Marshall University Speech and Hearing Center

SPEECH AND LANGUAGE EVALUATION

Date: February 12, 2015

Name: Shelly Adkins File No.: 39587-46Parents: Colin and Brooke Adkins Address: 134 Hubbs Lane Birthdate: December 12, 2006

Huntington, WV 25705

Telephone: 304-416-1264 (home) 304-429-6413 (mom’s cell)

Referral Information

Shelly is an 8 year, 2 month year old girl who is currently in the second grade at Jefferson

Elementary. Shelly was referred for an evaluation by her 2nd grade teacher after a parent teacher

conference was held regarding concern with Shelly’s academic success. Shelly’s teacher noted

that she seemed to be overwhelmed in the classroom and struggled to finish assignments. Her

parents expressed concerns about Shelly’s reading ability and social communication with her

peers. Shelly was seen for speech therapy to treat a severe phonological production disorder and

was dismissed when she was 6 ½ at the Marshall University Speech and Hearing Center

(MUSHC). Her parents and teacher felt that she may benefit from additional therapy.

Background Information

Birth History

Mrs. Adkins provided information about Shelly’s history by filling out an intake form prior to

the evaluation. She reported that Shelly was born vaginally at thirty-eight weeks with no major

complications and weighed 8lbs. 5 oz. Shelly was the 2nd born child and her health was within

normal limits during the first two weeks.

Medical History

When Shelly was two years old, she experienced frequent ear infections and her parents noticed

that she was not responding appropriately when they talked to her. They took her to Dr. Avery,

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an ENT, who recommended that Shelly receive P.E. tubes into her ears. Annotation: The first

few years of life is critical for children to learn speech and language when listening to other

people talk. If a hearing loss exists, a child does not get the full benefit of language learning

experiences. During this time, the child may miss out on some of the information that can

influence speech and language development (ASHA, 2015). After the surgery, she went to see

Dr. Avery for follow up visits and passed hearing screenings. Since then, Shelly’s parents require

her to use earplugs every time she swims or takes a bath. Furthermore, Becky has had no serious

illnesses, her eyesight is normal, and she is up to date with all her vaccinations.

Developmental History

Developmentally, Mrs. Adkins described Shelly as having “typical motor and growth

development”. She reported that Shelly began crawling at 10 months, took her first steps around

13 months, and began to eat solid foods at 8 months. She mentioned that Shelly was a quiet,

well-behaved baby and rarely threw temper tantrums.

Family Information

Shelly’s mother is a stay at home mom and her father is a traveling engineer. She has an older

sister, Amanda, who is 10 years old and a young brother, Zach, who is 5 years old. Mrs. Adkins

described Amanda as a “sociable, behaved young girl” and Zach as an “energetic, demanding

young boy”. Mr. Adkins travels frequently and is sometimes gone for weeks at a time. Mrs.

Adkins expressed concern that Shelly may not be receiving a lot of attention at home because

Zach requires a lot of her attention and Mr. Adkins not there all of the time. Furthermore, Mrs.

Adkins indicated that Mr. Adkins attended speech therapy for language problems during 2nd and

3rd grade. Annotation :A study conducted by Naseem Choudhury and April Benasich indicated

that specific language impairments (SLI) aggregate in families and that the risk for developing

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SLI is significantly higher for children born into families with a history of language disorders

(Choudhury, et al., 2003).

Educational History

Mrs. Adkins reported that Shelly needed to repeat the first grade because Shelly had difficulty

with phonemic awareness of consonants and vowels. In addition, Mrs. Adkins explained that

Shelly struggled sorting words into categories in order to gain a sense of the concepts.

Annotation: According to ELA.PD.1L, First graders at mastery level in language draw on

phonemic awareness to spell untaught words and use context clues to sort and determine the

meaning of words and phrases. Shelly’s inability to achieve mastery on phonemic awareness and

sorting words into categories, raised concern for her 1st grade teacher. In order to move onto the

next grade, Shelly needed to achieve a mastery level on the curricular standards. Annotation: In

the early learning years, ensuring that each student masters the content and skills needed for

mastery at the next grade level is critically important for student success (West Virginia Code,

2015). As a result, Shelly was unable to continue onto second grade until she performed at a

mastery level in the 1st grade. Mrs. Adkins reported that Shelly’s teacher was very supportive but

Shelly was upset that she was not able to continue on to the next grade with the rest of her peers.

Speech and Language History

In an initial interview with Mrs. Adkins, she explained that Shelly was unusually quiet during the

first six months of birth and was a “late talker” who did not produce her first words until 16

months. She also described that Shelly did not use words consistently with meaning until she

was almost 3. Annotation: Toddlers are identified as late talkers if they have less than a 50-word

productive vocabulary at age 2. Studies have indicated that 50% of toddlers who are identified as

late talkers fail to reach up to their peers by 3 years of age and are at risk for language learning

problems (Weismer et al., 1994). Mrs. Adkins reported that she thought that Shelly would catch

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up with her peers and when Shelly struggled with learning at age 4, she took her to the MUSHC

for a full evaluation where she was diagnosed with a severe phonological production disorder.

The graduate clinician at the MUSHC indicated that therapy focused heavily on working on final

consonant deletion and phonological awareness. Annotation: For children with severe/profound

disordered expressive phonological systems target patterns that are deficient, including word

structures related to omissions (Hodson , 2007). After 2 ½ years, Shelly reached all of her goals

and had age-appropriate speech production. As a result, she was discharged from therapy.

When Shelly began second grade, she struggled academically. Mrs. Adkins indicated that

Shelly’s speech is normal, but she seems to show difficulty pronouncing more complex words

that she does not hear as frequently. She also said that when Shelly tries to ask for something at

home, she sometimes does not “sound grammatical”. For example, instead of saying: “may I

have more noodles?” Shelly says: “may I have more noodle?” She also indicated that when

reading a story at home, Shelly often forgets what is going on and then fails to pay attention to

the rest of the story. Annotation: Gillon (2004) reported that literacy and phonological awareness

have been found to correlate strongly with phonological deficiencies.

Observations and Test Results

Formal Testing

The Clinical Evaluation of Language Fundamentals-5 (CELF-5) was administered to Shelly on

February 12, 2015. Annotation: “Standardized tests were designed to show whether a child

differs significantly from a normal population. To decide whether there is a meaningful

discrepancy between the client’s score and those of peers, a standardized test is the preferred

method” (Paul, et al., 2012). The CELF-5, composed by Semel, et al. (2011), is a comprehensive

language test used for children and adults ages 5-21. The test is designed to assess language and

communication skills in a variety of contexts, to determine the presence of a language disorders,

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describe the nature of the language disorder, and plan for intervention. The test includes 9

subtests and takes about 45 minutes to administer. The scaled scores are the result of 9 subtests

that measure general language ability, overall language performance, comprehension, listening,

oral language expression, vocabulary knowledge, and memory dependent language tasks. The

scaled scores are used to compare Shelly’s performance to the typical performances of the same-

age norm group. Her scaled scores are compared to a normalized score scale that has a mean of

10 and a standard deviation of +-3. A scaled score of 10 describes the average score of a given

age group and scores of 7-13 are 1 SD below the mean. Confidence intervals measure the

likelihood that a client will receive the same score with repeated numbers of administration. The

percentile rank provides the percentage of same aged peers whose raw scores are equal to or

lower than the client’s own score. For example, a percentile rank of 50 means that the client

scored equal to or better than 50% of the same age population. The CELF-5 was normed on a

sample of 3,000 people and reflects today’s diverse population. Record form 1, for ages 5-8, was

used to obtain data. Annotation: Information obtained from CELF-5 manual. The following is a

summary of Shelly’s scores on the CELF-5:

CELF-5Subtests

Scaled ScoreBased on a mean of 10

and a standard

deviation of 3

Standard deviation

From Scaled

Score and mean of 10

Confidence Interval

In relationship to the Scaled

Score at a 95% Confidence

Interval

Percentile Rank

% of test takers who scored at or below the

client

Test Tool Interpretation

Sentence StructureEvaluates comprehension of spoken sentences with increasing length and complexity

2 Between -2 & -3

0-4 .4 % Below Average

Linguistic Concepts Evaluates comprehension of spoken directions that include concepts such as: with, between, all, after, if

2 Between -2 & -3

0-4 .4 % Below Average

Word Structure Evaluates correct use of

3 Between -2 & -3

1-5 1 % Below Average

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morphology and pronouns Word Classes Evaluates comprehension of relationships between words

5 Between -1 and -2

3-7 5 % Below Average

Following Directions Evaluates ability to follow directions of increasing length and complexity separately from comprehension of basic concepts

4 -2 3-5 2 % Below Average

Formulated Sentences Evaluates the ability to formulate complete, semantically and grammatically correct, spoken sentences of increasing length and complexity

2 Between -2 & -3

0-4 .4 % Below Average

Recalling Sentences Evaluates the ability to listen to a sentence of increasing length and complexity, and repeat the sentence without changing word meaning, content, word structure, or sentence structure

2 Between -2 & -3

0-4 .4 % Below Average

Understanding Spoken Paragraphs Evaluates the ability to attend and focus while listen to spoken paragraphs, create meaning from narratives, answer questions about the content of information, and use critical thinking strategies for interpreting given information

5 Between -1 & -2

2-8 5 % Below Average

Pragmatics Profile To identify verbal and nonverbal pragmatic deficits that may negatively influence social and academic communication

6 Between -1 & -2

5-7 9 % Below Average

Description of subtests derived from: http://images.pearsonclinical.com/images/ca/brochures/CELF5_Test_Objectives_and_Descriptions

Based on the information above, Shelly performed below average on all of the subtests. A scaled

score of 7-13 (with a mean of 10 and standard deviation of 3) is considered average for a child

who is aged 8:0 to 8:11. Shelly scaled scores indicate that she is lower than the average mean of

children her age at a 95% confidence interval.

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Shelly demonstrated the most difficulty on the subtests that included: sentence comprehension,

linguistic concepts, formulating sentences, recalling sentences, and word structure. During the

sentence comprehension subtest, Shelly listened to a sentence and chose one of four pictures that

the sentence was describing. She struggled understanding sentences with prepositional phrases,

verb phrases, subordinate clauses, direct/indirect object, and interrogative. She demonstrated

strengths in comprehending sentences with indirect/direct requests, passive, relative clause,

infinitive, modification, and negation. In addition, the CELF-5 examinees ages 7-8 start on

number 10 of the linguistic concepts subtest. This subtest requires Shelly to listen to a command,

and then point to pictures. Shelly was unable to receive a perfect score on the first two items for

ages 7-8 and had to start the test from item number 1, and work up from there. She struggled

with inclusion/exclusion, sequence, and location concepts. On the formulating sentences subtest,

Shelly was provided with a picture and given a word. Then, she had to produce a sentence about

the picture using the word. Her results indicated that she struggled the most formulating

sentences with adjectives and adverbs. The test was discontinued when Shelly scored a 0 four

times consecutively. During the recalling sentences subtest, Shelly consistently recalled

sentences with 1-3 errors and frequently omitted articles in the sentences. The test was

discontinued when Shelly received 4 or more errors four times consecutively. In regards to the

word structure subtest, Shelly had to identify matching word forms to pictures. She struggled

with regular plural, irregular plural, third person singular, auxillary +ing, possessive pronouns,

irregular past tense, reflexive pronouns, and uncontractible copula/auxiliary. It should be noted

that Shelly was frustrated during this subtest and was upset when she could did not know the

answer.

On the remaining subtests, Shelly exhibited the following results. During the pragmatics profile,

she demonstrated age appropriate pragmatic skills except when she showed difficulty with:

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introducing appropriate topics of conversation, making relevant contributions to a topic, asking

for/responding to requests for clarification, using strategies for getting attention, giving/asking

for directions, asking for help from others, and offering to help others. In addition, Shelly was

able to follow one and two level commands during the following directions subtest. She

struggled when the commands increased in complexity and number of modifiers. In addition, she

showed strengths in the word classes subtest with semantic classes and location categories. The

test was discontinued when Shelly struggled with tasks that involved categories of composition,

synonyms, object function, and word opposites. During understanding spoken paragraphs

subtest, Shelly was able to answer questions regarding prediction and sequence, but struggled

with questions that involved the main idea, detail, and inference.

The CELF-5 index scores are calculated by converting the sum of particular scaled scores to a

standard score. The following table indicates the index scores that measures Shelly’s overall

language abilities on the CELF-5:

CELF-5 Index Scores

Standard Score

Standard Score

Deviations (+- 15) from

Mean of 100

Confidence Interval

In relation to the Scaled Score at a 95% Confidence

Interval

Percentile Rank% of test takers who scored at or below the client

Test Tool Interpretation

Core Language Score (Sentence Structure, Word

Structure, Formulated Sentences, Recalling Sentences)

53 -2 and below

46-60 .1 % Severe

Receptive Language Index(Sentence Structure, Word

Classes, Following Directions)63 -2 and

below56-70 1 % Severe

Expressive Language Index(Word Structure, Formulated

Sentences, Recalling Sentences)55 -2 and

below 48-62 .1 % Severe

Language Content Index(Linguistic Concepts, Word

Classes, Following Directions) 63 -2 and

below 56-70 1 % Severe

Language Structure Index (Sentence Comprehension,

Word Structure, Formulated 55 -2 and 48-62 .1 % Severe

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Sentences, Recalling Sentences below

The information above indicates that Shelly’s standard scores do not fall between the average

standard scores of 85-115 that 8-year-old children scored. Her standard deviations of -2 and

below, indicates that she is at a very low range and severe. Annotation: One way to determine

the severity of a language disorder is to examine the deviation of a student’s scores from the

mean of 100. Scores below -1 SD indicate that the student is demonstrated below average to very

low language abilities related to same age peers (Determining a Language Disorder, CELF-5).

Shelly performed at the level of severe in all areas of language. She exhibited more difficulty

with expressive language than receptive language, which is an important factor for intervention.

Non-standardized Testing

Shelly’s evaluation also involved a variety of non-standardized assessments that gave further

information about her abilities and behaviors outside the barriers of a standardized score.

Annotation: “other forms of assessment are necessary to establish baseline function, to identify

goals for intervention, and to measure progress in an intervention program. Standardized tests

were not designed for any of these purposes and they are not valid or efficient approaches for

gathering this type of information” (Paul et.al, 2012). Prior to the evaluation, the clinician

observed Shelly in the classroom and had an informal interview with Shelly’s teacher, Mrs.

Ross. During the evaluation, the clinician provided a variety of activities to assess Shelly’s

language and writing abilities. The following information provides a detailed description of the

non-standardized testing.

Curriculum-Based Assessment

A curriculum-based assessment was administered before Shelly’s evaluation on February 12,

2015. Annotation: A curriculum-based assessment refers to the use of a student’s progress in the

curriculum of the local school to provide the measure of success in education (Nelson, 1989).

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The assessment consisted of an interview with her teacher, Mrs. Ross, and an onlooker

observation of the classroom to determine how Shelly uses language while learning the

curriculum of the classroom. Annotation: Onlooker observation techniques are usually the most

natural because they allow observation of the student’s ability to process the written and oral

language of the curriculum without intervention (Nelson, 1989). During the assessment, the

clinician evaluated Shelly’s rule systems, modalities, and linguistic levels in a variety of

contexts. Based on West Virginia’s 2nd grade curriculum, Shelly needs to show mastery

performance in the second grade before advancing to the third grade.

Interview with Teacher

The clinician interviewed Shelly’s teacher, Mrs. Ross. Annotation: It is important to interview

school personnel to obtain information about official curriculum expectations and the student’s

daily schedule. Also, asking questions to teachers can cause them to reflect in a new way on their

student’s ability to process the language of instruction (Nelson, 1989).

Academic

Mrs. Ross stated that Shelly performs the best in math, but struggles with word problems.

Also, Mrs. Ross indicated that Shelly does well in science with hands-on activities, like

experiments, and struggles following multistep directions. According to the West Virginia 2nd

grade curriculum, science consists of understanding: the relationship of vibrating objects and air,

properties of solids and liquids, patterns of weather, and animal life cycles. In addition, Mrs.

Ross stated that Shelly takes longer to complete experiments and works harder when she is

verbally reinforced. In addition, Mrs. Ross reported that Shelly has difficulty switching tasks

because it takes her longer than her classmates to finish each task. Annotation: School-aged

children with LLD tend to take longer to comprehend and process passive sentences with relative

and adverbial clauses (Paul, 2000c). During social studies, Shelly is expected to explore

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communities in the United States, learn how to locate places on a map, and read about historical

people of the past. Mrs. Ross reported that Shelly generally gets B’s on Social Studies quizzes, if

the material is read aloud. However, if a short paragraph is assigned to write about, she does not

get the main point of the paragraph. Mrs. Ross showed an example of this (Appendix 1) and

explained that Shelly struggled answering questions based on information that she just read. For

example, she gave several wrong answers when asked to answer questions about the Earth. Her

score of 1/10 indicated that she struggles meeting expectations that is stated by the curricular

standards. Annotation: ELA.2.W.C11.2 states that 2nd grade students will gather information to

answer a question. Mrs. Ross stated that Shelly “does not prefer language arts and her

performance has been getting progressively worse since the beginning of the year”. Mrs. Ross

indicated the following about Shelly’s performance in Language Arts: Shelly exhibits the most

difficulty during reading and writing in Language Arts. She fails to understand age-appropriate

stories during Language Arts and struggles understanding characters, settings, and plots.

Annotation: ELA.2.R.C4.1 2nd grade students will use information gained from the illustrations

and words in a print to demonstrate understanding of its characters, setting or plot. During read

aloud activities, Shelly demonstrates difficulty by using labored speech, sounding out each sound

in words, skipping words, and reading in a quite voice. Annotation: Many children with LLD

have limited verbal fluency and do not talk very much. What they say is usually brief and

unelaborated (Oetting et al., 2009). Mrs. Ross expressed concern about Shelly’s reading ability

because, according to the WV curricular standards, Shelly needs to be able to read and

comprehend literature by the end of the year.

Teaching Style

Mrs. Ross indicated that each subject is taught for an hour and the children get an hour and a half

for recess and lunch. She uses the SmartBoard as a visual when teaching math and science and

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uses textbooks when teaching language arts and social studies. She assigns homework daily and

regularly checks to make sure students have completed their homework. In addition, Mrs. Ross

stated that Shelly does not ask for clarification or questions when she does not understand

directions. She goes over to Shelly to offer more assistance and re-explain directions whenever

she feels that the directions she gave are very complex. Mrs. Doss expressed concerns that

sometimes she does not know whether or not Shelly understands the directions and that it is

taking more time in class to re-explain directions. Annotation: Children with LLD, often have

difficulty in understanding complex oral directions (Murray et al., 1985).

Discourse Analysis

Appendix 2

During Language Arts, the children were asked to write about a fun dream that they had. When

writing her story, Shelly demonstrated difficulty by misspelling words and using short, choppy

sentences. For example she wrote: “I had a fun dreem. It was rilly fun.” instead of “I had a really

fun dream”. Her writing sample also showed difficulty writing singular and plural nouns,

personal and possessive pronouns, and incorrect usage of verbs to convey a sense of the past. For

example, she wrote: “Us like mirmades” and “I goed swim”. Annotation: Many children with

specific language impairments have particular problems with grammar. Hsu and Bishop (2011)

discussed difficulty with verb inflectional endings (e.g. “she comb her hair”) and poor

understanding of word order (Hsu, HJ. And Bishop, DVM., 2011). Also, Paul (2012) discusses

that children with LLD may display errors in plurals, possessives, third-person singular, irregular

forms, subject-verb agreement, comparatives, and superlatives. According to ELA.2.L.C15.1,

Shelly should demonstrate command of the conventions of Standard English grammar and when

writing. She is expected to use reflexive pronouns and past tense.

Behavioral Analysis

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Appendix 3

With regards to Shelly’s behavior, the clinician used Erikson’s (1987) worksheet for

analyzing Shelly’s behavior. The clinician used this worksheet to obtain the frequency of

Shelly’s discourse skills, speech acts, and communication functions. Annotation: in order to

perform a behavioral observation, a recording document that contains a way to collect

quantitative data must be used (Paul, 2013). In addition, the clinician will examine the Shelly’s

communicative performance without the restrictions and limitations within the therapy room.

The data was collected throughout the day in Shelly’s classroom and during recess. Results from

the behavior analysis indicated that Shelly did not start a conversation, responded with

inappropriate content, frequently interrupted, inappropriately ended a conversation, did not

recognize the listeners view point, did not demonstrate topic relevancy, and used inappropriate

response length (Erikson, 1987). For example, when Shelly was talking to a peer during recess,

she never took the initiative to talk to a girl in the sand box. She did not ask for toys in the

sandbox and left when someone asked to use her toy. She frequently apologized to her friends

during recess and rarely started a conversation with peers. In addition, when talking to peers,

Shelly occasionally did not show appropriate listening behavior by leaving the conversation or

giving a blank stare when someone was talking to her. In addition, Shelly’s results indicated that

she was unable to label, ask, or describe actions (Erikson, 1897) during a group activity in

reading class. She never asked for information from her peers or her teacher. Also, Shelly was

shy and only spoke when she was spoken to. The kids in her class tended to make fun of her, and

did not include her during play. She reacted by sitting and playing by herself. She did not speak

in class unless the teacher called on her. She sat near two boys in the back of the room who

talked often during class and were constantly being scolded.

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During recess, Shelly played with the younger children rather than the 2nd or 3rd graders

who are more her age. Annotation: Recent studies have shown that children with impaired

language skills interact differently than their normally developing peers in a classroom context,

are less preferred playmates than their peers, and experience difficulty with basic social tasks

(Fujiki et al., 1996).

Pragmatic Assessment

Appendix 4

The clinician assessed pragmatics by using Prutting and Kircher’s (1983) Pragmatic Protocol

throughout the observation. To use the Pragmatic Protocol, the clinician subjectively rates each

type of communicative act as appropriate, inappropriate, or no opportunity to observe. In regards

to Shelly’s verbal or non-verbal utterances, she demonstrated appropriately. During group work

in class, she was very quiet and was interrupted by a peer when she tried initiating conversation.

It was difficult for her to maintain conversation within the group. As a result, Shelly did not

provide much input and the group did not ask her questions. During recess, a peer asked if Shelly

wanted to play four square with them. She gave an incomplete response when she said: “I think I

want to go on the swings, but…”. Instead of repairing the conversation and completing what she

wanted to say, Shelly walked away. Shelly’s quiet and reserved personality made it difficult for

the clinician to assess all of the areas in the Pragmatic Protocol.

Socially

Mrs. Doss stated the following about Shelly’s social skills. In the beginning of the school year,

Shelly made strong attempts to be friends with other classmates. Many of the classmates did not

want to play with Shelly or include her in group activities because she frequently did not seem

like she was paying attention to what her peers with saying to her or she seemed uninterested..

Annotation: Students with LLD are often less: polite, clear, and complete than their peers

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(Brinton et al., 1988). During recess, Shelly either plays Barbies or swings on the swings the

younger students in 1st grade. If the 1st graders are not outside for recess, Shelly typically colors

pictures by herself or plays on the slide alone.

Portfolio Assessment

Prior to the evaluation, the clinician asked Mrs. Adkins to bring a variety of Shelly’s writing that

she completed throughout the year. An assessment of Shelly’s portfolio was done at this time.

Annotation: “Portfolio assessment involves systematically collecting samples of the student’s

writing ability throughout the course of the intervention program and using these samples to

evaluate progress” (Paul, et.al, 2012). Shelly’s writing reflected her oral language in that she

used short, limited vocabulary and frequently left off –ed and –s. Mrs. Adkins said that her

written work is usually shorter and more simple than the rest of the classmates.

Language Sample

Appendix 5

A language sample was taken during Shelly’s evaluation on February 12, 2015. Based on her

age, the clinician choose to elicit conversation by giving Shelly a wordless picture book and

having her tell a story based on the pictures in the book. Shelly’s ability to produce connected

discourse was also assessed during this activity. The wordless picture book contained pictures of

children playing outside during recess. The language sample was recorded and scoring

procedures were determined by the SALT database. Annotation: “Clinicians and researchers can

use the SALT software to automatically generate a data file documenting their target child’s

performance, average performance of age-matched children from the relevant database, and the

statistical significance of differences in performance” (Heilman et. al., 2010). SALT compared

Shelly’s sample to age-matched peers in the database. SALT calculates the mean, min, max,

standard deviation, and % of standard deviation of the 80 participants. In addition, the database

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calculates Shelly’s score and how many SD she was above or below the mean of the participants.

Then, Shelly’s data is compared to the participants to determine if she demonstrated scores

lower, the same, or higher to same-aged peers in the database. Shelly demonstrated lower scores

with 1 SD from the database mean in total complete words, MLU in words, utterances with

overlapping speech, number of maze words, and word-level error codes. In addition, her results

indicated that she is 2 SD below the database mean in total utterances, C&I verbal utterances,

MLU in morphemes, utterances with mazes, number of mazes, and maze words as % of total

words. As a result, Shelly performed lower than same-aged peers in length, syntax/morphology,

mazes and abandoned utterances, and omission and error codes. Annotation: All results from

SALT Software LLC, 2015. Annotation: Children with language learning difficulties differ from

typically developing peers on a number of measures including length of utterances; number of

grammatical errors such as omissions and substitutions; and prevalence of word finding

difficulties by over reliance on non-specific vocabulary, circumlocutions, or mazes (Fiestas et al.,

2005)

Speech, Fluency, Voice, and Hearing

An oral mechanism examination showed that Shelly’s oral structure and mechanisms were

within normal limits. Her rate and intonation during diadochokinetic activities were within

normal limits, which indicated accurate fluency. Her voice was appropriate in regards to quality,

pitch, and loudness. The clinician evaluated the intelligibility (the degree to which speech can be

understood) of Shelly’s speech during the formal language sample and conversational speech.

Her speech was judged to be intelligible, but the clinician noted short utterances, errors in

grammatical morphemes, and limited expressive vocabulary.

A hearing screening was conducting during the evaluation and the results of her otoscopy,

tympanometry, and pure tone screenings were within normal limits. Her tympanometry, a type of

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hearing test that assesses the ear drum’s functioning, was conducted and revealed a Type A

tympanogram with typical functioning. Annotation: Type A tympanogram, when the peak

compliance occurs at or near atmospheric pressure, indicates a normal middle ear system free of

fluid (ASHA, 2015). A pure tone hearing screening was conducted with tones at 1000 Hz, 2000

Hz, 3000 Hz, and 4000 Hz that were each presented at 20 dB. Shelly consistently responded at

each frequency level indicated that Shelly passed the hearing screening.

Impressions

Shelly Adkins is an 8 years 2-month-old 2nd grader with a severe receptive and expressive

language disorder with foundations in phonological processing deficits. She was referred to the

speech therapist at Jefferson Elementary due to parent and teacher concerns regarding academic

struggles in the classroom. Testing indicated that Shelly struggles in all language components

and scored the lowest on sentence structure, linguistic concepts, formulating sentences, and

recalling sentences. Her consistent errors in comprehension of particular words suggest

challenges in comprehension of various vocabulary and concepts. Her teacher, Mrs. Doss,

reported that she has difficulty comprehending what she is reading, and frequently shows

misunderstanding of directions. Mrs. Doss’s use of complex words during directions and

Shelly’s seating in the back of the room may be a factor resulting in misunderstanding of

directions. Also, Shelly’s inability to comprehend what she is reading could be the result of poor

decoding skills and a deficit in her ability to store phonological representations of new words in

her long term memory. She also may be lacking information about the specific topic that she is

reading, which is limiting her learning and making her fall further behind same-aged peers. Her

speech sample and portfolio assessment indicated that she has a limited expressive vocabulary

and frequently misuses –ed and –s. Her expressive abilities may be affected by her limited

knowledge and understanding of certain words. Her difficulty to make friends could be the result

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of her poor social skills. Furthermore, Shelly exhibits an inability to self-monitor and ask

questions when she does not understand directions given by her teacher.

Diagnosis

Shelly’s standardized, non-standardized tests, observations, and interview results indicated a

severe receptive and expressive language disorder with foundations in phonological processing

deficits.

Prognosis

Shelly’s chance of improving overall language abilities are judged to be good based on her

attentiveness and positive family and teacher support.

Recommendations

Shelly could benefit from speech-language intervention to improve her language and reading

comprehension in order for her to communicate effectively in all settings and progress in

academic environments. Individual instruction for strategies on how to use knowledge about

topics of her curricular reading material through oral language activities and exposure to

information in multiple modalities can be combined with group instruction or class-work with

the teacher to improve reading comprehension. It is recommended that Shelly receive language

therapy 2.3x per week for 45 minutes. Also, the clinician should administer a phonological

awareness test with goals to follow if necessary. The teacher should move Shelly to the front of

the room next to non-disruptive classmates. Collaboration with the teacher and parents should

be implemented frequently throughout the day to keep track of Shelly’s progress in learning. It is

evident that Shelly does well when given positive reinforcement and reminders of how well she

is doing. Hands on activities and art projects would be beneficial to use in therapy. Rewards of

stickers on a daily basis may boost her self-confidence and work ethic. Regular attendance to

class and speech therapy would result in the most beneficial outcome.

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Alison Stewart

_______________________________________________Alison Stewart

Graduate Clinician

Therapy Plan

Client Name: Shelly, A

Statement of Problem:

Referral Information:

Shelly is an 8 year, 2 month year old girl who is currently in 2nd grade at Jefferson Elementary. Shelly was referred for an evaluation by her 2nd grade teacher after a parent teacher conference was held regarding concern about Shelly’s academic success. Shelly’s teacher noted that she seemed to be overwhelmed in the classroom and her parents expressed concerns about Shelly’s reading ability and social communication. On February 12, 2015, Shelly participated in an evaluation that was administered by the speech therapist at Jefferson Elementary. Her standard testing showed below average in all of the subtests and a score of severe in all areas of language, indicating a severe receptive and expressive language learning disorder. Non-standardized assessments indicated deficits in: possessive verbs, and higher-level expressive vocabulary. These impairments have significantly impacted Shelly’s ability to excel in academic and social environments.

Recommended Goals

Terminal Goal:

1. Shelly will independently utilize language learning and comprehension strategies and perform curricular goals at a mastery level.

Intermediate Goals

Goal #1: Shelly will use evidence based multimodal strategies to increase correct usage of verbs in order to meet the second grade curricular goal of “using and irregular verbs correctly; and producing, expanding, and rearranging sentences “(WCDEO), ELA.2.L.C15.1 as measured by a minimum of four on the following five point rubric.

Morphology is the structure of a language’s morphemes and other linguistic units, such as

root words, affixes, part of speech, intonations and stresses, or implied context. Morphology

plays a vital role in improving vocabulary and reading comprehension. Based on Shelly’s

standardized and non-standardized results, she struggled with pronouns and verbs. In order for

her to explain and produce complex sentences, Shelly should acquire the ability to use these parts

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of speech in order to excel in second grade. It is imperative that her morphological system is at

the same level as her peers, so that Shelly can excel not only language arts, but other areas as

well. Annotation: Paul (2013) suggests that students can use morphological strategies to apply to

spelling skills as students become more able to take advantage of what they know about relations

among words to learn and retain new spellings. The clinician will use Connell (1982) 5 step

training procedures for teaching syntactic rules through contrasts to help Shelly develop

strategies. Annotation: Connell (1982)’s target behavior is for the child to use spontaneous

production of “NP is(verb)-ing” in response to questions. The clinician will use 20 pictures of

assorted agents doing various actions to elicit the response. For example, the first step is for the

clinician to say: “What is the NP doing?” Then, the client’s correct response would be: “NP is

(verb)-ing. In the second step, the clinician takes the picture away and says “NP is (verb)-ing.

Now the NP is done. What did the NP do?” As a result, Shelly will learn present and past tense

verbs by looking at a picture and indicating when it is there vs. when it is not there. For

generalization, the clinician will repeat Connell’s steps with different pictures and environments.

Shelly’s teachers and clinician will collaborate together to collect data about Shelly’s

ability to use verbs when writing and speaking. Her performance will be rated according to the

morphological rubric below. The teacher and clinician will rate Shelly’s ability after each

individual session with the SLP and each day in the mainstream classroom by the teacher.

1 2 3 4 5 Requires

explicit verbal prompting and

model from clinician.

Requires frequent verbal prompting and

model from clinician.

Requires occasional

verbal prompting.

Requires some assistance from

clinician.

Does not require any assistance

or verbal prompting from

clinician.

Requires no prompts or

assistance from clinician. Able to teach model

to another classmate.

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Goal #2: Shelly will use evidence based metalinguistic discussions and inference strategies in order to increase collaboration to meet the second grade goal of participating in collaborative conversation with classmates by providing sufficient contextual information about topics discussed in class and asking for clarification and/or explanation as needed (ELA.2.SL.C13.1) as measured by a minimum of four on the following five point rubric.

Students with LLD show many communication problems in the area of pragmatics. Since

Shelly is very shy and does not have many friends her age, it is important for Shelly to develop

strategies to use when communicating with peers of her same age. Westby, C (2007) discusses

using classroom scripts that can be used in therapy for metalinguistic discussions of classroom

discourse. Annotation: Components of classroom scripts include: rules for participation in class

discussion, turn-taking, and feedback. Each component consists of elements and an explanation

(Westby, 2007). During therapy, the clinician will construct a “mini classroom” for discussing

and practicing classroom discourse. Annotation: Each mini class session begins with discussion

of a school event or routine. After discussing the hidden rules and structure of each script, the

students do an activity involving script, with some taking roles of students and one taking the

role of the teacher (Ripich and Spinelli, 1985). For Shelly’s particular case, the mini class role-

play will involve a cooperative learning group. The clinician will collaborate with Shelly’s 2nd

grade teacher and use topics discussed in the classroom to incorporate in intervention. The mini

classroom for discussing and practicing classroom discourse will be used during individualized

therapy for Shelly to learn and practice a strategy that will help her when collaborating with

peers in her classroom.

Shelly must receive a 4 on the following rubric to meet this goal. Shelly’s teacher and

clinician will collaborate together to collect data about Shelly’s ability to use metalinguistic and

inference skills to collaborate in group discussions with peers:

1 2 3 4 5 Requires Requires Requires Verbal prompts Requires no

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explicit verbal prompting and

model from clinician.

frequent verbal prompting and

model from clinician.

general verbal prompting.

Requires some assistance from

clinician.

from clinician are indirect and rare. Does not

require any assistance from

clinician.

prompts or assistance from clinician. Able to teach model

to another classmate.

Goal #3: Shelly will use evidence based visual and application strategies to determine or clarify the meaning of unknown and multiple-meaning words and phrases based on grade 2 reading and content (ELA.2.L.C17.1) as measured by a minimum of four on the following five point rubric.

A student needs to have an extensive vocabulary for reading comprehension and

expressive language. In order to succeed in the second grade classroom, Shelly needs to develop

strategies to use vocabulary that the West Virginia standards require. Since Shelly scored low on

the receptive and expressive language subtests of the CELF-5 and showed limited vocabulary

during observation, incorporating vocabulary learning into therapy is essential. The clinician will

incorporate Marzano (2009) six step process for building academic vocabulary. Shelly will

develop strategies through this model and practice the strategies throughout therapy and in the

general classroom. Annotation: First, the clinician will model the model the word in context. The

child will put the word in context by showing pictures or telling a story using the word. Second,

student will describe and explain the term as it relates to them. The child will discuss this term

with peers to build understanding and seek additional information from other sources (e.g. books,

internet). Third, the student will create an illustration, drawing, or graphic. Fourth, the student

will provide activities to expand meaning of the term and make connects. This can be done by

identifying antonyms and synonyms, as well ass associating the prefix, suffix, and root words.

Fifth, the student will discuss their words and talk about a favorite and most challenging word.

Sixth, the student will play vocabulary games that will stimulate interest and enthusiasm about

vocabulary as well as provide multiple exposures to terms. Shelly’s teacher and clinician will

collaborate together on a word that they will use each week to teach and assess her ability to

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show understanding of each concept. Shelly will keep a notebook that has each word she is

learning with visual representations and strategies she used in therapy with the words. The

following rubric will be used to collect data on Shelly’s ability to show understanding of the

concepts:

1 2 3 4 5 Student

demonstrates no understanding of

the word.

Requires complete model and

maximal cueing from the clinician

Student demonstrates some understanding of

the word.

Requires model and frequent cueing from

clinician

Student demonstrates

partial understanding of

the word.

Requires no model and occasional

cueing from clinician

Student demonstrates

complete understanding of

the word

Requires no model or cueing from

clinician

Student uses the word with multiple

communication partners and in a variety of contexts

Requires no model or cueing from

clinician

Goal #4: Shelly will use evidence based metacognitive strategies in order to meet the 2nd grade curricular goal that states second graders will “develop from a dependent reader to an independent reader and will begin to make their own choices for informative reading (English Language Arts WVSC) as measured by achieving a 3 on the following rubric.

In order for Shelly to improve her reading comprehension, story understanding is a vital

component. Shelly needs to understand the components of story grammar in order to fully

comprehend what she is reading. In order to become an independent reader, Shelly needs to be

able to answer key ideas to demonstrate understanding of key details in literary text

(ELA.2.R.C1.1). In addition, the 2nd grade curricular requires students to describe how characters

in a story respond to major events and challenges in literary text (ELA.2R.C1.3). The clinician

will use Wichmann et. al, (2012) intervention plan to teach Shelly strategies that will allow her to

become an independent reader. Shelly will identify story grammar components, work with peers

to retell a story, retell a story to a group of peers, create a story with a group, and individually

create a story with all story grammar components (Wichmann et. al, 2012). This goal will be

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incorporated with group therapy and the clinician will consult with Shelly’s classroom teacher

and give instruction on how to use strategies to increase reading comprehension, not only with

Shelly, but also with the whole classroom. Data will only be collected on one skill at a time,

incorporating the next skill after the previous one is achieved.

Skill 3: Requires a model and

maximal cueing2: Requires occasional

cueing1: Independently uses skill with no model or cueing

3: Requires a model and maximal cueing

2: Requires occasional cueing1: Independently uses skill with no model or cueing

3: Requires a model and maximal cueing

2: Requires occasional cueing1: Independently uses skill with no model or cueing

3: Requires a model and maximal cueing

2: Requires occasional cueing1: Independently uses skill with no model or cueing

Identify Story Grammar Components

Student identifies: setting, problem,

episode, destination

Date:

Rate:

Date:

Rate:

Date:

Rate:

Date:

Rate:

Story Retell Group

Student works together with peers to retell story

Date:

Rate:

Date:

Rate:

Date:

Rate:

Date:

Rate:

Story Retell Individual

Students retell a story to a group of peers

Date:

Rate:

Date:

Rate:

Date:

Rate:

Date:

Rate:

Create A Story Group

Students create a story with a group using all components of a story

Date:

Rate:

Date:

Rate:

Date:

Rate:

Date:

Rate:

Create A Story Individual

Students individually use all components of a story create a story and share it

with peers

Date:

Rate:

Date:

Rate:

Date:

Rate:

Date:

Rate:

Derived from: Wichmann et al., 2012

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Daily Lesson Plan

Client: _______________________Clinician:_____________________Date:__________________________

Objectives Shelly will:

1) Use visual and application strategies when learning the word of the week and use her

vocabulary notebook as a reference guide

Procedures

The clinician will:

1) Use Marzano’s (2009) six-step process to teach Shelly academic vocabulary. The clinician

will develop a notebook for Shelly that will consist of all of the vocabulary words she is learning,

as well as the activities that she is doing to learn. The six steps are outlined below:

1. Clinician will provide a description, explanation, or example of the new term (e.g. providing context, telling a story that integrates the word, using videos

1. Shelly will use the word in context by showing pictures with the word or telling a story

2. Shelly will restate the description, explanation, or example her own words. She will record the word in her vocabulary notebook and seek additional information from other sources (books, internet, etc.) The clinician will monitor and correct misunderstandings.

3. Shelly will make a visual representation with a vocabulary card template that has the word, definition, and picture on it. On the back of the card, Shelly will write or draw other

illustrations of the word to increase her understanding. This will be added to her vocabulary notebook for a reference.

4. Shelly will participate in activities that help to build her knowledge and make connections of the terms in her notebook (highlighting prefixes, suffixes, root words that

will help them remember the meaning of the word, identify synonyms and antonyms, sort or classify the word, compare similarities or differences)

5. Shelly will discuss the terms with peers and the clinician periodically (e.g. think-pair-share, describe pictures to others)

6. Clinician will involve Shelly in games that allow her to play with the vocabulary word (e.g. memory, charades, Pictionary, bingo, create a skit)

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The clinician will collaborate with the teacher prior to therapy to develop a vocabulary word that

will be used that week in her general education classroom. Shelly will incorporate materials into

her vocabulary word notebook. The notebook will be a reference guide for Shelly to look back

when she is unsure of a word that she learned. The clinician will regularly check her notebook to

ensure that she is adding materials as needed. In addition, the clinician will encourage Shelly to

add words in her notebook and use the visual and application strategies learned in therapy to

learn additional words.

Materials

1. Notebook

2. Pictures that has word in it or represents vocabulary word

3. Books, magazines, objects that have work in it

4. Colored pencils, markers

5. Vocabulary card template

6. Vocabulary dice

Reference List

Barrier Games (2010, April). In Talking Matters: Speech Pathology & Occupational Therapy. Retrieved March 6, 2015.

Brinton, B., Fujiki, M., and Sonnenberg, E. (1988). Responses to requests for clarification by linguistically normal and language impaired children in conversation. Journal of Speech and Hearing Research, 53, 383-391.

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Causes of Hearing Loss in Children (2015). In American Speech-Language-Hearing Association. Retrieved from http://www.asha.org/public/hearing/Causes-of-Hearing-Loss-in-Children/

Choudhury, N., & Benasich, A. A. (2003). A family aggregation study: The influence of family history and other risk factors on language development. Journal of Speech, Language,

and Hearing Research, 46(2), 261-72.

Connell, P. (1982). On training language rules. Language, Speech, and Hearing Services in School, 13, 231-248.

Fiestas, C. E., Bedore, L. M., & Pena, E. D. (2005). Use of Mazes in the Narrative Language Samples of Bilingual and Monolingual 4- to 7-year old Children. , 730-740.

Fujiki, M., & Brinton, B. (1996). Social Skills of Children With Specific Language Impairment. Language, Speech & Hearing Services In Schools, 27(3), 195-202.

Gillon, G. T. (2004). Phonological awareness: From research to practice. New York: Guilford Press.

Heilmann, J. J., Miller, J. F., & Nockerts, A. (2010). Using Language Sample Databases. Language, Speech & Hearing Services In Schools, 41(1), 84-95.

Hsu, H. J., & Bishop, D. V. M. (2011). Grammatical Difficulties in Children with Specific Language Impairment: Is Learning Deficient? Human Development, 53(5), 264–277. doi:10.1159/000321289

Marzano, R. (2009). Six steps to better vocabulary instruction. Educational Leadership, 67, 83-84.

Montgomery, J.W., Magimairaj, B.M, % Finney, M.C. (2010). Working memory and specific language impairment: an update on the relation and perspectives on assessment and treatment. American Journal of Speech-Language Pathology, 19, 78-94.

Murray, S., Feinstein, C., and Blouin, A. (1985). The token test for children: Diagnostic patterns and programming implications. In C.S. Simon (Ed.). Communication skills and classroom success: Assessment of language-learning disabled students. San Diego, CA: College-Hill Press.

Nelson, N. W. (1989). Curriculum-based language assessment and intervention. Language, Speech, and Hearing Services in the Schools, 20, 170-184.

Oetting, J., & Hadley, P. (2009). Morphosyntax in child language disorders. In. R. G. Schwartz (Ed.). The Handbook of Child Language Disorders (pp. 341-364). New York, NY: Psychological Press.

Paul, R. & Norbury, C. F. (2012). Language disorders from infancy through adolescence: Assessment & intervention (4th Ed). St. Louis, MO: Mosby.

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Paul, R. (2000c). Understanding the “whole” of it: Comprehension assessment. Seminars in Speech and Language. 21 (3), 10-17.

Pennington, B. F., & Bishop, D. V. M. (2009). Relations among speech, language, and reading disorders. Annual Review of Psychology, 60(1), 283-306.

Prutting, C. A., & Kirchner, D. M. (1987). A clinical appraisal of the pragmatic aspects of language. Journal of Speech and Hearing Disorders, 52(2), 105.

Ripich, D., and Spineli, F. (1985). School discourse problems. San Diego, CA: College-Hill Press.

Semel, E., Wigg, E. H., & Secord, W. A. (2013). Clinical Evaluation of Language Fundamentals- Fifth Edition (CELF-5). In Pearson.

Weismer, S. E., & Murray-Branch, J. (1994). A prospective longitudinal study of language development in late talkers. Journal Of Speech & Hearing Research, 37(4), 852.

West Virginia Department of Education (WVDOE). CSO-Teach 21. Retrieved from https://wvde.state.wv.us/policies/p2520.1a.pdf

West Virginia Code: Transformative system of support for early literacy (2015). In West Virginia

Legislature: 1st session of the 82nd legislature . Retrieved March 28, 2015, from http://www.legis.state.wv.us/wvcode/ChapterEntire.cfm?chap=18&art=2E§ion=10

Westby, C. (2007). There’s more to passing than knowing the answers: Learning to do school. In T. Ukrainetz (Ed.) Contextualized language intervention (pp. 310-338). Eau Claire, WI: Thinking Publications.

Wiechmann, J., Rudebusch, J., & Kuhles, N. (2012). Language Lab: Response to Intervention Program for Teaching Grammar, Vocabulary, and Storytelling. Greenville, SC: Super Duper.

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