Case Study Presentation

·        Chronological Age at time of video: 4;3

·        Final session of his first block of speech therapy.  

·        I met him 2 sessions into this block of 6.

·        Referred by Preschool

·        Reported “mainly unintelligible”.

·        Reported finding certain sounds difficult. - (reported uses /k/g/ in place of all others, does not use fricatives and has final consonant deletion)

·        Reported not yet 5-6 words sentences but that sentence structure is progressing

·        Reported that he is very quiet.

·        Reported no concerns regarding play or understanding

At IA: (Age 3;9)

• Case History interview with parents
• Speech was assessed using STAP (South Tyneside Assessment of Phonology).
• Informal assessment of sounds in isolation.
• Informal observation of all other areas of communication.

At First Intervention Session: (Age 4;1)

•         Informal speech review using STAP as a basis.
•        production of sounds in isolation and discrimination.
•        Informal observation of all other areas of communication

Throughout the Intervention Block:

• Constantly informally reviewing speech progress and ability to inform intervention.  (evidence = initial targets changed)
• I took informal language and connected speech sample from final session. 

Hearing:

·        Passed hearing test aged 2

·        Concerns raised at SLT appointments

·        SLT referred for Hearing Assessments – (results gained in final session – pending further investigation)

·        Family History – Mum and Uncle have uni-lateral hearing loss (no details)

Medical:

·        Enlarged tonsils

·        History of recurrent ear infections  (No investigation done: referral to ENT?)

·        No concerns regarding Eating/Drinking

Communication Development:

·        “Late Talker” – progressed quickly after 1 session of early language package age 2 – missing mile stone info & details about severity of delay and (unclear why only received 1/what was involved)

·        Can now speak in sentences but using “urrrm” as filler ? Related to rapid increase in language ability

Social skills:

•  Described as “shy”
• Reported often chooses to play alone as becomes frustrated when other children don’t understand his speech.
• Sociable and communicative with adults in clinic

Attention:

• No concerns - Age appropriate according to (Cooper, Moodley & Reynell, 1978)

Play AND  Understanding

• No Concerns

Expressive language:

•  Referral: nursery noted not using 6 word sentences
•   Parents: not concerned. Note use of filler. MONITOR
• No concerns noted by SLT’s – deemed “good use of language with some immature grammar”
• Language Sample Analysis (Age 4;3):

Paperwork (PAGE 15-20) for a language sample and in-depth description and analysis using LARSP and STASS principles.

•      Age appropriate on the whole. Minor grammatical errors.  - Expect this will resolve now he is in school.

---  No Concerns. Monitor Progress.

Using Developmentally Typical Processes on the whole.

Stage 4 (age 2;6-3;0 years) ~~ approximately 18 months delayed at IA

IN PAPERWORK:

•      SEE Appendix 1 STAP ANALYSIS FORM from IA (done using notes)

•      SEE Appendix 2 for PACS profile at 4;1 (first therapy)

•      Page 11 TRANSCRIBED SAMPLE (from videoed session)

•      PACS profiles for all ages in appendices

. 

**DONT NEED TO READ OUT**

At IA, Age 3;9 (STAP): STAGE 4 on PACS

•/t/ inconsistent across all positions (voicing or fronted)

•Stopping of fricatives /θ/ð/f/.  /s/ʃ/ in WI and WM

•Stopping of affricates /tʃ/dʒ/ (emerging WF)

•Gliding of approximants /r/j/. /l/ in WM and WF

•Cluster reduction

•Some Final consonant deletion

•Some Context Sensitive Voicing (Occasional)

Progress made (within clinic environment at age 4;3) since STAP from Initial Assessment (age 3,9)

•   Since initial assessment ** has progressed with a number of sounds within his speech, including sounds which have not been specifically targeted.
• PACS -- difficult to pinpoint exactly - some chronological mismatch but predominantly still Stage 4 (age 2;6-3;0 years) ~~ approximately 18 months – 2 years delayed
• Mismatch between stages E.g. /tʃ/ is emerging and /ʃ/ is inconsistently used or fronted to /s/ rather than stopped now     (both stage 5 processes) and he is able to use /z/ WM and WF (age appropriate  @  Stage 6). 

• Stopping of /f/ and /s/ and context sensitive voicing - eliminated between 2;6 and age 3 (Grunwell, 1987 cited by Bowen, 2015,).
• /f/ and /s/ and /l/ are emerging but not consistent or generalised - IF could use them consistently he would move up a stage. 
• Held back in process of cluster reduction - needs /s/l/ - to form the clusters which developmentally are achieved first.
• Occasional glottal stops in connected speech.  - Not evident in STAP. Which is atypical rather than delayed  (Hirst, 2011 – Service criteria)
• Collected within a clinic environment so potentially more tuned in to using /f/.
• Parents report trying /f/ in speech at home.

FOR DETAILS PLEASE SEE PAPERWORK page 23. This is a summary:

Causal Factors:

•      unconfirmed as there is some information missing.

•      Bowen (2015) highlighted that in the majority of cases, there is no organic cause for speech sound difficulties.

•      However, the medical and hearing history, observations and reported info points to ** having some degree of hearing loss.

•       Likely that this is fluctuating and conductive loss related to ENT issues (potentially enlarged adenoids) which would also account for his hypo-nasal voice. – HOWEVER this was unconfirmed at the time of the intervention.  WE NOW KNOW MORE BUT needs further investigation and ENT referral. 

Type Of Impairment: 

• Ruled out articulation -  because can produce sounds in isolation. Articulators typical.  Progress being made (some spontaneous).
• Query different difficulty at different word positions as struggling to articulate /f/ WF – monitor progress with this aspect of speech.
• Ruled out DAS/DVD (FOR NOW) - according to Dodd (2005) and Bowen (2015) - fails to meet much of the criteria- not felt that those which he did meet were significant enough to warrant this diagnosis .  --  However, kept in mind as progress with therapy and generalisation revealed.
• Ruled out Dysarthria as doesn't meet ANY of the significant indicators according to Bowens description (2015).
• Language difficulties ruled out early on by SLT – confirmed by my analysis. 
• Hypo-nasality was observed - no investigations/assessments

(NEXT CARD FOR PHONOLOGICAL....

•  Phonological difficulty seemed most likely and fits the descriptors.
• Delay vs Disorder less straightforward - ** occasionally uses glottal stops in atypical places (during connected speech), and displays some inconsistency of substitutions and some inconsistent voicing errors which is indicative of a more disordered pattern of speech development.
• However not severely, and I felt he was primarily delayed in his speech (18 months - 2 years behind that of his peers according to PACS)
• Esp. considering the likelihood of hearing impairment,-Might give reason to the more disordered pattern and delay.
• American Pediatric association (2004) recognises that ability to hear and can effect language and communication development if on going.
•  (Bowen, 2011)  -   even with mild hearing loss, the highest frequency speech sounds (fricatives such as /s/ and /f/) are not audible. Which may suggest **'s delay with developing them. -  -  Although can disc. in clinc, in noisier environments, even more of the speech signal would be inaudible.

Severity:

• For phonological difficulties used service criteria.
• For voice/resonance, judgement based on impact of nasality as no service criteria to use for this area.

Impact:

• Lack of information!
• Emotional and social - can draw some conclusions based on reported behaviour. (Nash and Stengelhofen, 2002   and   Joffe and Serry, 2004 ) – Children with SSD more likely to have social, emotional and interaction difficulties.
•  Literacy/educational development – But highlighted SSD as a risk factor for literacy dev. (Hodsen, 1998 cited by Joffe and Serry, 2004 )
• NEEDS looking into 

CURRENT HYPOTHESIS:

•      ** has a moderate phonological delay with some features of a disorder, (according to the service criteria, Hirst 2011)

•      ** has a mild-moderately hypo-nasal voice.

•      Both are likely to be in-part due to a history of hearing impairment and wider ENT issues.

Joffe & Serry (2004)-  writing about EBP -  acknowledge that articulation and phonology and disorderd/atypical substitutions  - not clear cut, - as “avoidance” or inability to use another sound, a pattern of substitution is logical.  - highlighting that sensory deficits such as hearing loass would be expected to impact on production of sounds  

PACKAGE OF CARE: 1:1  - Meets service Criteria

•      Impairment focus rather than social

•      Clinician Directed

•      Allows for 6x 1:1 sessions and a review of progress after a break. May then require another package.

•      The most intensive therapy on offer from the community team

•      Aim for parents to carry out activities to encourage progress at home.

•      Requires specialist SLT knowledge to assess client and then decide on what should be worked on and how.

•      Potential for this to be carried out by school in future if they are deemed to be the “agents of change” and to have the resources and enough understanding to carry out therapy with only ½ termly reviews and training for staff.

Package of Care is Ideally suited and appears to consist of a psycholinguistic approach to intervention

Other packages such as the speech sound groups take a more meta-phonological approach.

(Williams, McCleod, McCauley, 2010) teach psycholinguistic approach involves:

•  assessment to identify what is underlying the speech sound difficulties
• where the breakdown
• forming a description of the output using phonetics/phonology.

Appropriate for any age, or any speech difficulty so a definitive diagnosis not needed.

(Stackhouse and Wells, 1997).The approach is in the head of the therapist  NOT about using battery of tests to build a comprehensive profile before beginning therapy, it’s about testing through therapy tasks and analysisng the childs ability at different levels of input, lexical representation, and output, to inform the next tasks and what to target.

However, Joffe & Serry (2004) emphasise that can use multiple approaches and must adapt to the need of the child. 

•      Initial aims changed during the course of therapy to reflect **’s progress

• Discussed between myself and the lead clinician (after week 3/6)
• Decided focus on production of /f/.
• because ** progressing more quickly with f/b discrimination work than s/d,
• and ** beginning to identify /f/ in conversational speech and was keen to try and produce it,

•      I do not have a copy of the new goals which were set, and I’m not sure that these were changed on his care plan ?!?!

• He had met initial goal 2 by the end of week 3
• able to discriminate f/b and s/d in WI consistently using an adult model after week 2. 
•  Less consistent when relying on his own internal representation --- continued to work on this with f/b and could do it after week 4. 

SESSION AIMS – See session plan in paperwork

* DONT READ OUT*

•For ** to be able to use 2 /f/ initial targets within a (non-set) sentence at 80% consistency within a focused activity.

•To assess **’s ability to use /f/ in word medial position at single word level within a focused activity.

•To assess **’s ability to use /f/ in word medial position at phrase levelwithin a focused activity.

•For ** to be able to blend /f/ with a vowel in VC structure at 50% accuracy with adult models and promptswithin a focused activity. 

Clip 1: (5:00-10:00)

Clip 2: (7:45-12:45)

Key Learning: Regarding spontaneous sentences task. Have had to consider how to adapt this and step it down.

üI gave specific articulation feedback

üModelling games and sentence production (Should have done more of this)

üAllowing ** to have some control.

üUse of R/W strategy

üincluded dad and used his feedback from home (good relationship)

üKept ** on task even though visibly keen to move on

X       Try substituting p/b in next time for ** to detect.

X       More R/W detection

X       Spontaneous sentence – next time step down to model and repeat.

Able to meet the aims bar spontaneous sentences.

•  AIM 1:  difficulty with the “non-set sentence” part of this aim as he struggled to makeup sentences on the spot. But able to achieve 100% consistency in short 2 target phrases. Could use 2 targets in a sentence remembered from home, and could copy and use 3 targets in a phrase if prompted.
•  AIM 2: was met fully as it was investigative. Approx. 80% consistency.
•   AIM 3: was met fully as it was investigative. Approx. 99% consistency.
•   ADDITIONAL: Able to identify adult R/W 80% VC – could self correct when prompted to listen
•  ADDITIONAL: Able to copy CVC non-words /f/ WF  3/3 and Name 4/4 images wf /f/. 

**SEE NEXT NOTE CARD

What factors influenced these outcomes?

Client perspective:

•      Ability to make up a sentence or to understand the purpose of the task. – Age/cognitive ability/educational level.

•      Surpassed expectations for ability regarding speech sound work

•      +++Progression in the week.

•      Enjoyment of games/motivation

Student perspective:

•      misjudgement of **’s abilities.  He is borderline age appropriate for sentences task and I had assumed he would be able as had done similar tasks at home. 

•      Could have explained task differently. “sentence” likely a fairly new concept for child of his age and educational level.

•      Could have adapted that task and got him to copy then produce from memory.  --MAIN LEARNING FROM SESSION

• I WAS able to gather pleny of data to inform future actions and choice of homework etc.

ABOUT MYSELF:

•      Previous reflection -  planning contingency activities - key aspect of my learning during this placement - made use of and saw its value – allowed me to gather extensive information and lent more evidence to my hypothesis making decision and to inform next steps for tasks

•      I need to be more flexible in stepping activity down - even if it compromises aim level of difficulty  -- should have modelled sentences for repetition. ESP in Activity 2 (fishing) after seeing him find it fairly difficult to make up a sentence. Talking about the images generally not enough for **.

•      Feeding back about care pathway – not rehearsed. Didn’t check that clinician had already talked to parents about it at start of the block. – therefore maybe appeared a little insensitive – should have fed back reason for consolidation period first.

ABOUT **:

•      Ability to progress etc

The results move ** towards aims of  overall therapy as show he is progressing significantly with his use of /f/ and moving towards generalization.

Understanding of the client?

Confirmed that change of block aims right decision.

Hypothesis: confirmation/added info

Articulation / DVD / Disordered pattern all less likely considering progress. 

Hearing Impairment (results) – Show that has middle ear loss and flat tympanic membranes. Pending investigation.

   Final session of block therefore consolidation break then reassessment for **

Need to know more about Hearing Impairment – does he need aids? Treatment? What is he functionally able to hear?

BUT

•      Moving on to WM /f/ multiple targets

•      WF /f/ in phrases and sentences

•      Encouraging ** to self correct WI in speech / phonological awareness during conversation (towards generalization). 

•      Important to reAx speech as is showing signs that may make significant progress in the consolidation period.

•      Copy sentence, Remember and Repeat?

•      Combinations of word placements in a sentence.

•      Encouraging to look at books and talk – more like free-speech – point out /f/ words?

•      Correcting adults and self

·        Access HI theory so understand difficulties and how it might impact on progress. And so understand when parent talks about it.  Which I have begun to do:

o   American Peds association Clinical guidelines (2004) state that flat tympanic membranes (** has) would indicate OME.  Different from Acute OM as is fluid in the middle ear without signs or symptoms of ear infection.

o   Recognises that impacts on ability to hear and can effect language and communication if on going.

o   Cause: Can be caused by blocked/abnormal eustation tubes.

o   Treatment:  AAP notes long term antibiotics and antihistamines not effective. Surgical intervention (removal of nasal bloackages/ adenoids recommended after age 4).

·        Potential for Pycholinguistic profile – useful in mapping but not a necessity – consider if little progress made

·        Psycholoinguistic approach should include an investigation of non-word processing as (Bridgeman & Snowling, 1988, Cited by Williams, McCleod, McCauley, 2010) acknowledge this can be more difficult for children with SSD. – would impact ability to learn new vocabulary.  – maybe for future tasks

    Consider Contacting School. 

•      Encouraging self monitoring both within therapy but sensitively outside of therapy

•      Building on phonological awareness  - detection of R/W productions in others, (not just in single words).

•      Practicing /f/ production in all word positions in longer and non-modelled sentences so articulation becomes a natural skill that can be done with ease (motor programme). (Rees, 2001).

•      Consolidation period

Reassessment = End of Care Package!

However, likely enrolled on a new block of therapy.

-Work on other sounds / speech processes

-Potential to hand over to school?

Long Term AIM:  Age Appropriate Speech