Speech Diagnosis: Age-appropriate
Diagnosis: Typically Developing
The following assessment materials were used for this bilingual evaluation (taken place on
– Parent interview (email and video-conferencing)
– Teacher interview (email)
– Clinical observation (video-conferencing, including literacy tasks)
– Review of classwork (writing samples)
– Narrative assessment (video-conferencing)
o School-age Language Assessment Measures (SLAM) cards:
§ The Subway (Cantonese), The Crayons (English),
Dog Comes Home (Cantonese), Lost Cellphone (English)
o SLAM Understanding Spoken Paragraphs: Snowy Day, Problems at Burger
– Dynamic assessment (video-conferencing)
o Following multistep directions
o Nonword repetition tasks
o Phonological awareness tasks
o Cantonese and Mandarin articulation and phonology
§ Hong Kong Cantonese Articulation Test (HKCAT) recording form
§ Mandarin Speech Sound Screener
– Informed clinical opinion/judgment
SL is a 9;1 girl born to a Chinese-Hong Kong-immigrant home in South Carolina. SL’s mother
was the primary informant during the parent interview conducted via emails and a follow-up
video conference. SL’s mother is a full-time housewife and she manages SL’s academic and
personal affairs. She is a reliable informant. SL’s father owns and operates a local pan-Asian
restaurant. The parents immigrated to the United States in 2002. SL’s mother is a college
graduate with a bachelor degree in business, and her father is a high school graduate. The
family lives in a private house with their pet cat. The extended families are located in Hong
SL was born at full-term via vaginal delivery. Her parents denied any family history of
speech-language or academic deficits. Medical history was unremarkable, except for serious
eczema at birth. SL had no prior history of special education or known ear infection.
Developmental milestones were within normal limits. She was well-coordinated.
There has been no significant change in family structure or dynamic. The family has been local
to Greenville, South Carolina, for 19 years. The parents have no concern regarding SL’s speech
and language development and consider her communication skills to be on-par with her
age-equivalent peers. SL’s mother expressed some mild concerns regarding SL’s attention
skills. She described that SL could be “forgetful” and “easily distracted” (e.g., forgetting to bring
back water bottles/snack packs, misreading questions/instructions from school work (math
arithmetic in particular), and needing reminders to check her work, etc.). On the other hand, SL’s
teacher provided high reviews of SL’s academic performance. SL, who currently obtains straight
A’s in school, was described to have transitioned well to fourth grade and been meeting all
classroom expectations, despite being “home-schooled” through Kolbe Academy (a private
virtual online program) during the pandemic last year.
Language Background and Use:
SL was exposed to only Cantonese at birth. English was introduced at two months old, and
Mandarin at around six years old (through Chinese Sunday school, 2 hours/week). SL is
considered to be a simultaneous English-Cantonese bilingual and sequential beginning
Mandarin-learner. The mother indicated that SL’s Cantonese development began to show signs
of slowing down when she started attending English-only preschool at the age of two and a half.
SL’s immediate speech community is primarily English-speaking and Cantonese at times with
the family. She does have some mixed-aged peers who share similar multilingual Chinese
backgrounds and whose families are Hong Kong-immigrants, but they meet only periodically
and they communicate primarily in English. According to the mother, SL currently uses
Cantonese 40% of the time at home (with infrequent code mixing) and English 70% of the time
outside of school (see the table below).
In summary, SL is strongly English-dominant (consistent with a monolingual speaker) with signs
of language attrition in Cantonese (exposed to social language use only, as result from reduced
input and limited formal teaching/corrections). Her Mandarin and simple Chinese writing skills
are slowly emerging. Interlanguage (e.g., inconsistent change in tonality of speech sounds or
words in Cantonese) and cross-linguistic transfers are expected (e.g., grammar of English
applied to spoken Cantonese).
Behaviors and Relationships:
SL has a calm and confident personality. She enjoys reading and is active in various extracurricular activities, including girl scouts, swimming, ice-skating, etc. She was extremely pleasant and easy to work with. Throughout the entire 2-hour video-conference session, she was able to maintain and sustain attention with no difficulty, engaged in active listening and interactive exchanges with the evaluator. She demonstrated excellent self-awareness and self-monitoring skills. Her teacher also commented that:
“SL works well independently as well as with a group of peers. She is organized and independent. She shows commitment to her learning and takes pride in meeting and exceeding expectations at school. I can always count on SL to make positive classroom choices and to serve as an excellent example for other students. SL’s helpful, kind characteristics bring such joy to our classroom.”
According to clinical observations and informant reports, SL’s behaviors are unremarkable and she retains amiable and cordial relationships with both adults and peers.
Teacher Interview and Academic Skills:
SL currently attends Christ Church Episcopal School, a private and independent school in Greenville, SC, with a rigorous and supportive academic environment. The school focuses greatly on fostering leadership, creativity, critical thinking, and teamwork, to prepare for student success. The medium of instruction is English only.
According to the SL’s teacher, Ms. Evans, “[SL] is always full of creativity and is an incredibly deep thinker. Her contributions to classroom discussions are insightful and SL can always be counted on to share exciting information.” She maintains excellent attendance, performs well academically (all A’s), and does not require additional support. Based on the STAR assessments (adaptive computer tests on reading and math) completed in the beginning of the school year, SL’s math skills are at 96th percentile nationally. Both her reading and math skills have a grade equivalent of 6.4 (comparable to those of a typical 6th grader after 4 months into the school year). Her zone of proximal development (ZPD) on reading is 4.2-6.4 (4th- 6th grade level) for optimal growth in reading.
Her writing samples are displayed below, which exemplify her content knowledge, good organization and planning, ability to generate ideas and formulate sentences, command of a variety of syntactical structures (simple and complex sentences; use of relative, temporal, and conditional clauses), while attending to high-order thinking and processing.
SL had hearing adequate to develop age-appropriate speech and language. Her last hearing
examination in 2020 with the pediatrician was unremarkable.
Oral Peripheral Assessment:
SL is within normal limits in oral motor skills to produce age-appropriate speech sounds.
Voice – SL is within normal limits in pitch, resonance, and tone.
Fluency – SL is within normal limits in speech fluency.
Articulation and Phonology:
SL is able to produce all sounds in English as expected for her age including /m, n, h, w, j, p, b,
t, d, k, g, f, v, s, z, l, r/, “ng,” “dj,” “ch,” “sh,” voiced and voiceless “th” and clusters.
Given a list of 41 sets of high-frequency vocabulary encompassing all phonemes in Cantonese
across initial, medial, and final positions of words with all 9 tones (see the image below), SL
demonstrates ability to produce all the sounds, with common dialectal differences on initial “ng,”
which may be deleted (i.e., “au4” for “ngau4” [牛], “o5” for “ngo5” [我], etc.), and inconsistent
substitution of final “ng” with /n/ (e.g., “pɛn2” for “pɛng2” [餅]). Both of which relate to the
“relaxed/condensed pronunciation” (懶音) common to Hong Kong-Cantonese speakers. Those
are acquired differences.
Mandarin phonemes were only partially assessed with repetition prompts given her limited
Mandarin input. It is not uncommon for Cantonese speakers with “relaxed pronunciation” to
transfer the final /n/ for “ng” in Mandarin, as in the case with SL. Similarly, the confusions
between [Pinyin:] “sh” vs. “s” and “ch” vs. “c,” along with the tonal inflections (four tones in
Mandarin vs. nine in Cantonese), are anticipated. Parents and teacher expressed no concerns
regarding SL’s speech and communication. Overall speech intelligibility is high.
SL demonstrated great receptive skills at comprehending verbal instructions, multistep
directives, all wh- and how- questions as well as other high-level questions at various lengths in
both English and Cantonese, without the need for repetition. For example, [SLAM: The Crayons]
when asked what she would say to the big crayon to convince that she didn’t draw on the wall
if she were the little blue crayon, SL responded with careful organization of her thinking:
“I would say that there was a bit of evidence that the marks on the wall were red, so it couldn’t
have been me (compound sentence). Also, I was a good girl and that… I would be somewhere
so I couldn’t have done it (compound sentence). [I would tell the purple crayon] what was I
doing while it was happening… Because some people they need more evidence than what you
say (complex sentence)… Because sometimes it’s [what you say is] not always true (complex
sentence). So I just tell the purple crayon to go look at the security camera (simple sentence).”
(problem-solving, inferencing, reasoning)
Similarly, [SLAM: Dog Comes Home – Cantonese] when asked why the girl was getting so dirty,
SL effectively stated that:
「係因爲個“wool wool” (an acceptable Cantonese onomatopoeia used as a descriptive modifier
for the “dog,” indicating the “woof” sound) 狗呢,佢應該[係]未冲[過]涼。佢係應該係白色嘅,不過
(Translation: It’s probably because the dog hasn’t taken a bath [adverbial clause, complex
sentence]. He [The dog] was supposed to be white, but he rolled around the dirt so much that
he has turned black [compound sentence]. And when the girl played with the dirty “black” dog,
she also got all dirty herself [temporal clause, complex sentence].) (problem-solving,
When asked how did the teacher find out that there was going to be a big storm, she
spontaneously expressed, “I think she looked out the window like Danny (inferencing). Or they
were in a silent reading time or something, when the teacher was looking on her phone, (she)
saw the weather forecast and told the class (temporal clause, complex sentence).” (inferencing)
It is evident that SL has strong reasoning, inferencing, and problem-solving skills. In both
Cantonese and English responses, she is able to establish causal cohesion, effectively use
conjunction links (e.g., “and,” “but,” “so”) and complex syntax to offer plausible explanations and
expository narratives in creative ways. Her performance illustrated her sound ability to listen,
retain, process, and answer questions accordingly and with solid reasoning and organization.
Additionally, SL was able to follow multistep related and unrelated directives without prompt or repetition, e.g., “go to your room, bring your favorite toy here, put it on the desk, tell me your favorite color, and why you chose that toy.” She also sequenced the SLAM picture cards from Dog Comes Home, in less than one minute with 100% independence and accuracy.
Based on the assessment materials administered and clinical judgment, SL presents with at
least age-appropriate comprehension of complex questions, multistep functional directions, and
classroom-based spoken stories in the bilingual capacity. Mild interlanguage patterns
(English-influenced Cantonese) and “less fluid” Cantonese grammatical structures were noted
(see orange highlights and strikethrough denoted above); however, they did not significantly
SL demonstrated excellent narrative skills that were at least age-appropriate. At baseline, she
was able to illustrate good macrostructure and microstructure components in her narratives of
The Crayons by effectively assigning meaningful and relational characters to tell the story:
“I think that the purple crayon is the mom or dad, and then the blue crayon is the little sister or
something, and then the red crayon is older (compound-complex). And then it [the red crayon]
drew on the wall and then blamed the little blue crayon (inferencing) but the purple crayon
caught the red crayon because the marks on the wall were red (compound-complex).”
She effortlessly synthesized the story in a couple of compound-complex sentences and made
reasonable inferences of what happened. She also showed good understanding of theory of
mind (ToM), motivations, and perspective taking of the different characters when she elaborated
further: ‘Blue, you were right. I’m sorry for yelling at you (because the purple crayon probably
yelled at blue crayon at first) and then it’s (referential cohesion) gonna turn to the red crayon
(and the red crayon’s gonna be scared) and then [it’s (referential cohesion)] gonna say “No no
no, I didn’t do it,” even though there’s already evidence.’
In this example, she clearly established referential cohesion, temporal links (e.g., “and then”),
and causal relationship (to connect the characters and events in the story), and made
meaningful predictions through functional use of language in her narratives. She even explained
her thought process to the evaluator unaidedly with the remarks in the parentheses above. Her
inclusion of the red crayon’s monologue was also neatly placed to support her narration.
SL also exemplified this level of functional language in Cantonese with simpler syntax. In The
Subway scene, when asked what she would do if similar situation happened to her, she
described the following with an expressive tone and good nonverbal communication skills (with
「我會嗌得好大聲。我會突我個頭去嗰個罅,跟住(嗌)“哎呀! 我個 [隻] 腳夾住左啊! 幫手啊! 開個 門啊! ”好大聲(咁嗌)。」
(Translation: I would scream loudly [simple sentence]. I would stick my head out of that gap
(between the doors) [prepositional phrase], and then [temporal link] (scream) “Ouch! My leg got
stuck! Help! Open the doors, please! (Scream) loudly.) (problem-solving, theory of mind,
Although the mother was not able to provide quoted examples of SL’s highest communications
due to a misunderstanding of the task, the language samples collected in this assessment
provided ample examples of SL’s wide range of syntactical structure and language functions in
expressive productions (see blue and green highlights throughout this report). SL displayed
acquisition of some sophisticated Cantonese lexicons such as “罅” (“la3” = gap). In addition, she
used conditional clauses appropriately in Cantonese in Dog Comes Home:
「如果 (= if) 佢擺喺佢手上,佢個媽媽就肯定見到。要第二啲大嘅位黎裝個 “wool wool” 狗。如果 (=
(Translation: If she brought him (the dog) [referential cohesion] in with her hands, then her mom
would see it for certain [conditional clause]. Then, (she) needs a larger space to fit the dog. If
she put him (the dog) [referential cohesion] under her shirt, she would look fat [conditional
clause]! [hint of humor])
More specifically, when she was challenged to provide different solutions to a functional problem
(as in Problems at Burger King), SL spontaneously responded, ‘She must have said, “Hold the
order, I need to go back to my house and get my wallet.” And then I think Burger King would’ve
put aside the order and kept managing until Sophie went back through the line and said, “I was
the one who forgot my order, can I get my order? And here’s my money.”’ She also added that
“(she would) ask if they could pay by apple pay (since she has her phone).” This is another
example of her excellent expressive language and creative problem-solving skills with good
Per mother report and clinical observations, SL’s Cantonese is more colloquial and based
mainly on verbal communication. Examples of codemixing, especially in the case that a
Cantonese Chinese word is replaced with an English word during a word retrieval difficulty or
limited lexicon (vocabulary), were recorded. Yet, this phenomenon is common among Hong
Kong Cantonese-English speakers in general due to historical reasons (British colonialism). For
example, “stay 喺我地嘅屋企” (= “stay at our house”), “我normally 都可以 balance 到” (= “I
normally could balance (well on the ice)”).
As influenced by her dominant language, SL’s Cantonese expressions are sometimes noted to
be “translated” expressions from English. For example, “冇乜驚”(not a valid expression) from
“not so scared” as opposed to “冇咁驚”(= “not that scared”), and confusion of the passive voice
in Cantonese vs. English “佢個腳夾住左啲門口”(= “the door got sandwiched by his foot”) vs.“佢
個腳被門口夾住左”(= “his foot got stuck by the doors”). However, SL demonstrated potentials
and motivation in learning new concepts and words. When a corrective feedback or model was
provided, she was willing to imitate and reattempt, as in her learning of the Mandarin production
of “black (color)” (hei1 se4 [黑色]), which she was able to generate an accurate delayed recall.
The nonword repetition tasks (NWRTs) and phonological awareness are helpful measures in
assessing a child’s ability to apply knowledge and experiences of sound patterns of the target
language to perceive, store, recall, and reproduce phonological sequences and his or her ability
to identify and manipulate units of oral language. As expected, SL demonstrated good
phonological working memory, speech perception, phonological assembly, and short-term
memory. She reproduced the nonsense words with all syllables grossly intact. There were only
two mild vowel distortions at three- and four-syllable levels (once each), demonstrating strength
in word learning and ongoing language acquisition.
During the phonological awareness tasks, SL was asked to manipulate segmental units of
words and syllables to combine and separate productions, differentiate and generate rhyming
words. Her positive performance on both tasks is reflective of her high literacy skills in decoding
Based on the assessment materials administered and clinical judgment, SL presents with at
least age-appropriate ability to synthesize content to identify a main idea at bilingual capacity.
Her English academic language is excellent. She is able to produce sentences with appropriate
word order and morphology consistent with her cultural and linguistic background (stronger in
English, as expected). Her expressive language strengths are many, including a wide
application of syntactical forms, good vocabulary and narrative cohesion, perspective taking,
theory of mind, reasoning, inferencing, creative problem-solving, metalinguistic and
Social/Pragmatic Language Skills:
SL demonstrated her ability to extract useful context clues (e.g., reading facial expression) and
verbalize them to support her arguments, understand theory of mind, motivations and
perspective taking, as in the example illustrated above with The Crayons. In the Dog Comes
Home story, when asked what would you say to your mom if you were the girl now, SL
presented herself in a responsible manner when providing a well-constructed persuasive
argument in Cantonese:
「我會同媽咪講,媽媽,我好鍾意呢隻狗呀! 我真係好想養,你會唔會畀我養㗎? 我會同佢玩,我會
自己養,你唔使搞,你淨係,你會就咁抖,好似冇隻 “wool wool” 狗[咁]。」
(Translation: I would tell my mom, “Mom, I really like this dog! I really want to have it, will you
please let me have it? I will play with him. I will take care of him. You won’t have to do anything.
You can… just… relax and rest, as if he wasn’t here.)
It is obvious that SL presents with at least age-appropriate social/pragmatic language skills to
engage in social exchanges, in addition to the sense of social and emotional maturity that she
portrays, as well as excellent topic maintenance skills and effective use of humors.
SL is an avid reader. Her favorite book is Charlie and the Chocolate Factory, which she had read twice to its entirety. According to her teacher and the STAR assessments, SL’s current grade level in reading is 6.4 (6th grade level) and her ZPD on reading is between 4th and 6th grade levels for optimal growth. Charlie and the Chocolate Factory, a 5th grade level novel, is perfectly appropriate for her.
During shared book reading of the assessment (“The Miracle” chapter from Charlie and the
Chocolate Factory), SL demonstrated fluency in oral reading. She was able to independently
scan through the text, read aloud effortlessly and with expression. She was able to recognize
words and comprehend (decode) at the same time, making connections among the ideas in a
text and between those ideas and her background knowledge. This is consistent with her high
performance in the NWRTs and phonological awareness tasks. Note that Chinese literacy skills
could not be assessed as SL was only minimally exposed to written Chinese. She was,
however, able to write her name in Chinese characters, composing of complex parts.
Based on clinical observation and clinical judgment, SL presents with literacy skills comparable
to age-matched peers from similar cultural and linguistic backgrounds. Her abilities to read
above and beyond grade-level text, connect ideas from text, formulate sentences to express
central ideas, produce various complex syntax, and learn new words in the dynamic
assessment tasks have helped to support this claim.
All assessment materials have been carefully selected and administered so as not to be discriminatory on a racial/cultural basis for the child under evaluation. Various clinical measures were used and referenced in order to provide an all-round overall of the child’s speech-language skills, including sociolinguistic factors. They offered detailed analysis of the child’s overall language strengths and weaknesses, areas of potential growth and improvement, and an informed decision on differential diagnosis. These include narrative assessment using age-appropriate SLAM materials, NWRTs, phonological awareness tasks, Cantonese and Mandarin articulation and phonology screeners, informant interviews, and clinical observations of social and literacy skills.
In review of the clinical findings, SL demonstrated good speech and language skills across all
aspects in at least one language. Her overall performance during the evaluation was deemed to
be typical and representative of her normal communication with other culturally and
linguistically-matched adults and peers. SL’s command of the English language is comparable
to a monolingual English speaker. Her syntax, morphology, phonology, semantics, social
pragmatics, and literacy skills in English are excellent. As she began formal exposure to English
in structured academic and social settings, signs of language attrition of her Cantonese have
occurred. That was attributable to the limited systematic/formal teaching and feedback as her
Cantonese input was only socially and colloquially acquired.
Because she learns English and Cantonese simultaneously and her speech community has
been primarily English-speaking, she shows strong dominance in English and hence,
English-influenced Cantonese expressions. Those are cross-linguistic influences normal to
bilingual speakers. I am to conclude that SL does not have a language disorder or delay and is
performing at an age-appropriate level for matched-peers from her cultural and linguistic
This finding has been shared with SL’s mother and teacher, who agreed on the clinical insights,
conclusion and recommendations.
SL presents with age-appropriate speech-language skills and no skilled speech therapy is
warranted at this time.
She is a bright and emotionally composed young girl with deep critical and independent thinking
skills. She possesses good task initiation and does not hesitate to attempt a given task. She is
willing to start and refine her output with ongoing self-assessment and organization of thoughts
along the way. She is not afraid to ask for clarifications when appropriate. Throughout the
assessment, she exhibited excellent concentration, deep level of self-awareness and great
self-monitoring skills. When asked what she thought of the tasks, she eloquently stated:
“I think the rhyming and the comprehension questions were easier. There’s a straightaway answer. I’m better at memorizing than opinion questions. Sometimes there are multiple answers and sometimes I just choose the one that instantly popped into my mind. I have to think about what I think. There’s no a rule that I can follow that can guide me. I need to think of what I could say myself. That’s [opinion prompt] not something that I could say that’s already in my brain.”
SL was encouraged that “being able to express one’s thoughts and opinions is a gift.” While
sometimes it can be challenging to try to construct something from scratch in one’s head,
learning to develop those thoughts and opinions by being in touch with one’s inner self can help
her become a more effective and comfortable communicator. Participating in debates may be a
viable platform for SL to develop those skills further.
The concerns raised by her mother initially regarding her attention were not observed during the
session. While cultural expectations may play a role, the mother was encouraged to prompt SL
(as appropriate) to verbalize the homework instructions prior to performing them and include
“re-evaluation” as a final step for her math work prior to handing in her assignments (given the
mother’s main concern is on math).
As SL continues to grow and develop her social and academic English, offering more specific
and direct feedback on her social Cantonese and using them along with her established English
skills to build on academic Cantonese would be beneficial for her. Given that the family is
interested in developing SL into a balanced trilingual (English/Cantonese/Mandarin) in response
to the globalization trend, tapping into her current bilingual advantage would be strategic,
especially considering the typological similarity between Cantonese and Mandarin and shared
written forms. Family is encouraged to continue using Cantonese with her to avoid language
loss and improve overall language growth by promoting cross-linguistic transfers.