Download Case Study Project

Case Study Project
Evaluation and Diagnosis in Speech-Language
Pathology
Fall 2011
April Fischer
12/5/2011
April Fischer
CSD 688- Fall 2011 Case Studies Project
Anatomical observations
A child with apraxia of speech (CAS) would be expected to have no abnormalities of their
articulators. Hodge (2008) found that the resting posture of their lips, teeth, tongue, and jaw would be
insignificant (p. 14). This being said, the child would have healthy lip tissue with nice symmetry. They
would have all of their primary dentition with a normal occlusion (Hall, 2002). Their tongue would be
proportional to the overall size of their mouth, and when observing the tongue at rest there would not be
any involuntary twitching. When told to stick their tongue out as far as they possibly can, there would be
no deviation of the tongue to one side (Hall, 2002). Their hard palate would have normal pink and white
pigmentation at the midline, and the palatal vault would be normal in regards to height and width. Lastly,
the soft palate would have the same coloring as the hard palate and would have normal symmetry while at
rest (Hall, 2002). The uvula would be intact and the faucial pillars and tonsils would be average in size
with no signs of white matter on them or any signs of inflammation (Hall, 2002). Overall, everything
would present normally since the child does not have any sort of cleft or any disparities with their
innervation.
Physiological observations
Childhood apraxia of speech is a motor speech planning and programming disorder; therefore, a
child with CAS would not have weakness or paralysis of any of their articulators. They would not show
any signs of problems with the innervation of their face, lips, tongue, or velopharyngeal mechanism.
There would not be any facial drooping of their eyelids or corner of their mouth. However, Velleman
(2006) informs us that children with CAS experience “Difficulties with timing and sequencing, including
more difficulties with transitions between postures or states than within static postures or states” (p.3).
Several tasks in the oral mechanism examination are voluntary sequencing and imitation tasks
(i.e., to check lip function you are to instruct the child to do a series of “pucker, smile”), which children
with CAS perform poorly on due to their deficits in motor planning. According to Hodge (2008), when
children with CAS are faced with volitional nonspeech novel movements/sequences of movements of
articulators (imitation), they will put their articulator in the wrong position (p. 15). Consequently, when
assessing the tongue function during the exam this child would be unable to make repeated elevations of
their tongue tip to the alveolar ridge with their mouth slightly open (Hall, 2002, p. 109). Any sequencing
or imitation task on the oral mechanism examination would prove to be very difficult, if not impossible,
for this child with CAS.
Acoustical observations
Strand and McCauley (2008) stated that generally, “children with CAS will display relatively
more vowel distortions, occasional groping for articulatory positions for utterances they have not
previously produced, irregularity over repeated trials, inconsistent voicing errors, lexical stress errors, and
segmentation of multisyllabic words.” For example, this child would perform the diadochokinetic task at
a slow rate and the “alternating syllable repetition task (puhtuhkuh) [would be] much more difficult than
repetition of [the] same syllable (e.g. puhpuhpuh)” (Hodge, 2008, p. 15).
This child would have demonstrated unusual intonation, pausing and stress patterns. The child
might have used sounds in some words but excluded them from others. They might also have produced
the same syllable different every time. For instance, when assessing lip function they would have been
told to say “puh” five times, however, the child would have said “puh, buh, pih, pah pei” (Bowen, 1998).
This oral mechanism “examination allows the clinician to make observations of those behaviors
frequently associated with deficits in speech praxis, including vowel and consonant distortions, timing
errors, dysprosody, and inconsistency across hierarchically organized stimuli” (Strand & McCauley,
2008).
1
April Fischer
CSD 688- Fall 2011 Case Studies Project
Three aspects of assessment affected by atypical social-interactive behaviors
Atypical social-interactive behaviors can be conveyed through many different qualities. The
following actions exude atypical social behaviors: poor eye contact, deviant tone of voice and vocal
inflections, trouble making and keeping friends, taking turns, lack of initiating, and the inability to see
something from someone else’s point of view (Kuzma, 2008). With this in mind, some aspects of
assessment that would be effected would be the gathering of the case history, building rapport, and the
use of standardized test measures. Gathering a case history is often times done by interviewing the client,
however, if the client is showing signs of atypical social-interactive behaviors it might best be done by
having them fill out a case history form prior to the first session. Another option to explore in regards to
collecting their case history would be to interview their stakeholders—i.e., family members, caretakers,
teachers. These people tend to be a vital resource when it comes to gaining beneficial information about
the client. Another concern would be the challenge of building rapport with a client like this. Individuals
that have atypical social-interactive behaviors will most likely try to avoid social-interactive events, or
remain closed off and unengaged since they would feel uncomfortable. Under these circumstances, the
best advice for building rapport would be to be relatable and empathetic. Share a personal experience that
is relatable to one of theirs to demonstrate that it is a safe environment to open up in. Finally, a client
with atypical social-interactive behaviors would not fare well on a standardized pragmatic language
measure. A thoughtful suggestion would be to supplement this quantitative measure with direct
observation of this client in their natural environment (Kuzma, 2008). This would allow a great
opportunity for gathering qualitative data (Kuzma, 2008).
Affect of cultural differences on evaluation process and modifications
Beliefs about health and disabilities vary greatly across cultures. Be sure to use neutral terms like
“communication difficulties,” versus “communication disorder,” or “special language needs” versus
“language impairment” when interacting with a family or client that is culturally and linguistically diverse
(CLD). When working with CLD clients and family take note of their familiarity with the clinical service
delivery model. If English is not their first language enlist a professional medical interpreter. Assert the
roles and responsibilities of everyone involved in the evaluation process and ensure the client and their
family members that the confidentiality of their case will be upheld.
Norm-referenced tests can serve as useful tools in the evaluation process; however, if the
normative sample does not match your client’s cultural, linguistic, and/or educational characteristics, then
you cannot use it for your client. An alternative to norm-referenced tests would be to use a criterionreferenced test. Results from a criterion-referenced test are compared to pre-established criteria and tell
you if the client has a specific skill or not; whereas results from a norm-referenced test solely rank the
individual’s performance.
When you have a CLD client you will have to consider format bias. This is where the format of a
test is unfamiliar to the client; for example, the materials, content, responses required, and expectations of
the test are all novel to the client. Some specific tasks that can potentially have format bias are eye gaze,
interactions, discourse, and responding to requests (Heilmann, 2011, p.5). Format bias can be countered
by implementing criterion-referenced testing that allows the tailoring of an appropriate measure for
testing of a specific skill.
Determining difference v. disorder of the atypical social-interactive behaviors
The most valid and reliable manner to determine if a client has a difference or a disorder would
be to use the test-teach-retest method (Gutiérrez-Clellen & Peña, 2001, p. 213). With this specific
situation, the clinician has identified the deficient or emerging skills as the atypical social-interactive
behaviors. First, the clinician would administer a criterion-referenced pragmatic test measure in order to
gather a baseline. Once the test is analyzed, the clinician would be able to verify which specific
pragmatic deficits the client has. From there, the clinician would need to investigate whether these
behaviors can be attributed to a lack of mediated experiences (MLA) with these skills or not (Gutiérrez-
2
April Fischer
CSD 688- Fall 2011 Case Studies Project
Clellen & Peña, 2001, p. 213). For instance, this atypical social-interactive behaviors evident with this
client may be attributed to their cultural norms. So, in order to do substantiate whether these atypical
behaviors are due to a difference or a disorder, the clinician would provide “an intervention (the MLE)
designed to modify the child’s level of functioning in the targeted areas” –i.e., the client’s nonconforming
social-interactive behaviors (Gutiérrez-Clellen & Peña, 2001, p. 213).
So let’s say this client had a definite deficit in the pragmatic skill initiating conversation. The
clinician would teach this skill to the client with a therapy activity. For instance, let’s assume this client
is a male adolescent and it is known that he is a fan of soccer. The clinician could work on the client’s
initiating skills by giving the client a magazine with the client’s home country’s soccer team in it. It
would be expected that the client would not initiate a conversation about the topic at hand, but the
clinician should remain silent and allow them ample opportunity to initiate conversation. If after several
few minutes they have still not initiated, then the clinician would instruct the client to tell them something
they saw or read in the magazine. If the client did not initiate that time, then give them a new magazine
and sit and wait for them to initiate. There would likely be awkward silence, but eventually the client
would understand that the clinician was waiting for them to initiate a conversation. It would be
imperative to give the client descriptive feedback about their response so that behavior of initiating
becomes reinforced.
Now that the teaching phase of test-teach-retest has been completed, the next step would be for
the clinician to retest this skill. The idea here is that if the client’s atypical social-interactive behaviors
are attributed to their cultural differences and not an actual language disorder, then after having been
taught these skills they would make significant gains the second time around. However, if the client had a
language impairment, he would likely benefit from the MLE sessions but would demonstrate little or no
quantitative change in the posttest (Gutiérrez-Clellen & Peña, 2001, p. 213). If the latter is the case, then
the assessment would provide useful information about the client’s future responsiveness to intervention
for the atypical social-interactive behaviors (Gutiérrez-Clellen & Peña, 2001).
Scenario of a difference
You have a CLD child client that is presenting with deficits in the use of copula is. You know
that the client speaks with an African American English Vernacular (AAEV), so you want to determine
whether their discrepancy is due to a disorder or a difference. After the initial testing you implement the
teach phase of test-teach-retest. Here you would set up a MLE to teach them the use of copula is. You
could do this in a very naturalistic manner of following the child’s lead during play and modeling the use
of the target. After eliciting the target from the client several times and providing descriptive feedback,
you would retest the skill. The results improved greatly the second time around, therefore the child
clearly benefited from the MLE, and their deficits with the target were explained by their cultural
differences.
Scenario of disorder
You have a CLD child client that is presenting with some articulatory deficits. English is not this
client’s first language so you want to be certain whether these deficits are due to a difference or a
disorder, so you decide to employ the test-teach-retest method. After administering the Goldman-Fristoe
Test of Articulation-Second Edition (G-FTA-2) the results show that the client definitely has an
articulation disorder. In order to decipher whether they have a true articulation disorder or not, you
provide a MLE and teach them how to properly articulate the phonemes that they have difficulty with.
After a sufficient MLE has been provided, you re-administer the G-FTA-2 and you see that there was
little to no gains made in the posttest. This would be indicative of a true articulation disorder.
3
April Fischer
CSD 688- Fall 2011 Case Studies Project
References
Bowen, C. (1998). Children's speech sound disorders: Questions and answers. Retrieved from
http://www.speech-language-therapy.com/phonol-and-artic.htm on 12/06/11.
Gutiérrez-Clellen, V. F. & Peña, E. (2001). Dynamic assessment of diverse children: A tutorial.
Language, Speech, and Hearing Services in Schools, 32, 212-224.
Hall, P. K. (2002). The oral mechanism. In Tomblin, B. J., Morris, L. H., & Spriesterbach, D.C. (Eds.)
Diagnosis in speech-language pathology (2nd ed.) (pp. 91-123). San Diego, CA: Singular.
Heilmann, J. (2011). Assessment considerations when working with diverse clients. [25]. Retrieved
from https://uwm.courses.wisconsin.edu/d2l/lms/content/viewer/main_frame.d2l?ou=263619&tId
=1922639
Hodge, M. M. (2008). Motor speech disorders in pediatric practice [81-90]. Retrieved from
http://www.asha.org/Events/convention/handouts/2008/2347_Hodge_Megan/
Kuzma, J. D. (2008). Jill Kuzma’s social and emotional skill sharing site: Ideas for educators supporting
social/emotional language skills. In Assessment of pragmatics and social language. Retrieved
December 7, 2011, from http://jillkuzma.wordpress.com/assessment-of-pragmatics-and-social
language/
Strand, E. A. & McCauley, R. J. (2008, August 12). Differential Diagnosis of Severe Speech
Impairment in Young Children. The ASHA Leader.
Velleman, S. L. (2006, November 16). Childhood apraxia of speech: Assessment/treatment for
school-aged child. Retrieved from http://www.asha.org/Events/convention/handouts/
2006/ SC09_Velleman_Shelley/
4