Anthony is a 3-year-old child with multiple-handicaps. He has “Shaken Baby Syndrome” due to abuse. He lives with his grandmother who primarily speaks AAE, but is also exposed to SAE. With all children, but especially children with severe multiple handicaps, it is critical to describe the child’s strengths which can be built upon in developing strategies to improve the child’s functional communication.
Anthony has been attending the center-based early intervention program here at preschool where he receives bilingual speech-language therapy, occupational therapy, and physical therapy, as well as educational services. He also receives home-based physical therapy three times a week for one hour. This evaluation is for his transition to CPSE.
Anthony was born via vaginal delivery and weighed 8 lbs. 9 oz. at birth. He was the product of an uneventful pregnancy. When he was one month old, Anthony was hospitalized for one month with a skull fracture reportedly from being thrown on the floor. He was released into his grandmother’s care. In April, he was hospitalized again for a brain injury due to abuse. Anthony was diagnosed with Shaken Baby Syndrome.
Anthony resides with his maternal grandmother who has custody of him. His mother was convicted of child abuse and remains incarcerated. His grandmother reported that she expects the mother will be released within the year, but she does not expect that she will “have anything to do” with Anthony. His father remains incarcerated but for a different crime.
Anthony’s grandmother works as a school aide. When Anthony finishes school, he goes to a babysitter where he stays until his grandmother picks him up after work at about 3:30. His grandmother reports that Anthony plays with several other children at the babysitter’s home.
When asked to describe Anthony’s greatest improvement in the past year, his grandmother said it was that he could now walk. Anthony walks independently, but with a helmet for protection in case he falls. His grandmother said that she prayed every day for him to walk. She said he wanted so much for him to walk and that Anthony was always very motivated to move around and walk.
Language Background and Use
Anthony lives in Harlem. He has only been exposed to English. His grandmother primarily speaks African American Vernacular English (AAVE) and code switches to Mainstream American English (MAE). His teacher speech MAE but also the children and support staff also code-switch between AAVE and MAE in the classroom.
Anthony’s grandmother confirmed that his hearing was recently tested at XX hospital and was found to be within normal limits.
Oral Peripheral Mechanism and Feeding
Examination of the oral peripheral speech mechanisms revealed structures to be symmetrical and intact with moderate hypotonia. Evidence included open mouth posture, significant drooling, continuous tongue protrusion, limited tongue and lip movement, and poor lip and tongue coordination. He could not move his tongue from side to side, elevate it, or depress it. He could protrude his tongue, but had difficulty retracting his tongue.
When Anthony attempted to swallow pureed food or thickened liquid, he “swallowed” the food by thrusting his tongue forward. This would cause the food or thickened liquid at the back of his mouth to be pushed forward and the food or thickened liquid at the front of the mouth to be pushed out of the front of the mouth. As a result, there was a great deal of food and liquid forced out of his mouth during feeding by the “tongue thrust” manner of swallowing.
Anthony’s mouth was primarily open with a large smile so the corners of his mouth were retracted. When his mouth was at rest, his tongue protruded and his lips and cheeks appeared quite flaccid.
Lip closure is poor. During all observations, in imitation, and according to his grandmother’s report, Anthony did not close his lips. However, he did close his lips weakly around an extra-thickened spout of a sippy cup when drinking. Mostly when drinking, he wanted to hold his head back and let the thickened liquid drip down his throat. When his head was held up, Anthony had some difficulty managing the liquid.
His maternal grandmother said that she believed he had not had a feeding study. His doctor recommended pureed foods and thickened liquids, but without a swallow study. Overall, his oral musculature and his swallowing skills are severely delayed.
Vocal parameters for pitch, intensity, and resonance were within normal limits.
No stuttering behaviors were observed.
Anthony is an exceptionally charming child. He makes contact with everyone and makes up games to reinforce that contact. He continually has a smile on his face and especially enjoys interacting with people.
His grandmother reports that he plays with a truck and ball at home.
Anthony plays with cause-and-effect toys in school. He will sit and turn the dial or hit the button so that the character pops up. Anthony also plays functionally with toys. For example, he picked up a toy basketball, put it in the toy basketball hoop, and then clapped to show that he knew that he had accomplished the goal of basketball.
He is most attentive and motivated when engaging with another person, usually an adult in the class. He will initiate games such as taking a picture card, looking at the adult, and then tossing it to the side and laughing because he enjoys playing this game with the adult. Another game he plays is to approach the adult and move his head or his body toward them in a funny way, and then he will start laughing. (Not incidentally, the adults laugh with him because he is so endearing and funny.)
Articulation and Intelligibility
Due to his weak oral musculature, Anthony produces primarily vowels. He reportedly has produced bilabials on imitation by his previous speech-language pathologist, but this could not be elicited and his grandmother reported that she had not seen that either. During the evaluation, he produced the CV combination /ga, ga, ga/ and used the phoneme /h/ with a few vowels.
- Rossetti Infant-Toddler Language Scale (Rossetti)*
- Language sample
- Observations with peers, teacher, and teaching assistants
- Classroom observations
- Interview with maternal grandmother (his primary caretaker)
- Interview with teacher and teaching assistants
- Interview with physical therapist
- Clinical judgment
*The Rossetti is a criterion-referenced test that has not been normed on children from Anthony’s cultural and linguistic background, or on physically involved children to determine biases due to limited physical mobility. Therefore, the Rossetti is only used as a general guide, with clinical judgment and the other testing tools used as primary diagnostic tools.
Anthony generally understands and follows simple, context-embedded, one-step commands and questions. For example, Anthony understands the following commands and questions, presented in context-embedded situations: “Where is your chair?” “Do you want more?” “Give me the ball,” “Come here,” “Which one do you want?” and “Show me your eyes.” Anthony will look at familiar people and objects when named. He also responds to his own name.
Anthony enjoys hearing and seeing big books at circle time. For example, when one of the “Spot” books is read, Anthony will focus on the pictures, will watch as the other children open their flap-pages, will wait for his turn, and will open his flap-page appropriately. Anthony will also participate when a book like From Head to Toe, by Eric Carle is read. In this case, he will imitate the gestures and movements in the book, such as the gorilla pounding his chest or the giraffe bending his neck.
Anthony demonstrates good attending skills during circle time. He waits for his picture to be shown, then goes up, and puts it on the board. He follows turn-taking rules, and knows and anticipates the sequence of events during circle time.
An augmentative communication system is used during circle time. Anthony can make a choice between three line-drawing pictures of songs. He can also make choices among line-drawings of within-song events such as choosing among the doors, windows, or driver in “The Wheels on the Bus Song.” Anthony can also anticipate a repeated line in a song so when it comes to that line, he will hit a Big Mack switch at the appropriate time to complete the song.
Anthony has also internalized routines. For example, after lunch, Anthony and this evaluator had to clean up. First, this evaluator washed her hands and then, with visual prompts, told Anthony to wash his hands. Anthony washed his hands well and then pointed to the paper to dry his hands. He dried his hands well and then this evaluator told him to throw the paper away. Then, Anthony walked out of the bathroom and threw the paper in the garbage. Similarly, after a meal, when Anthony was seated at the table, he took a wet piece of paper towel and wiped the table in front of him.
Based upon the Rossetti and clinical judgment, Anthony’s language comprehension skills appear to be at the 9 to 12 month level, with a few skills at the 12-15 month level.
Anthony communicates primarily through gestures, facial expressions, and eye contact. He says four words consistently, “hi,” “bye,” “more,” and “Nana” (his name for his grandmother). He nods his head for “yes” and shakes his head for “no.” He will also sometimes say the word, “no.” (Although Anthony cannot produce /y, n, b, n/, he uses the back of his tongue to approximate the consonants, but the words are primarily understood by the change in vowels, intonations, and contextual cues.)
The following are examples of his communication. 1) An adult in the classroom offered him two toys. She asked him which he wanted and then said, “You want this one, don’t you?” while holding out one of the toys. Anthony shook his head no, said, “no” and then he reached for the other toy, which was the one he wanted. 2) Anthony wanted to engage with an adult who sings, “The Itsy Bitsy Spider” so he went up to her with a big smile and started doing the gestures to that song. 3) During lunch, when asked if he wanted meat or milk, Anthony looked at the meat and then at the adult offering it to him, and then either reached for what he wanted or signed and said, “more.”
During circletime, Anthony will volunteer to dance or choose a song selection. When his picture is displayed, he will raise his hand to indicate that he knows his picture. Anthony enjoys music very much. He will hum some of his favorite songs to himself.
Based upon the Rossetti and clinical judgment, Anthony appears to be functioning at the 9-12 month level, with a few skills at the 12-15 month level.
Summary and Conclusions
1. Anthony has delays of approximately two years in language and play skills. He can understand routine, context-embedded, commands and questions. He has an expressive vocabulary of four words, but he communicates a great deal through gestures, facial expressions, intonation, and by shaking his head “yes” and “no.” Anthony’s greatest strengths include his interest in communicating with people, his ability to follow and participate in routine activities, his charm, and his sense of humor. His greatest weaknesses are his limited attending skills when not motivated and his severely impaired oral-motor development.
2. Examination of the oral peripheral speech mechanisms revealed structures to be symmetrical and intact with moderate hypotonia. When Anthony attempted to swallow pureed food or thickened liquid, he “swallowed” by thrusting his tongue forward.
3. Due to his weak oral musculature, Anthony produces primarily vowels. During the evaluation, he produced the CV combination /ga, ga, ga/ and also used the phoneme /h/ with a few vowels.
Individual speech-language therapy is recommended three times a week for thirty minutes.
An augmentative communication evaluation is recommended.
Clinical Judgment/Informed Clinical Opinion Part 1