Questions Regarding Evaluation of Speech and Language Disorders in - - PowerPoint PPT Presentation

Frequently Asked Questions Regarding Evaluation of Speech and Language Disorders in Children Under 18 months

Presenter: Nicole Kret, MA, CCC-SLP

My favorite way infants communicate

How do you evaluate a child’s speech and language skills when he/she is not talking?

Standardized Assessments Used

• The Rossetti Infant-Toddler Language Scale by Louis Rossetti, Ph.D.
• Preschool Language Scales, Fifth Edition (PLS-5) by Violette G.

Steiner, BS, Roberta Evatt Pond, MA

Interaction Attachment

• SLP will assess the cues and responses that reflect a reciprocal

relationship between the caregiver and the child

• Example checklist from the Rossetti for a child 3-6 months old
• Smiles spontaneously to human contact
• Smiles when playing alone
• Smiles at faces of several family members
• Stops crying when spoken to
• Shows different responses to different family members
• Example checklist from the Rossetti for a child 9-12 months old
• Shows sensitivity to others’ moods
• Displays fear of strangers
• Allows release of contact in new situations
• Performs for social attention

Gestures

• Definition: To express an idea or meaning through the movement
• f a part of the body
• There are no expected gestures for a child 3-6 months old
• Example checklist from the Rossetti for a child 9-12 months old
• Covers and uncovers face during “Peek-a-boo”
• Reaches upward as a request to be picked up
• Waves “hi” and “bye”
• Extends arm to show an object
• Points to objects to indicate awareness

Pragmatics

• Assess the way the child uses language to communicate with and

affect others in a social manner

• Example checklist from the Rossetti for a child 3-6 months old
• Produces different cries for different reasons
• Maintains eye contact
• Vocalizes in response to vocalization
• Imitates facial expressions
• Example checklist from the Rossetti for a child 9-12 months old
• Vocalizes to call others
• Indicates a desire for a change in activities
• Vocalizes when another person calls

Play

• Assess the changes in a child’s play that reflect the development of

representational thought

• Example checklist from the Rossetti for a child 3-6 months old
• Enjoys frolic play
• Smiles at self in a mirror
• Reaches for objects
• Bangs objects in play
• Example checklist from the Rossetti for a child 9-12 months
• Participates in speech-routine games
• Covers face with a towel during “Peek-a-boo”
• Resists removal for a toy
• Tries to secure an object out of reach
• Imitates stirring with a spoon
• Pushes a toy car

Language Comprehension

• Assess the child’s understanding of verbal language with and

without linguistic cues

• Example checklist from the Rossetti for a child 3-6 months
• Turns head toward a voice
• Searches for the speaker
• Responds to sounds other than voices
• Recognizes own name
• Stops crying when spoken to
• Responds to “no” half of the time
• Discriminates between threatening and friendly voices
• Anticipates feeding
• Cries at an angry tone of voice

Language Comprehension

• Example checklist from the Rossetti for a child 9-12 months
• Attends to new words
• Gives objects upon verbal request
• Looks at a person saying child’s name
• Performs a routine activity upon verbal request
• Looks at familiar objects and people when named
• Attends to objects mentioned during conversation
• Follows simple commands occasionally
• Understands simple questions
• Gestures in response to verbal requests
• Verbalizes or vocalizes in response to verbal requests
• Participates in speech-routine games
• Identifies two body parts on self

Language Expression

• Assess the child’s use of preverbal and verbal behaviors to

communicate with others

• Example checklist from the Rossetti from a child 3-6 months
• Vocalizes in response to singing
• Vocalizes feelings through intonation
• Takes turns vocalizing
• Laughs
• Babbles
• Vocalizes to express displeasure
• Stops babbling when another person vocalizes
• Initiates “talking”
• Demonstrates sound play when alone or with others
• Whines with a manipulative purpose
• Attempts to interact with an adult
• Interrupts another person’s vocalizations

Language Expression

• Example checklist from the Rossetti of a child 9-12 months
• Says “mama” or “dada” meaningfully
• Imitates consonant and vowel combinations
• Imitates non-speech sounds
• Vocalizes with intent frequently
• Uses a word to call a person
• Says one or two words spontaneously
• Vocalizes a desire for a change in activities
• Imitates the names of familiar objects

PLS-5

• Contains 2 subtests which

evaluate the child’s receptive language and expressive language skills. There is also an articulation screener.

• Uses manipulatives in addition

to a picture book to assess the child’s language skills.

• Completing this test results in

a standardized score for receptive, expressive, and total language skills.

Oral Motor Skills

• Assessing the speech motor system consists of examining facial

symmetry; dentition; the structure and function of the lips, tongue, jaw, and velopharynx, and respiratory, phonatory, and resonance functions as they are used for speech. (Paul, 2007)

Beckman Oral Motor Assessment

• Is a clinical tool in addition to standardized tests
• Criterion referenced
• Uses assisted movement
• Looking at muscle response to displacement, either reflexive or

active

• Assess these components of movement:
• Response to pressure and movement
• Range
• Strength
• Variety
• Control of movement
• For the following structures:
• Lips, cheeks, jaw, tongue, soft palate, hard palate

(Beckman, 1986 Rev. 2007)

Using the Beckman Oral Motor assessment on an infant to assess labial musculature

(Beckman, 1986 Rev. 2007)

• Upper lip:
• First observe the movement during facial expression, talking,

eating.

• Measure assisted movement: measure protrusion and

elongation

• “Place finger and thumb together at top of philtrum.
• Compress the tissue and move downward to end of upper

gum.

• Move fingers away until finger pads line up with edge of

nose.

• Bring fingers together, supporting lip muscle between

fingers.

• Move fingers downward to the end of the upper surface.
• Release slowly.”

“Caution This information is to be used only under the direction of a therapist trained in the application of this information.” (Beckman, 1986 Rev. 2007)

Beckman Oral Motor Assessment Cont.

• Assess labial strength
• “Place middle finger and thumb of the dominate hand on the

lower edge of the jaw.

• With pad of index finger, provide light touch to displace

vermilion of the lip at 6 points, 3 on upper, 3 on lower.

• Displace the lip, moving away from the center of the mouth,

maintaining contact with the finger pad for 1 second at each point.

• Minimal competence is a change in muscle state from flaccid to

firm within 1 second following displacement.” (Beckman, 1986

• Rev. 2007)

“Caution This information is to be used only under the direction of a therapist trained in the application of this information.” (Beckman, 1986 Rev. 2007)

The infant’s hearing was WNL when tested at birth, should it be evaluated again if the child is demonstrating speech/language difficulties?

Hearing Evaluation

• Yes, I normally recommend a child receive a formal hearing

evaluation if there are concerns with speech development.

• Newborns receive a hearing screening when they are born consisting
• f 1 of these 2 tests:
• Otoacoustic Emissions: in which a miniature earphone and

microphone are placed in the ear, sounds are played and a response is measured. If a baby hears normally, an echo is reflected back into the ear canal measured by the microphone.

• Auditory Brainstem Response (ABR): in this test sounds are

placed in the baby’s ears. Electrodes are placed on the baby’s head to detect responses. This test measures how the hearing nerve responds to sounds.

• These 2 tests are good at screening initially but it is possible for

hearing loss to go undetected in the initial screen or for the child to develop hearing loss after this initial screen, often seen with children with severe OME. (My Baby’s Hearing, 2016)

Early Signs of a Hearing Impairment

• If a child is NOT doing these things at:
• 4 months
• Child awaken/stirs to loud sounds
• Child startles to loud noises
• Calms to the sound of familiar voices
• Responds to parents voice (smile, coo)
• 4-9 months
• Turns eyes toward source of sound
• Smiles when spoken to
• Notices sound making toys
• Makes babbling sounds
• 9 to 15 months
• Babbles with many different sounds
• Responds to name
• Responds to changes in tone of voice
• Says “ma-ma” or “da-da”
• Repeats some sounds you make
• Uses his/her voice to attract attention

(Hearing Loss in Children, 2015)

The child interacts differently at home, how will you get an accurate evaluation of the child’s speech and language skills?

Parent/Caregiver Report is key in 0-18 month evaluations.

 Normal for a child under 18 months to be shy to a stranger.  Will complete a parent interview throughout the evaluation.  Is beneficial to have multiple family members present. Parents/primary caregivers can over report child’s skills.

What are the receptive language milestones for children 0-18 months?

Receptive Developmental Language Milestones

• 1 month: startle response to loud or sudden sound, human voices

usually has a quieting effect, generally looks at speaker

• 2 months: alert to surroundings, direct regard of speaker’s face,

visually and auditory recognizes mother, anticipates nursing/bottle

• 3 months: Localization: turns head when hears voice, frightened by

angry voices, excited when desired toys are present, aware of strange people/situations

• 4 months: cessation of crying upon hearing human voice, reciprocal

gaze (4-8 months), responds to name by turning head (4-6 months).

• 5 months: Localization: horizontal plane to right or left depending
• n sound source, responds to “no” when said with inflection,

responds to gesture stimulus with a gesture response (come up), recognizes familiar environmental sounds

• 6 months: Localization: 2 step behavior, horizontal scan then

vertical scan, begins to understand a few familiar words “mommy”, “daddy”, and phrases “Do you want a bottle?” (Roth, Worthington, 2005)

Receptive Developmental Language Milestones, Cont.

• 8 months: responds to “no” said without inflection, ceases activity

when name is called, recognizes the names of a few common

• bjects, responds to “scary” faces, “stranger anxiety”, pats image

in mirror

• 9 months: gives toy in hand on request, follows simple verbal

directions when accompanied by a gesture (e.g. get ball), uses gesture in response to verbal stimulus “bye-bye”

• 11 months: responds to music with body movements
• 12 months: responds to simple commands without an accompanied

gesture, identifies 1 body part, selects object in a 2-way objects discrimination task, understands up to 10 words

• 14 months: responds to verbal direction “give me + object” without

an accompanied gesture cue

• 15 months: pats pictures in a book, points to common objects when

named

• 16 months: identifies object in a 4-way object discrimination task
• 18 months: responds to some question forms “what-doing”, “where-
• bject”, points to 3 body parts, understands up to 50 words

(Roth, Worthington, 2005)

What are the expressive language milestones for children 0-18 months?

Expressive Developmental Language Milestones

• 1 month: produces undifferentiated crying and vegetative sounds (0-

1.5 months), produces differentiated cry (1.5-2 months)

• 2 months: gurgles and coos when played with, produces 2 or more

syllables, produces vowels with consonant like sounds (gu, nu) that are one second in duration, social smile (2-4 months)

• 3 months: vocalizes in response to speech, produces pleasure sound,

coos without external stimulus

• 4-5 months: produces early babbling sounds (p, b, d, h, w), produces

some intonation during sound making, produces vocal play when playing with toys, produces approximately 4 different sounds, produces displeasure sound, takes turns with sounds

• 6 months: produces reduplicative babbling, responses to name 50%
• f the time by vocalizing
• 7 months: vocalizes upon seeing bottle, produces more consonant

sounds (t, n, d) (Roth, Worthington, 2005)

Expressive Developmental Milestones, Cont.

• 8 months: vocalizes to persuade, produces 5 or more consonants,

shakes head for “no”

• 9 months: produces “uh oh” exclamation
• 10 months: produces nonreduplicative babbling, tries to imitate

sounds

• 11 months: produces 3 or more words or protowords, produces and

imitates sounds and correct number of syllables

• 12 months: produces 5 or more words (12-14 months), produces true

words during sound play, uses voice and gesture to get objects (12- 14 months), uses jargon; mixes words with jargon, most words are 1- 2 syllables (12-18 months), speech is 25% intelligible to unfamiliar listeners (12-18 months), imitates animal noises

• 14-16 months: produces 4-7 words, communicates using gestures +

words/vocalizations, uses jargon and words in conversation

• 16-18 months: produces 6-12 words, uses words to express wants

and to communicate, imitates most words, uses jargon (Roth, Worthington, 2005)

Videos of Expressive Language Skills in Children 0-18 months

• Developmental Milestones: Baby Talk

from First Sounds to First Words Albert Einstein College of Medicine Example of reduplicative babbling

What are causes of speech and language disorders?

Causes of Speech and Language Disorders

• Hearing Loss
• Intellectual Disability
• Prematurity
• Neurological Disorders such as Cerebral Palsy, Muscular Dystrophy,

and Traumatic Brain Injury

• Genetic or chromosome abnormalities such as Down’s Syndrome and

Rett Syndrome

• Autism Spectrum Disorder (ASD)
• Structural problems such as a cleft lip or cleft palate
• Apraxia of speech
• Auditory Processing Disorder
• Cause may be unknown

(Boyse, 2012)

What are common speech

• r language disorders which
• ccur in children?

Expressive and Receptive Language Disorder

• An expressive language disorder occurs when a child has difficulty

using spoken language.

• A receptive language disorder occurs when a child has difficulty

understanding spoken language.

• Many children present with a mixed receptive and expressive

language disorder in which both expressive language and receptive language are impaired and intervention is recommended to increase language skills to improve a child’s ability to communicate.

• Best way to detect early signs of a receptive and/or expressive

language disorder is to know the developmental milestones of each.

Articulation Disorder

• Articulation Disorder: “Involves problems making sounds. Sounds can

be substituted, left off, added or changed.” These errors make it hard to be understood.

• Many children make age appropriate speech errors. Very common will

be making the “w” sound for the “r”. The child may have an articulation disorder if these errors continue past the expected age.

• Link to a Speech and Articulation Development Chart:

http://www.talkingchild.com/speechchart.html

Phonological Disorder

• A phonological disorder “involves patterns of sound errors. For

example substituting all sounds made in the back of the mouth (k,g) for those in the front of the mouth (t,d). As with articulation errors it is normal for a child to demonstrate phonological errors, although these errors should not continue past an expected age.

• Phonological errors result in decreased child intelligibility and will

result in a phonological disorder if not disappeared at a certain age.

• Link to a chart which shows the expected age of elimination of

phonological processes:

• http://www.speech-language-

therapy.com/index.php?option=com_content&view=article&id=31:t able3&catid=11:admin&Itemid=117

Early Signs of a Speech Impairment

• Failure to babble or late onset of canonical (speech-like) babbling.
• “Nearly all infants with normal hearing begin the canonical stage

by 10 months.” Studies indicate late onset of babbling is a predictor of a speech disorder (Oller, Elilers, Neal, & Scwartz, 1999)

• Otitis media with effusion
• Initial consonant deletion
• Small phonetic inventory
• Losing words

(Bowen, 2016)

Childhood Apraxia of Speech (CAS)

• Childhood apraxia of speech (CAS) “is a motor speech disorder.

Children with CAS have problems saying sounds, syllables, and

• words. This is not because of muscle weakness or paralysis. The

brain has problems planning to move the body parts (e.g. lips, jaw, tongue) needed for speech. The child knows what he or she wants to say, but his/her brain has difficulty coordinating the muscle movements necessary to say those words.

• Early signs of CAS
• No cooing or babbling as an infant
• First words are late and may be missing sounds
• Only has a few different consonant and vowel sounds
• Problems combining sounds; may show long pauses between

sounds

• Simplifies words by replacing difficult sounds with easier ones
• r deleting the sounds
• May also have feeding difficulties

What is the definition of a Late Talker?

Late Talker

• A “Late Talker” “is a toddler (between 18-30 months) who has a

good understanding of language typically developing play skills, motor skills, thinking skills, and social skills, but has limited spoken vocabulary for his or her age. This group of children has all the building blocks for spoken language, yet they don’t talk or talk very little.” (Lowry, 2012)

• Difficult to predict if the child will “catch up” to his/her peers.

Good to have a speech language evaluation so the SLP can determine if speech treatment is warranted. Here is a list of risk factors which suggests the child is more likely to continue to have language difficulties:

• Quiet as an infant, little babbling
• History of ear infections
• Limited number of consonant sounds
• Does not imitate words
• Difficulty playing with peers
• Family history of a communication delay, learning or academic

difficulties

• Mild comprehension delay
• Uses few gestures to communicate

(Lowry, 2012)

Is a speech-language pathologist able to identify autism with a speech- language evaluation?

Evaluation for Autism

• Unable to diagnose a child

with ASD with only a speech evaluation.

• Disordered speech and

language skills are a big component of ASD, but this is not the only component which is assessed

• A multidisciplinary evaluation

with a speech therapist, behavioral therapist, psychologist, and physician is required to make an accurate diagnosis.

Warning/Predictive Signs of Autism

• Children who later develop ASD show differences in skill

development and other behaviors within the first year of life, and, as development progresses, becomes more widespread and pronounced differences become evident (Bolton, Golding, Edmond, & Steer, 2012)

• No response to name by first birthday (Nadig, Ozonoff, Young, Rozga,

Sigman, & Rogers, 2007)

• Limited/no joint attention
• No use of gestures when non-verbal
• Any loss of speech, babbling, or social skills at any age (not due to

recurrent ear infections)

• Poor eye contact/imitation skills
• More interest in objects than people
• Restrictive & Repetitive behaviors

Examples: hand flapping, rocking, spinning, peering at objects, putting objects in specific patterns

• Appear in their own world – little awareness of others

ASD vs. Speech Delay

DSM-V Diagnostic Criteria For Autism

• For a child to be diagnosed with Autism they need to meet the

diagnostic criteria in 2 categories

• Criterion A: Are there persistent deficits in social

communication and interactions NOT accounted for by general developmental delays? DSM gives a specific list of behaviors.

• Examples: Abnormalities in social approach, unusual

prosody, abnormal eye-to-eye gaze, exhibiting less interest in people than objects.

• Criterion B: Are there restricted, repetitive patterns of

behavior, interests and activities? DSM gives a specific list of behaviors.

• Examples: hand flapping, repetitive use of objects, marked

distress over changes in seemingly trivial aspects of the environment, an unusual attachment to a particular

• bject, excessively bothered by noises or sounds.
• The DSM outlines the number of these behaviors a child needs to

have in order to get the diagnosis

If you teach a child signs to communicate will it delay speech?

Baby Sign

• I have not seen baby sign result in a delay in verbal expression
• I encourage parents to use signs with their children
• Common signs I teach to children include “more”, “all done”,

“please”, “thank-you”, and “milk”

• Baby sign language can decrease the child’s frustration when

communicating, as children understand words earlier than they are able to express them

• Signing results in children becoming symbolic communicators earlier

Is there anything a parent/caregiver can do at home to improve a child’s speech and language skills?

Speaking Tips

• Place yourself at the child’s eye level when speaking.
• Establish eye contact before speaking.
• Slow your speech rate when talking to young children.
• Exaggerate your vocal inflection.
• Be sure to vary your tone of voice when speaking.
• Respond appropriately to the child’s tone of voice.
• Use animated facial expressions.
• Be sure your facial expressions match your message.
• Initially pair verbal messages with gestures.

(Quick, O’Neal, 1997)

Language Stimulation Techniques

• Call children by their names often.
• Talk to children, using all parts of speech. Verbalize what you are

doing and what the child is doing as it is happening.

• Reinforce an attempt to communicate.
• Realize overgeneralization is normal for children.
• Label objects and actions that are new to the child.
• Provide prompts or cues which allow the child to interact at a level

slightly above his/her current ability.

• Whenever possible offer the child choices.
• Encourage vocalizations or pointing when the child is indicating

preferences.

• Label feelings to assist the child in communicating his/her feelings.
• Expand the child’s utterances.
• Encourage child to make request verbally and provide a verbal

model if necessary.

• Provide simple commands for the child to complete.

(Quick, O’Neal, 1997)

Listening Tips

• Provide adequate time for children to respond to questions.
• Be silent at appropriate times when trying to encourage spontaneous

communication.

• Show the child you are listening by repeating parts of what they say

in your response.

• Avoid interrupting your child when you disagree.
• Always give the least intrusive prompts and cues to assist your child

in responding appropriately. (Quick, O’Neal, 1997)

Daily Activities which promote Language Development

• Talk through routines. Examples: wake up, diapering, dressing,

cooking, eating, nap time, leaving.

• Emphasize early concepts. Examples: more, hi/bye, all done, all

gone, fast/slow, uh-oh, yes/no, stop, please/thank-you, inside/outside.

• Read to the child each day.
• Complete musical activities. Examples: play with musical

instruments, dance to music, sing songs.

• Set aside a time each day to give the child your complete attention,

remove distractions, keep language simple, and make the play fun and exciting. (Quick, O’Neal, 1997)

Talking to children is what improves the child’s language skills.

https://www.youtube.com/watch?v=IYbaZ_828Lk

• Video Highlighting the importance of parents talking to their

children

Questions?

References

Beckman, D.A. (1986 Rev. 2007). Beckman Oral Motor Assessment and Intervention. Pulished by Beckman & Associates, Inc. Bernthal, John E. and Bankson, Nicholas W. Articulation and Phonological Disorders, Fifth Edition. Boston: Pearson Education, Inc., 2004. Print. Bolton, P.F, Golding, J., Emond, A., Steer, C.D. (2012) Autism Spectrum Disorder and Autistic Traits in the Avon Longitudinal Study of Parents and Children: Precursors and Early Signs. Journal of the American Academy of Child and Adolescent Psychiatry, 51(3): 249-260. Bowen, Caroline (2016). Red Flags for Speech Impairment. Retrived from www.speech-therapy.com Boyse, Kyla R.N. (2012). Speech and Language Delay and Disorder. Retrived from http://www.med.umich.edu/yourchild/topics/speech.htm Childhood Apraxia of Speech (2016). Retrived from http://www.asha.org/public/speech/disorders/ChildhoodApraxia/ Lowry, Lauren. (2011). How to Tell if Your Child is a Late Talker- And What to Do About It. The Hanen Centre. Retrieved from http://www.hanen.org/helpful-info/articles/how-to-tell-if-your-child-is-a-late-talker-–-and-w.aspx Hearing Loss in Children (2015). Retrived from http://www.pamf.org/hearinghealth/facts/children.html My Baby’s Hearing (2016). Retrived from http://www.babyhearing.org/hearingamplification/newbornscreening/howscreeningworks.asp Nadig, A.S., Ozonoff, S. Young, G.S., Rozga, A., Sigman, M., Rogers, S.J. (2007) A Prospective Study of Response to Name in Infants at Risk for Autism. Archives of Pediatrics and Adolescent Medicine, 161(4): 378-83. Oller, D. Kimbrough, Elilers, Rebecca E., Neal, A. Rebecca, and Schwartz, Heidi K. (1999) Precursors to Speech in Infancy: The Prediction of Speech and Language

• Disorders. Journal of Communication Disorders, 32, 223-245.

http://homepage.psy.utexas.edu/HomePage/group/NealLAB/Pubs/Precursors_to_speech.pdf

References Continued

Paul, Rhea. Language Disorders from Infancy Through Adolescence, Assessment and Intervention, Third Edition. St. Louis: Mosby Inc., 2007. Print. Quick, Jennifer, O’Neal, Alexandra. Promoting Communication in Infants and Young Children: 500 Ways to Succeed. Speech Bin. (1997). Print. Roth, Froma P. and Worthington, Colleen K. Treatment Reasource Manual for Speech- Language Pathology, Third Edition. Clifton Park: Thomson: Delmar Learing,

• 2005. Print.

Speech Sound Disorders: Articulation and Phological Processes (2016). Retrived from www.asha.org/public/speech/disorders/speech/sounddisorders/