Peds Assessment Exam 2

why do clinicians integrate standardized and alternative assessment data rather than relying on a single test?

a single test cannot identify a disorder alone. a comprehensive evaluation is needed to provide enough information to confirm a diagnosis by differentiation

progression of speech-language evaluation

• case history/caregiver interview

• assessment procedures

• interpretation

• counseling/reporting

articulation

• few sound errors

• primarily phonetic

• no clear pattern

• production of individual sounds

phonology

• multiple sound errors

• errors fall into recognizable patterns

• patterns persist beyond expected ages

• intelligibility may be greatly reduced

what is eliminated by age three?

• final consonant deletion

• assimilation

what is eliminated by age four?

• fronting

• weak syllable deletion

• deaffrication

• cluster reduction without /s/

what is eliminated by age 5?

• cluster reduction with /s/

• stopping

what is eliminated by age 6/7?

• gliding

language and SSD

SSD and language can coexist— severe SSD and language difficulty can increase academic risk

literacy and SSD

poor speech sound skills coexist with reading and spelling difficulty— ask about school performance

SSD and function

how much does the childs speech affect participation, socialization, and everyday communication?

dysarthria

• neuromotor control problem

• may affect articulation, respiration, phonation, resonance, prosody

• look for weakness, abnormal tone/range/speed/coordination

childhood apraxia of speech

• motor planning/programming disorder

• look for inconsistent errors, disrupted transitions, groping/searching, prosodic abnormalities and worsening with complexity

CAS red flags

• inconsistency

• lengthened/disrupted transitions between sounds/syllables

• groping

• distorted vowels

• abnormal prosody

• accuracy deteriorates as utterances become longer/more complex

hearing and SSD

• normal hearing supports learning and self monitoring

• conductive loss/oitis media can fluctuate

• sensorineural loss can significantly affect SSD

• FCD and weakness, vowel distortions, voicing confusions, prosodic differences, resonance changes common

screening for SSD

• quick, pass/fail, identifies children at risk

• may use convo, reading, eliciting words/sentences, brief narrative tasks

• failed screening = further assessment

comprehensive evaluation for SSD

• answers bigger clinical questions

• integrates history, hearing, oral mech, formal/informal measures, speech sample, stimulability, and differential diagnosis

connected speech and SSD

• collect spontaneous/connected speech sample

• aim for at least 50 utterances

• transcribe errors, unintelligible words

• find PCC, phonemic inventory, persistent patterns, intelligibility, rate, fluency, prosody, resonance, voice

• compare performance in connected speech with single-word

formula for speech rate

number of words divided by minutes of speaking equals words per minute

how to test stimulability in SSD

• model errored sound

• try isolation → syllables → words

• add cues

• observe whether production corrected or improved

why does stimulability matter for SSD

• adds prognostic information

• helps prioritize treatment targets

• nonstimulable errors may need more immediate/direct attention

steps after assessment for SSD

• integrate history, testing, speech sample, observations

• describe errors, patterns, severity, functionality

• differentiate between diagnosis

• recommend— treatment? monitoring? referral? additional testing?

language disorder

significant difficulty learning and/or using language

• can affect communication, school performance, social participation, later occupational functioning

how can language disorder show up

• comprehension

• spoken language

• reading

• writing

• can affect one or all of these areas and can occur on its own as an SLI or with another condition

classic SLI description

significant language difficulty despite otherwise relatively typical development

• language problem is not explained by a known hearing, neurological, intellectual or other major clinical condition

SLI vs DLD

SLI is older terminology

• DLD is broader— a child does not have a demonstrate a big discrepancy between nonverbal IQ and language ability to qualify

domains of language and communication

• vocabulary/semantics

• morphology

• syntax

• pragmatics

• nonverbal communication

• literacy

vocabulary/semantics

limited vocabulary, slow word finding, word-finding difficulty

morphology

difficulty with grammatical markers such as plurals possessives, tense or -ing

syntax

shorter or less complex sentences, difficulty understanding or producing complex structures

pragmatics

difficulty initiating or maintaining topics, taking turns, repairing breakdowns, using language appropriately in context

nonverbal communication

may show difficulty using or interpreting gestures, facial expression, or other nonverbal cues

literacy

reading and writing difficulties may emerge because oral language supports later literacy development

preschool language difficulties

• slow word finding

• limited combinations

• grammatical errors

• shorter utterances

school-age language difficulties

• complex grammar

• following classroom language

• narratives

• reading/writing

• academic vocabulary

adolescence language difficulties

• abstract language and figurative language

• complex discourse

• explaining, reasoning, defending ideas

• academic and expository language

how to create a language sample

• elicit— create opportunities

• observe— listen for what appears/what doesn’t

• analyze— quantify patterns then interpret them in context

types of language sample

• conversational

• narrative

• expository

conversational language sample

• back-and-forth interaction

• topic initiation and maintenance

• turn-taking

• requests for clarification

• most naturalistic

narrative language sample

• child retells the story

• use picture story and have them tell it to you

• tell them a story and have them retell it to you

• older kids can read a story and retell it

expository language sample

• most difficult

• child has to create the structure

• higher level language required

• “tell me how to make a sandwich'“

alternative assessments for specific language target

• make it skill-specific

• prompt the missing skill

• model the missing skill

• make the behavioral assessment

make it skill-specific

create targeted opportunities to elicit the missing skill

prompt the missing skill

provide a cue or partial support to help the child produce the skill

model the missing skill

provide a clear model then give then child another opportunity

make the behavioral assessment

assess the function of the childs verbal behavior rather than specific language structure

MLU

total morphemes divided by total utterances

lexical language analyses

what words are they using?

• type token ratio

• shows lexical diversity

syntactic language analyses

how are they putting those words together

• short/simple vs complex utterances

functional language analyses

how are they using the language to communicate

• initiate

• turk-take

• repair

• maintain

• clarify

• narrate/explain

type-token ratio

number of different words divided by total words

• if higher TTR — generally more varied vocabulary

stuttering

• interruptions such as repetitions, prolongations and blocks

• effort and secondary behaviors may occur

• the child may anticipate or avoid stuttering

• can occur alone

cluttering

• perceived rapid or irregular rate with reduced clarity

• speech may sound compressed or poorly organized

• monitoring and awareness may vary

• can coexist with stuttering

onset of stuttering

usually occurs in early childhood

• as early as 18 months, usually before 5

family history of stuttering

• occurs more often in families with stuttering

• father who stutters possess risk to son but mother does to both children

• may have to do with GNPTAB, GNPTG, NAGPA

• informs risk but not prediction

spontaneous recovery of stuttering

resolves without formal intervention

• assessment helps determine whether to monitor or intervene

dysfluency types

• repetitions

• prolongations and pauses

• interruptions

• blocks

• interjections

• revisions

• incomplete phrases

A young child may stutter without obvious struggle or distress which is why we also examine….

• fluency

• repetition

• duration

• tension/effort

examples of motor behavior with stuttering

• dysfluency amount changing with environment

• tension

• blinking

• secondary movements

why does documenting secondary behaviors matter in stuttering?

it can help identify whether or not this is a bout of stuttering or if it is a prolonged condition

thoughtful caregiver interview questions for stuttering

• when did your child begin showing symptoms of stuttering?

• how has their stuttering changes since?

• does your family have a history of stuttering?

• what is the functional impact of their stuttering? in other words how does it impact how they communicate?

delayed auditory feedback

can act as a helpful treatment for someone who stutters

appropriate communication behaviors when interacting with someone who stutters

• patience

• do not finish sentences

• do not assume they are dumb

four perceptual dimensions of voice

• pitch

• loudness

• quality

• resonance

pitch

perceived highness or lowness of voice

loudness

perceived vocal volume and intensity

quality

how the voice sounds— breathy, rough, strained

resonance

how the sound energy is shaped through the vocal tract

aphonia

absence of voiced phonation during speech, may present as whispering

dysphonia

abnormal or impaired voice production affecting pitch, loudness, and/or quality

fundamental frequency

rate of vocal fold vibration, measured in hertz (Hz)

habitual pitch

pitch typically used during everyday speech

breathy voice quality

audible airflow mixed with voicing

rough/hoarse voice quality

irregular, raspy or aperiodic-sounding phonation

harsh voice quality

perceptually abrasive voice quality

strained/tense voice quality

pressed, effortful-sounding phonation

hypernasality

excessive nasal resonance on oral speech sounds

hyponasality

reduced nasal resonance especially on nasal consonants

perceptual quality alone does not…

establish the cause

etiology of voice disorders

• behavioral/functional

• medical/inflammatory

• structural

• neurological

behavioral etiology of voice

vocal misuse, phonotrauma, maladaptive voice production

structural etiology of voice

lesions, webs, anatomical differences

medical/inflammatory etiology of voice

infection, irritation, trauma, reflux-associated symptoms

neurological etiology of voice

immobility, neuromuscular impairment, hearing loss, endocrine factors

why is laryngeal visualization by ENT important before beginning voice therapy for persistent dysphonia

helps identify specific lesions

• it is also helpful in identifying what is causing the dysphonia so treatment can be specific for the patient

purpose of VisiPitch IV

visual biofeedback and selected acoustic voice measures

• shoes feature of speech like pitch, loudness, frequency

purpose for computerized speech lab

acoustic recording and analysis of speech and voice

• provides acoustic information on patients voice

purpose for nasometry

measures nasalance— relative nasal acoustic energy

• velopharyngeal function

purpose for electroglottography

• uses two electrodes place don thyroid cartilage and emits small, high-frequency electrical current between them

• device records how impedance changes as vocal folds open and close

• produces waveform representing vocal fold contraction patterns

purpose for laryngeal EMG

electromyography and nerve conduction studies are diagnostic tests that assess health of muscles and nerve controlling them

• helpful in identifying various neuromuscular disorders

purpose for aerodynamic assessment

evaluates how respiratory system and vocal folds work together to produce voice

• quantifies airflow and subglottal pressure, offering insight into vocal efficiency

purpose for voice stimulability trials

trying to figure out if we can change the voice

• observe

• trial

• compare

response to stimulability cues can inform this clinical planning…

• a positive stimulability response does not guarantee therapy success

six voice stimulability techniques

• automatic vocalizations

• glottal fry

• tone focus

• inhalation phonation'

• yawn-sigh

• pitch range