consistency is key!

My client, J, is 5 years, 5 months old and is still being seen in our clinic, but his frequent absences have proven to be a problem. For our first few sessions, I administered the Goldman-Fristoe 2, as well as the expressive language subtest of the Preschool Language Scale-4 in order to assess J's language and articulation skills. During the testing, I was able to note several of J's articulation errors. Several of the sound's in J's repertoire are not produced correctly, so my supervisor and I had to pick sounds that were more important to acquire/needed in order to work on other errors.

Currently, J's targets in therapy include:

• Initial /'sh'/ in words
• Final /k/ in words
• Initial /f/ in words
• Medial /f/ in syllables and small words
• Correct placement/production of /l/
• Correct placement/production of /j/

(*when targeting /l/ and /j/, we work on placement, and occasional attempts at vocal productions because these sounds have proven to be very difficult and discouraging to J.)

J is still presenting several errors, none of his errors seem to be improving by any noticeable degree, and his attendance at therapy sessions would be beneficial. Results of therapy sessions for J vary from week to week. Accuracy rates continue to fluctuate throughout the semester, and J's errors appear to be inconsistent. I do not doubt that J's mother wants to get all the help she can for her child, but frequent absences have made achieving progress difficult. Overall, J's accuracy rates for his errors have improved, but very slightly.

Due to his frequent absences, obtaining new data and a new direction for therapy has been difficult. I firmly believe that due to the number of times J has missed therapy, he has missed out on the benefits that therapy could provide. Granted, I know I'm not a super-clinician. I haven't been at this whole therapy biz for long, but I know enough to realize that missing out on the services that are provided can definitely hinder the success that could potentially be achieved.

There are several techniques that have been identified that could help transfer success into environments outside of the clinic, and I would like to link this article as the reference to my blog. If I do have the opportunity to see J again before the semester ends, I would like to implement some of these strategies and urge clinicians who word with J in the future to do the same. Hopefully, even though J may miss sessions frequently, he may be able to generalize his accuracy in articulation into everyday life.


Reference:
Mowrer, D. E. 1971. Transfer of training in articulation therapy. [Electronic Version].
Journal of Speech and Hearing Disorder, 36, 427-446.

i wanna check you for (ar)tics...

JD is a 5 year, 3 month old cutie patootie who began therapy for articulation at the WVU speech clinic in the Fall of 2007 after being referred for a diagnostic. He was seen in the diagnostic class, and presented a lot of errors that have proven to be a challenge. He is a very silly boy, and he definitely keeps me on my toes! He is very well behaved during therapy, usually cooperates well enough to do the activities I have planned, but tends to have a few ornery moments. The little boy inside of me understands....sometimes you just have to be silly! :-)

First of all, J presents with several different phoneme distortions. At first, his speech may seem unintelligible to the average listener, but after speaking with him for a couple sessions and "opening my ears," it was much much MUCH easier to follow along with his conversation. I still have a few "HUH?" moments when I just nod and say "that's cool...", but now J is relatively easy for me to understand.

At the beginning of the semester, I administered the expressive language subtest of the Preschool Language Scale-4 (PLS-4) and the Goldman-Fristoe Test of Articulation 2 (GFTA). J's expressive language was excellent! He received a standard score of 108 (70th percentile) on the PLS-4, and actually never obtained a ceiling before reaching the end of the test. However, the the GFTA was a different story. He received a standard score of 44 (<1>

• final /k/
• initial and medial /∫/
• /l/ in isolation (which was recently dropped to isolation because of poor productions!)
• /w/ and /f/ in isolation.
• Along with his articulation errors, I am also making sure to listen for pronoun errors.

So far, things have been going pretty well. J's accuracy levels are fluctuating a bit, but strong productions are staying relatively high, and we're slowly (but surely!) starting to make some progress on sounds that aren't so strong.

I know what you're thinking... Where's the reference to an ASHA article!! Wellllll.... I am a huge fan of child literacy, and (i think this is a given) as upcoming speech and language professionals, we should all begin to consider how children who present with speech/language errors will fare in the schools. This article by Rvachew, Chiang, & Evans, 2007, lays out the facts pretty clearly: kids who begin school with articulation skills that are not well-developed are much more likely that have difficulty acquiring language and literacy skills as they progress through school.

I hope that all parents are as concerned if their children have speech problems. Luckily, J's mother is so interested, desperately wants to be involved, and is concerned about getting him help so he can do as well in school as possible!

Reference:
Rvachew, S., Chiang, P., & Evans, N. (2007). Characteristics of speech errors produced by children with and without delayed phonological awareness skills. [Electronic version]. Language, Speech, and Hearing Services in Schools, 38, 60-71.

One step at a time...

My client, M, is a 3yr., 6mo. old male with Down Syndrome diagnosed with delayed speech and language. During the semester, we have continued to work on building up M's functional vocabulary of signs. Two of M's most important goals at the beginning of the semester included communicating functionally with signs and learning basic social skills regarding play.

Because M has not really communicated independently in a functional way during the semester, my supervisor and I began to keep track of M's vocabulary, as well as talking with M's mother about words that he uses at home and not in therapy.

Independently, M produces the following signs on his own in the correct context, without cueing:
eat, drink, bath, help, more (pertaining to crackers), sleep, and book.

M is able to imitate the following signs in the correct context, with cues:
more ball, more eat, all done (2 word phrases), ball, again, bird, play car, open, book.

M is able to vocalize the following words as approximations:
"muh" (mom) "da" (dad) when in distress.
"bub" (bubbles)
"buh" (bye)
"ak" (quack)
"uh" "oh" "ow" (uh-oh, wow)

Although M has made considerable progress during the semester, my supervisor and I are beginning to realize that M's primary mode of communication may be signing for much of his life. After analyzing his vocabulary, my supervisor and I determined that M's language level was approximately at the level of an 18 month old, although he is over 3 and a half years old.

M's mother is working with him wonderfully on carrying over signs that are used in therapy, introducing new signs, reinforcing good behavior, and communicating with myself and the supervisor about her concerns for M during his treatment. We have continued to target the signs and words that M understands, introduce new signs, and hope for generalization in the home. Because M is so impaired, it will take a lot of dedication on behalf of M's parents and the clinician that is working with him in therapy in order for M's language to develop on a level that is functional for communication--especially since children with Down Syndrome typically display a delayed language system. I have referenced the following article as a resource for planning activities and homework assignments for M throughout the course of the semester:

Reference:
Berglund, E., Eriksson, M., & Johansson, I. (2001). Parental reports of spoken language skills in children with down syndrome. Journal of Speech, Language, and Hearing Research, 44, 179-191.

Speaking through the Silence

My client, M, is a 3 year, 6 month old boy who has been diagnosed with Down’s Syndrome. He is currently nonverbal, and communicates by using a limited inventory of American Sign Language (ASL). M began therapy in June 2007, after he was discharged from the WV Birth to Three program due to his age.

M’s therapy includes a lot of play activities that are structured in ways that elicit or require a response from M in order to continue. The majority of activities included in M’s therapy are play, with signing being integrated by the clinician. The clinician models signs that M is familiar with, which he imitates and occasionally uses spontaneously in the correct context. M currently does not communicate verbally, but will occasionally verbalize “uh oh” or “wow” when excited during play. Therapy has progressed from simple play activities where the clinician models signs and M imitates, to a more sophisticated type of play where M is cued to use basic signing and guided by the clinician in sequenced activities. The social aspects of play are also considered during therapy, and the clinician frequently models appropriate turn-taking and behavior traits that typical children use during play.

The major goal of M’s therapy, is that he would being to build up a vocabulary of signs that he is able to use functionally and in the correct context, providing him the ability to communicate his needs and wants, as well as the ability to understand and communicate with others. At the beginning of therapy in June 2007, simple one word signs were introduced to M, most of which he has retained and now uses spontaneously or when cued for a response. Some of those signs include the following: want, again, more, help, open, close, more, bird, ball, play. The clinician began integrating these signs into two-word phrases in therapy, such as the following: want more, do again, help me, tell me, help open, help close, all done, let’s play. M is clearly gaining and understanding of the techniques being used in therapy and it is reported by his parents that M is beginning to show some of the same communicative behaviors that we use in therapy at home; however, his ability to communicate, even nonverbally, is obviously attenuated. Because he is unable to communicate verbally, his lack of nonverbal cues makes understanding his needs and concentrating on therapy very difficult.

Because it was difficult to find much researched evidence related directly to this topic, I turned to an article written by Mundy, Kasari, Sigman, and Ruskin. The article broadly states that several studies have reported similar findings that children with Down’s Syndrome display a deficiency in their ability to display nonverbal requests, which could later be linked to their early verbal development. They also suggest that their delay in expressive language, such as speech motor control or cognitive approaches related to speech, may be adversely related to a disturbance in behaviors related to nonverbal communication. The most likely cause of these difficulties that have been reported are hypotonia (lack of muscle tone) or neuromotor development delays.

Reference:

Mundy, P., Kasari, C., Sigman, M., & Ruskin, E. (1995). Nonverbal communication and early language
 acquisition in children with down syndrome and in normally developing children. 
 Journal of Speech and Hearing Research, 38, 157-167.