Making the Best Use of Speech-Language Therapy

Celia Neavel, MD, FSAHMLee Anne Holmberg M.A., CCC-SLP

Ellen S. Kester, Ph.DJon Yates, AAC Specialist

2012, Dell Children’s Hospital, Austin, TX

OBJECTIVES

1. Discuss speech and language in school-age youth.

2. Identify when referral for Speech-Language Evaluation and Therapy would benefit the patient.

3. Explain utilization of Alternative and Augmentative Communication (AAC).

4. Describe community resources for youth with speech and language delay and their families.

STRUCTURES INVOLVED IN SPEECH AND VOICE PRODUCTION.

PREVALENCE SPEECH PROBLEMS REPORTED BY PARENTS

ALL OF THE DOCUMENTS AND CHARTS IN THISPRESENTATION CAN BE DOWNLOADED FROM OURFREE RESOURCE LIBRARY.

Click here to visit the Resource Library

LANGUAGE DISORDERS Language

Shared system for communicating Involves sounds, signs, gestures, and/or spoken or

written words Specific Language Impairment

Absence other developmental problems Other language disorders assoc. with

Hearing impairment Autism Mental retardation Congenital or acquired disorders of brain

development Head injury, brain tumors.

MEAN LANGUAGE SCORES AND NON-VERBAL I.Q.SCORES

PREVALENCE HAVING READING DISABILITY

NORMAL LANGUAGE DEVELOPMENT IN CHILDREN AND ADOLESCENTS

Verbal AND non-verbal; follows predictable course

4-5 y.o. 200-300 words; can describe, define, answer why; tell

simple story; understandable to all 5-6 y.o.

Understands > 2000 words, sequencing, rhyming; creates stories; carries out series 3 directions

School Years; Huge demand on skills for school and social

acceptance; emerging figurative language

WARNING SIGNS SCHOOL-AGED CHILD

Phonological awareness problems

New inattentive or not well-controlled ADHD

Problems reading, writing, understanding social

interactions

Feelings hurt or gets angry/frustrated

Trouble learning second language

Parents with language/literacy problems

LANGUAGE AND COGNITIVE DEVELOPMENT INADOLESCENTS

Core language skills established. Semantics, syntax, language concepts and basic pragmatic skills Early adolescents more concrete

Adult pragmatic and social language skills being refined, including ability to: Interact with adults and peers in classroom and social

activities Maintain or shift topic of the conversation; participate

appropriately in conversation Take another person’s point of view to know what information

is needed during a communication event Incorporate subtle variations in tone, word usage, rhythm

depending on situation

IMPLICATIONS OF VOICE, SPEECH, AND LANGUAGE DISORDERS

Need to communicate to function in our society

Affect emotional and social life, education and job

Substantial cost in life quality and human

potential

Number will likely increase Improved survival for medically fragile infants and

individuals who sustained injury or acquired disease

GOALS FOR INTERVENTIONS Help with developmental trajectory Maintain or improve self-esteem Maximize function Decrease anxiety Educate other important adults so can:

Understand youth’s weaknesses Make appropriate modifications and contribute

further to interventions

IDENTIFYING VOICE, SPEECH, AND LANGUAGE DISORDERS Suspected by family, physician, or educator

Consider delayed versus disordered ASK FUNCTIONING AGE

Speech-language pathologists evaluate & diagnose History, exam, comparison to standardized norms

Voice assessment Speech assessment

Motor speech disorders and/or stuttering Language assessment

Formalized questionnaires; direct observation; testing vocabulary, understanding, word and sentence production, language in social situations

Must take into account the native language of the speaker

BILINGUAL CHILDREN

Ellen S. Kester, Ph.DPresident, Bilinguistics Speech and Language Services5766 Balcones Drive, Suite 205Austin, TX 78731(512) 480-9573 Phone (512) 458-9573 Faxwww.bilinguistics.com

EXAMPLES FROM BILINGUISTICS

4-year-old Spanish-speaking child with a total of approximately 20 words, who could follow one-step commands with gestures but not without gestures. Intelligibility of 30-40%.

3-year-old bilingual child who has difficulty following simple directions with gestures. He uses single words and two-word utterances. Intelligibility is 40-50%.

Neither of these children had been referred for a speech-language evaluation previously.

WHY DO WE GET REFERRALS LIKETHIS? Misconceptions about bilingual development Mobility of population Parents don’t understand “no cost” options Parents not comfortable expressing concerns Parents not aware of developmental differences Parents may be aware of differences, but not

know value of early intervention Language barriers may impede referral process

Children code switch between languages because they don't know either language well.

Raising children with two languages will confuse them.

Children with language impairment should not learn more than one language at a time.

Children who use the sentence structure of one language when speaking the other likely have language impairment.

We should expect bilingual children to be delayed in developing communication skills

Bilingual children develop early vocabulary at the same rate as monolingual children (Pearson, 1993).

Early language milestones are similar (single words, lexical spurt, 2-word phrases, following directions) (Pearson and

Fernandez, 2001).

Conceptual scores are similar (Pearson, 1998).

DETERMINING SPEECH-LANGUAGEIMPAIRMENT IN BILINGUALS

EnglishEnglishSpanish

OKSpanish

OK NormalNormal

EnglishOK

EnglishOK

Spanish Spanish NormalNormal

EnglishEnglish SpanishSpanishImpaired*Impaired*

Difficulty learning both languages, even with adult assistance

Family history of language/learning disabilities Slower development than siblings Difficulty interacting with peers Inappropriate pragmatic/social language skills (i.e.,

turn-taking, topic maintenance, considering listener needs, non-verbal communication)

Difficulty with language in many routines Idiosyncratic error patterns Language performance unlike others with similar

cultural/linguistic experiences

Click here to visit the Resource Library

LEE ANNE HOLMBERG M.A., CCC-SLPSPEECH-LANGUAGE PATHOLOGISTEASTER SEALS OF CENTRAL TEXAS

SPEECH-LANGUAGE PATHOLOGY YOUSHOULD KNOW

• Language Disorders:– Receptive Language Disorder– Expressive Language Disorder– Pragmatic Language Disorder

• Articulation Disorders:– Oral Apraxia– Stuttering-– Voice Disorder

• Feeding Disorder:– Dysphasia

A FEW DIAGNOSIS THAT WARRANT REFERRAL TO SPEECH-LANGUAGE PATHOLOGIST Children with ADD or ADHD

Hearing Loss or Chronic Ear Infections

Cleft Palate or other Craniofacial Anomalies

Difficulty Feeding and Swallowing

Autism Spectrum Disorders

Variety of Syndromes including- Down Syndrome, Fragile X

Syndrome, Turner’s Syndrome, etc.

Children with Cerebral Palsy

OTHER SITUATIONS THAT WARRANT REFERRAL TO SPEECH-LANGUAGE PATHOLOGIST Children that schools discharged from speech therapy Learning disabilities or children struggling in school School-aged and cannot identify significant details in story or

situation and then sequence them in understandable way 2 – 5 y.o. with very small vocabulary and having difficulty

stringing words together in phrases and sentences When parent of a 2 y.o. or older says, “My child is not talking and

using words, and does not seem to understand me.” When parent says, “I do not understand what my child says.”

Please do not tell a parent who is concerned to wait until child is 4 or 5 y.o. A lot of speech-language development goes on before then!!!!

TESTS MOST COMMONLY USED FOR EVALUATIONS Language Tests:

Preschool Language Scale 4 (PLS4) Clinical Evaluation of Language Functioning (CELF) Clinical Evaluation of Language Functioning-Primary (CELF-

P) Test of Language Disorders (TOLD)

Articulation Tests: Goldman Fristoe Test of Articulation

WHAT TO LOOK FOR IN SPEECH-LANGUAGE REPORT

Speech-language diagnosis accompanies medical diagnosis, if applicable

Chronological age of child included

Standard scores from formal testing (average range 85-

115)

Language age levels in all subtests of formal testing

Narrative discusses child’s strengths and weaknesses

Specific recommendations

Stated goals to be addressed in therapy

WHAT A SPEECH-LANGUAGEPATHOLOGIST CAN OFFER

• Speech and language Screenings, evaluations, and treatment.

• Recommendations for referrals to other therapies i.e. OT, PT

• Collaboration with other service providers (doctors, psychologists, other therapists, and schools).

• Education on the child's communication issues for parents, and other providers

• Parent training on communication and the child’s needs and goals

WORKING WITH THE SCHOOLS:WHAT SPEECH-LANGUAGE PATHOLOGIST FOCUSES ON

Collaboration with teachers, school speech-language pathologists, and counselors

Education and training on specific techniques that are working well in the child’s therapy

Opening a dialogue to share progress and difficulties the child is experiencing

QUESTIONS TO SCREEN FOR POSSIBLE SPEECH-LANGUAGE DELAYS

Young Children:How much is your child talking?How many words is your child using?How many words is your child stringing

together? Is your child able to follow directions (Go

get your shoes.)?Does your child understand what your are

telling him/her?How much are you able to understand

your child?

QUESTIONS TO SCREEN FOR POSSIBLE SPEECH-LANGUAGE DELAYSAdolescents: How is your child functioning in school? How much of what your child tells you are you

able to understand? Is your child able to use logical sentence? Is their spoken grammar correct? Is your child able to identify the main details in a

story? Then is your child able to sequence these main

details to retell the story? Can your child follow multi-step directions? Does your child have pronunciation difficulties?

WHAT IS AUGMENTATIVE ALTERNATIVECOMMUNICATION (AAC)?

Augmentative and alternative communication (AAC) includes all forms of communication (other than oral speech) that are used to express thoughts, needs, wants, and ideas.

asha.org

TYPES OF AACUnaided AAC: Using body to communicate with

others. Includes, gestures, body language, and/or sign language.

Aided AAC: Using tools along with the body to communicate with others. Tools can include: Pencil and paper. Communication boards or communication books. Electronic Voice Output Devices (VOD).

www.asha.org

TOTAL COMMUNICATION APPROACH TOAAC Includes use of combination of speech, gestures, sign,

and AAC.

Important because it gives person variety of methods to use for successful communicate with others.

TYPES OF CLIENTS WITH AN AAC DEVICESEEN AT EASTERS SEALS

Clients with Down Syndrome

Clients with profound oral apraxia

Autistic clients

Clients with severe Cerebral Palsy

AAC 101

Jon YatesAAC SpecialistDynaVox Mayer-Johnson

ASSESSMENT

AAC Devices recognized as treatment by:

American Medical Association

American Academy of Neurology

American Academy of Physical Medicine & Rehabilitation

American Speech-Language Hearing Association

CONDITION SETS THAT BENEFIT FROM THE USE OF A COMMUNICATION DEVICE

•Cerebral Palsy•Down Syndrome•Mental Retardation•Autism•Muscular Dystrophy

Congenital/Develop‐mental

Acquired

Child Adult

•Traumatic Brain Injury (TBI)

•Spinal Cord Injury (SCI)

•TBI •Stroke•SCI

•Amyotrophic Lateral Sclerosis (ALS)

• Parkinson’s Disease•Huntington’s Disease•Multiple Sclerosis (MS)

Degenerative

Acute

•Cerebral Palsy•Down Syndrome•Mental Retardation•Autism•Muscular Dystrophy

SOME INTERESTING FACTS8 out of 1000 people worldwide cannot use speech to communicate.

2‐3 million in U.S. could benefit from speech generating devices.

Only 5% of these people have a speech device.

Funding is available. 

Source: Univ of NebraskaLincoln Website

WHAT BENEFITS DOES AAC PROVIDE TO YOUR PATIENTS?WHAT BENEFITS DOES AAC PROVIDE TO YOUR PATIENTS? Improves overall quality of life Supports meaningful personal relationships Develops functional communication skills

Improves Functional Communication Measures Reinforces traditional rehabilitation activities

Schedules (appointments and daily activities) Reminders (medication and appointments) Videos (physical therapy examples)

Helps patients communicate important medical and personal information to healthcare teams

FUNDING: SHOW ME THE MONEY

Medical Model Medicare Medicaid Private Insurance STAP Other Organizations

ALS VA

School IEP

Third Party Billing Other

Fund Raising

FUNDING: MEDICAL MODEL

Private Insurance Many insurers follow Medicare guidelines.

Call insurance company and ask questions about benefits. Confirm whether coverage available for Durable Medical Equipment/Speech Generating Devices.

Payment varies by policy. Ask if met deductible and Out of Pocket Maximum for

calendar year.

Any co-payments or deductibles need to be collected before device is shipped. Go through STAP for this!!

FUNDING: MEDICAL MODEL

Texas Medicaid Assistance 100%

Covers approved equipment with no out pocket cost to client

Does require 30-DAY trial period

Process takes about 2 months with trial

FUNDING: STAP

STAP stands for:

Specialized Telecommunications Assistance Program

Falls under umbrella of DARS Department of Assistive and Rehabilitative ServicesThis is a TAX that we pay for on our phone bills every month

FUNDING: STAP

Process

Fill out STAP application and provide small report. Application must be accompanied by proof of TX residency.

Everyone in Texas with a dual diagnosis qualifies for STAP.

FUNDING: STAP

With this funding there is no reason why anyone in Texas should be without a voice.

This is also a great alternative for schools! STAP timeline is about 4 weeks. Times do

fluctuate!! Follow up with STAP!!

RESOURCES 0-3 y.o. Early Childhood Intervention =/ >3 y.o. Child Find through School/School District or

youth’s school if already enrolled Non-Profit Therapy Organization Private Therapy Organization Consider:

Hours Location – home or center-based; family’s transportation Type Insurance Accepted If Youth-focused Waiting List Areas of Specialization

THANK-YOU DCMCCT speech therapists for sharing list!

REFERENCES

http://www.nidcd.nih.gov/health/voice/ National Institute on Deafness and Other Communication Disorders, National Institutes of Health

asha.org American Speech-Language-Hearing Association

Crossed Wires: Identification, Impact, Management and Outcomes of Language Disorders presentation by Lynn Wegner, MD at Texas Scottish Rite March 6, 2010

CODING 784.3 Aphasia 784.40 Voice and

resonance disorder, unspecified

784.42 Dysphonia 784.43 Hypernasality 784.44 Hyponasality 784.49 Other voice

and resonance disorders

784.59 Other speech disturbance,NOS

784.61 Alexia and dyslexia

783.42 Delayed Milestones

CODING 315.31 Expressive

language disorder 315.32 Mixed

expressive-receptive language disorder

315.34 Speech and language delay due to hearing loss

315.39 Other language disorder (phonologic, articulation)

315.5 Mixed developmental disorder

315.8 Other specified delays in development

315.9 Unspecified delays in development/ learning disorders NOS

Click to visit www.bilinguistics.com

Rapidly identify speech-language patterns related to second language acquisition to distinguish difference fromdisorder.

DIFFERENCE OR DISORDER: UNDERSTANDINGSPEECH AND LANGUAGE DEVELOPMENT INCULTURALLY AND LINGUISTICALLY DIVERSESTUDENTS