University of Washington



|University of Washington |File #: |* |

|SPEECH AND HEARING CLINIC |Client: |Smith, Terry |

|4131 15TH Ave NE |DOB: |* |

|Seattle, WA 98105 |Parent/s: |* |

|206-543-5440 |Address: |* |

| | | |

| |Phone: |* |

SPEECH-LANGUAGE PATHOLOGY REPORT

|Date of Evaluation: |04/04/200X |

|Lead Clinician: |Student 1, B.S. |

|Asst. Clinician: |Student 2, B.S. |

|Interviewer: |Student 3, B.S. |

|Supervisor: |Laura Sargent, Ph.D., CCC-SLP |

HISTORY

Identifying Information, Referral source and Chief Concerns

Terry Smith, currently age 7 years and 5 months, was seen for a speech and language re-evaluation on April 4, 200X at the University of Washington Speech and Hearing Clinic (UWSHC). Terry was accompanied by Mrs. Smith. Terry was referred for the re-evaluation by his parents as he had received previous treatment at the UWSHC for articulation delay and pre-literacy skills. Mrs. Smith wanted to make sure that Terry’s articulation was age appropriate. Previously, Terry’s parents expressed concern over Terry’s reading skills and his phonemic awareness. Though Terry made excellent progress in Summer quarter 200X (details below), continued treatment for articulation and pre-literacy skills was recommended for fall quarter. Terry’s family chose to postpone further speech therapy at that time due to conflicts in scheduling. The purpose of this evaluation was to determine if treatment for speech and language should be re-initiated.

Medical

Terry’s medical history is relatively unremarkable, except for a sack of fluid that appeared at the back of his head and gradually recessed at four weeks of age. Mrs. Smith reported that Terry passed a hearing test at school two weeks prior to the evaluation. Terry has been having some trouble with his eyesight; Mrs. Smith mentioned that he should have his vision evaluated soon.

Developmental

Developmental milestones for motor and self-help skills were age appropriate. Delays in speech and language milestones were reported by Terry’s parents. First words occurred between 18 and 24 months of age and two-combinations appeared around 2 ½ years of age.

Social

Terry lives at home with his parents, a 10 year-old sister, Sally, and his 3 year-old brother, Jake. Mrs. Smith reports that Terry gets along well with his siblings. Occasionally, Sally corrects Terry’s production of certain words. Terry has experienced some negative reactions to his speech at school. For example, at the beginning of the year, some of his classmates told him that “he talked funny.” Mrs. Smith reported that he is aware of his articulation errors. For example, the night before the evaluation, Terry told his mom that he only needed to work on his /r/ and /l/ sounds. Mrs. Smith mentioned that she understands everything Terry says, with and without context, except for some words (e.g., the word rare); in these instances Terry will repeat the word until his mom understands, but with noticeable frustration.

Mr. and Mrs. Smith have implemented a happy/sad face sticker reinforcement system at home to motivate Terry and to help him be successful in certain activities. A vivacious boy, Terry benefits from running around the track after school. He also enjoys soccer, gardening, baking with his mom, and feeding and watering his chickens.

There is a paternal history of dysgraphia and dyslexia. Currently, Terry’s younger brother started attending the Experimental Education Unit (EEU) in January for expressive language delays.

Educational

Terry is in first grade and attends a private school, the St. Sebastian School. According to his teacher, Mary McGann, his is a hard worker and is a pleasure to have in class. He has been seeing a learning specialist, Teresa Tack, consistently since October 200X to practice his reading skills. The reading practice sessions are one on one out of the classroom. According to Mrs. Tack, Terry has improved in his ability to read sight words. One of her main objectives for Terry is to have him re-read easier material as much as possible, to focus on speed and accuracy.

Previous Evaluations

Terry was suspected as having speech and language difficulties early on at 2 years of age. His parents, Mr. and Mrs. Smith, have brought Terry to multiple facilities for recommended evaluations and second opinions. A summary of evaluation sites, dates, and findings is displayed in the table below:

|Site |Date |Reported Findings |

|X’s Hospital |February 200X |Moderate-to- severe apraxia |

|X Clinic |July 200X |Apraxia diagnosis confirmed |

|XSpeech/Language Center |August 200X |Moderate speech deficits; improving expressive language skills |

|Language Disorderss Center |October 200X |Improved abilities in speech and language |

|UWSHC |January 200X |Deficient intelligibility and articulation skills, borderline expressive language delays|

|UWSHC |January 200X |Deficient articulation skills, normal expressive language skills, borderline |

| | |pre-literary skills (i.e. rhyming, segmentation, and blending) |

|UWSHC |February 200X |Borderline articulation and pre-literacy skills (i.e. rhyming, phoneme awareness, |

| | |grapheme-phoneme awareness, and print knowledge) |

|UWSHC |February 200X |Age-appropriate articulation, phonological processing and pre-literacy skills. |

| | |Recommendations included: |

| | |Treatment for production of s-blends. |

|UWSHC |April 200X |Age-appropriate articulation, phonological awareness, early literacy skills, and |

| | |expressive language skills. |

| | |Recommendations included: |

| | |Treatment targeting generalization of s-blends and further assessment and possible |

| | |treatment of /l/, /f/, and /θ/ |

| | |Syllable segmentation |

| | |Parents should continue to read to Terry to expand on his knowledge of how stories are |

| | |structured |

Please see the associated reports for more details.

Previous Treatment

Terry has received therapy for speech, language, and pre-literacy skills at several sites over the last five years. A summary of his treatment history is described below:

|Therapy Site |Dates and Frequency of Therapy |Therapy Targets |

|X Children’s Clinic |March 200X – September 200X; twice weekly |Using sibilants, using CVC words, increasing MLU, |

| | |increasing intelligibility |

|X Preschool |October 200X – May 200X; 30 minutes weekly |Asking questions, using articles, using contractions |

|UWSHC |September 200X – June 200X; twice weekly |S-clusters, using articles, pre-literacy skills (i.e. |

| | |rhyming, segmenting, blending, phonemic awareness, |

| | |alphabetic principle) |

|UWSHC | April 200X – August 200X; once weekly |S-blends |

|UWSHC |June 200X –August 200X |Correct production of /l/ and s-clusters, syllable |

| | |segmentation |

Please see these reports for specific treatment goals.

EVALUATION

Test Environment and General Behaviors

The assessment took place at the UWSHC in a quiet treatment room. A graduate clinician and an assistant introduced Terry to the positive behaviors that were expected in the session. Terry was also presented with a sticker chart that could be redeemed for a prize if these behaviors were met. Terry was immediately talkative with the clinicians and very curious about the games and activities that were to follow. He maintained energy throughout the session, and although he was at times very talkative which slowed down the assessment, he readily participated in all of the assessment procedures.

Assessment Tools

• Hearing screening

• The Goldman-Fristoe Test of Articulation-2nd Ed (GFTA-2)

• Structural Functional Exam

• Non-standardized language tasks

• The Expression Connection

• The Strong Narrative Assessment Procedure (SNAP)

Hearing

Terry’s hearing was screened at 500, 1000, 2000, and 4000 Hz at 20dB bilaterally. He passed the screening at all frequencies with the exception of 500 Hz in both ears. This may have been due to masking caused by the air conditioning system in the room. Terry was well informed of the procedures and even reminded the clinicians that he remembered how this test was conducted from previous evaluations.

Speech

Formal Measures: The GFTA-2 was given as a measure of speech sound production within a single word context. The results follow:

GFTA-2 (Sounds-in-words subtest)

|Standard Score* |Percentile Rank |Interpretation |

|89 |14th |Within normal limits |

* “average” = 85 – 115

Errors observed on formal measures

|Sound |Substitution |Word Position |Example |Age Sound Typically Mastered |

| | | | |(years)* |

|/r/ |/w/ substitution and |initial |rabbit ( wabbit |8 |

| |vowelization |medial |carrot ( cawot | |

| | |final |feather ( feathou | |

|/r/-clusters |/w/ substitution |initial |brush ( bwush |8 |

|/l/-clusters |/w/ substitution |initial |flowers ( fwowuws |6-7 |

* Smit, Hand, Freilinger, Bernthal, & Bird (1990)

Connected Speech: The GFTA-2 Sounds-In-Sentences subtest assesses articulation in connected speech. Results from this subtest were largely consistent with the Sounds-In-Words subtest with additional errors found on the initial singleton /l/ sound, though these errors were inconsistent across opportunities.

In spontaneous connected speech, sound errors were consistent with those found in the GFTA-2 including the /l/ sound in all positions.

Intelligibility. On a seven point scale of intelligibility (“1” = no noticeable differences from normal, “7” = unintelligible), Terry’s intelligibility was rated as a “3” (intelligible, although noticeably different). He was easily understood despite his speech errors.

Stimulability. Terry was highly stimulable for /l/ in all positions of words given a direct model; however, stimulability for /l/ broke down at the sentence level. He was minimally stimulable for /r/ in final position (vowel + /r/) at the syllable level given visual cues, verbal instruction, and direct models. He exhibited frustration with his attempts to produce the /r/.

Structural-Functional Exam. A structural-functional exam revealed normal symmetry, range of movement, strength, and coordination in Terry’s tongue, lips, and jaw.

Receptive Language

Informal observations: Terry’s receptive language was not formally assessed, however, informal observations showed that he responded appropriately to wh- questions (who, what, when, where) from the clinician. Correct responses to wh-questions extended to factual and inferential comprehension questions regarding a story that was told with a picture book (see information from the SNAP below). Additionally, Terry understood basic locatives (under, on), and was able to respond in the correct tense when asked questions about past, present, and future. Terry followed all commands from the clinicians.

Expressive Language

Form and content.

Terry’s expressive language was age appropriate. His language contained multiword utterances in syntactically correct sentences and revealed a rich vocabulary. He connected related thoughts with conjunctions including “and,” “and then,” “because,” and “but.” He was able to use the past, present and future tenses appropriately with only one incidence of an error on the irregular 3rd person form of the word “eat” (ate(ated). Examples of some of Terry’s complex sentences include:

• “Cause I might have better things to do like watch T.V. all day long.”

• “I can’t believe you couldn’t guess it.

• “The guy went out to get the dog to see if it was okay.”

Narrative Skills.

Two tests were used to assess Terry’s ability to tell a narrative.

Story Retell with the SNAP. Administration of the SNAP required Terry to look at the picture book Where Are You Frog? and to listen to a narrated story on an audiocassette. At the end of the story, the picture book was removed and Terry was asked to retell the story to a novel listener. The assistant played the role of the novel listener. Analysis of Terry’s performance showed that he provided all story grammar elements (setting, initiating event, attempt, and consequence), with the exception of “internal responses.” This performance is within normal limits for his age. He adequately used additive (“and”), temporal (“and then”), and some adversative conjunctions (“but”). Terry seems to be in the process of learning appropriate use of reference cohesion ties. For most objects, Terry used the appropriate article (“a”) to introduce the objects and later referred to them with the correct article (“the, they”) However, there were a few instances where Terry introduced the object with the article “the” erroneously. There were several errors resulting in ambiguous references (“And then Tim found his frog, but he got a baby frog.”) On the other hand, Terry used the correct sequence of events in retelling the story and remembered many of the minor details. Terry was highly focused during this task and seemed to particularly enjoy this activity.

Story Generation with the Expression Connection. The procedure for the Expression Connection required Terry to hear a modeled story from the clinician given a line drawing, and then to generate a story himself given a new line drawing. Terry produced a “Level 3” narrative with regards to inclusion of story grammar components. That is, Terry used at least 3 story grammar components including setting, initiating events, attempts, and consequences. Components Terry omitted included a formal ending and an internal response. A level 3 is expected for a child aged 5-7. Terry used all coordinating conjunctions appropriately (and, but, and then), but did not use any subordinating conjunction (since, because, if, although). The only pronominal or demonstrative reference Terry used was “them,” although it was used appropriately. These results in combination with the results from the SNAP show that Terry is at an appropriate level for his age in narrative skills.

Use.

Terry demonstrated strong social-communication skills. He used a variety of communicative intentions throughout the evaluation. In addition, he used appropriate eye contact and physical proximity, and demonstrated adequate turn taking skills in conversation. He verbally informed his listeners of topic changes by making remarks such as, “This is one comment I need to say.” In addition, Terry was able to maintain conversational topics initiated by the clinicians.

Voice

The quality, pitch, resonance, and breath support of Terry’s voice were normal for a 7 year-old boy.

Fluency

Terry’s speech was appropriately fluent with only a few revisions and fillers (uh...) that increased with cognitive load. These dysfluencies were normal and did not disrupt the flow of his speech.

Related Factors

There were no concerns regarding Terry’s cognition.

SUMMARY

Terry Smith, age 7;5 exhibits a developmental articulation delay. The sounds in error include /l/ and /r/ both in singletons and in consonant clusters. His primary means of compensating for these errors are to substitute /w/ for /l/ and to substitute /w/ or to use vowelization for /r/. Although his overall score in articulation is within normal limits on a standardized test, the errors he exhibits have had social consequences for him. He is highly stimulable for /l/ at the word level given a direct model, and only minimally stimulable for /r/ at the syllable level given visual cues, verbal instruction, and a direct model. This suggests that Terry will respond well to treatment of the /l/ sound at this time; treatment focused on /r/ should be introduced but until he shows more readiness to learn, kept to a minimum.

Terry passed the hearing screening at 20dB for 1000, 2000, and 4000 Hz, but failed the screening at 500 Hz during our assessment. It is likely that this result was due to the masking caused by the air conditioning system, especially given that Terry passed his hearing screening at school two weeks ago. Overall, Terry demonstrates age-appropriate expressive and receptive language skills as well as adequate narrative skills. Additionally, his voice and fluency are within normal limits.

RECOMMENDATIONS

1. Terry should resume articulation therapy at the University of Washington Speech and Hearing Clinic (UWSHC) this summer pending student availability and scheduling. It is suggested that treatment primarily target /l/ at the level of connected speech and /l/-blends at the word level. In addition, it is suggested that treatment focused on /r/ should be minimal as he is easily frustrated. It might be appropriate to spend only a couple of minutes each session with some instruction on /r/ until he appears more ready to work more intensively on it.

Student 1, B.S. Laura Sargent, Ph.D., CCC-SLP

Graduate Clinician Clinical Supervisor

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