK’s attention before beginning a lesson or giving directions (Richard & Fahy, 2005). Speech-Language Therapy RecommendationsInappropriate social behaviors displayed during class should be discussed during AK’s scheduled speech-language therapy sessions (e.g. what behaviors were displayed and how the situation could have occurred appropriately). Role-playing games of social situations should be used to facilitate practice of social skills. AK should be required to modify any inappropriate behavior. Facilitate generalization of these pragmatic skills by requiring AK to draw conclusions based on social situations at recess or lunchtime. Discuss the emotions and feelings of others and how he should respond to appropriately apply pragmatic skills. Conduct therapy in novel environments with unfamiliar communication partners to generalize social pragmatic skills to real-life situations. Practicing pragmatic skills in a more functional setting will increase AK’s ability to carry-over his skills.Implement activities that require AK to develop a plan for successful completion. For example, provide AK with a task such as the Trail Making task and ask him to complete the activity using a thorough, thought out plan. Teach AK self-talk strategies to provide him the skills needed to independently complete all steps required in a specific task. Using a checklist to complete tasks and to increase use of planning skills may also be implemented. See Appendix A for an example checklist (Richard and Fahy, 2005).Refer to Think Social by Michelle Garcia Winner (2008) for visual charts and activities to help increase AK’s self-awareness and inhibition. This resource provides numerous activities, as well as printables and goals to use during therapy for various pragmatic and executive functioning skills.Specific weaknesses observed during the diagnostic process that should be addressed in speech language therapy include: inhibition, self-awareness, and planning. Activities and goals for these areas can be found in the Think Social resource (Winner, 2008).It was a pleasure to meet and evaluate AK. We hope these recommendations prove to be helpful and provide further success. Please do not hesitate to contact the Clinic with any questions. Jenna Didier, B.A. Jillian Norman, B.S.Lynn Calvert, M.A. CCC-SLPGraduate Clinician Graduate ClinicianFaculty SupervisorReferencesAmerican Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC.Brown, M. L. (2002). The ADHD companion. LinguiSystems, Inc.: East Moline, IL.Kowalksi, T. (2002). The Source for Asperger’s Syndrome. East Moline, IL. LinguiSystems. Nyden, A., Gilberg, C., Hjelmquist, E., & Heiman, M. (1999). Executive function/attention deficits in boys with Asperger syndrome, attention disorder, and reading/writing disorders. Autism 3(3), 213-228. Richard, G. J., & Fahy, J. K. (2005). The Source for Development of Executive Functions. Moline, IL: LinguiSystems.Garcia Winner, M. (2008). Think Social: A social thinking curriculum for school-age students. San Jose, CA: Think Social Publishing, Inc.Appendix A:Example Planning Checklist 120967596520Write my name at the top.Read the directions.Identify the task.How many blanks are there to fill in?Where do I get the answers?Start with number one, then number two, etc.Work until all the blanks are filled.Double check my work.0Write my name at the top.Read the directions.Identify the task.How many blanks are there to fill in?Where do I get the answers?Start with number one, then number two, etc.Work until all the blanks are filled.Double check my work.Fahy and Richard, 2005. ................
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