Children’s Hospital Report of Speech and Language Evaluation 12.17.08

Children’s Hospital Report of Speech and Language Evaluation 12.17.08

Anna-Li (Li-Li) H Q-, who will turn 3 years of age in February, was seen in December of 2008 for “follow along”  through the Deaf and Hard of Hearing Program of the Children’s Hospital Boston at Waltham.  She presents with known, bilateral, sensorineural hearing loss (status post bilateral cochlear implantation) and has been seen previously for assessment of emergent language skills and she and her parents for psychological assessment/consultation prior to each cochlear implant surgery. For this appointment, Li-Li was again accompanied by parents, Elizabeth and John.

While Li-Li was being seen by Jennifer Johnston, speech-language pathologist, her parents participated in an interview with Dr. Terrell Clark, pediatric psychologist. Li-Li settled comfortably into the assessment session. Among children at her young age the assessment session appears to be a play session with colorful objects and toys, puzzles, books, and pictures; all of these appealed to Li-Li. Her parents remained in the room for a short time and then were able to excuse themselves and meet in a separate room with Dr. Clark while Li-Li was engaged with Dr. Johnston. At the beginning of the session, and again at the end, Dr. Clark was able to join the session with Li-Li to observe and interact. Impressions from the session were also shared with Ms. H- and Mr. Q-.

The family resides in W-, MA. Li-Li has been involved with Early Intervention services (Laurie Wallace) and she participates in the Parent-lnfant/Toddler program of The Learning Center for the Deaf in Framingham where she also attends for day care.

As she turns three, Li-Li will be transitioning to a preschool level program. She will be having a final developmental assessment through Early Intervention soon and transitional planning meetings involving her parents, EI providers, and school district have already begun. A formal decision regarding preschool level placement has not been made as yet. Several options are under consideration. Her parents acknowledged they are favoring the possibility of Li-Li attending preschool at The Learning Center for the Deaf, provided there is an appropriate grouping of children close to her in age and support for auditory access to language along with continued support for Li-Li’s developing her American Sign Language proficiency.

Li-Li, who is absolutely adorable, was wearing her two speech processors. Her parents described that she requests the devices, wears them all day, and jabbers away at home when she has auditory stimulation through her bilateral cochlear implants. In this setting, with clinicians who do sign fluently, she communicated predominantly through signing at the beginning of the session. As the session continued, she became increasingly vocal. She often signed and spoke words simultaneously. Her mother described that Li-Li is a “natural signer” (who) switches almost effortlessly between sign and spoken language depending upon her environment, the mode of communication in use around her, and her knowledge of vocabulary.” Further, she describes Li-Li as being “very much a chatterbox, singing and talking constantly at home and among people familiar to her. Her parents described Li-Li as agile and dexterous. She has been entirely healthy. She loves books and having her parents read to her. Li-Li has already begun to recognize letters and numbers. They characterize her as “doing beautifully” and seeming to be “very smart.” Li-Li certainly impresses as bright, attentive, alert, curious, and delightfully engaging. She also impresses as having a determined personality and
definite “mind of her own.”

Assessment
Li-Li used either Sign Language or spoken English for expressive communication purposes during this session. When she was not attending visually to the examiner, the examiner used spoken English. At other times, the examiner used ASL to communicate with Li-Li. She is acquiring two languages, ASL and spoken English, at the same time.

The examiner followed Li-U’slead when choosing which language to use. There were times when Li-Li paired a spoken word approximation with a sign. She participated in most of the adult-directed activities that were presented to her. Li-Li enjoyed drawing with the examiner and asking the examiner to draw specific items (e.g., ~ make fish big.”)

Receptive Language
The miniature toys from the Reynell Developmental Language Scales were presented to Li-Li. The items on this task were presented to Lili through either ASL or spoken English. Li-Li identified objects by name, function and by two critical elements. Li-Li did not continue participating with this activity and therefore her performance represents a minimal estimate of her abilities. She was credited with a Standard Score of 80, indicates language comprehension abilities that are mildly delayed for her age.

Expressive Language
The Expressive Scale of the Reynell was administered to assess Li-Li’s expressive language abilities. She was credited with using three + word or sign utterances, use of prepositions and pronouns. Expressive language abilities are judged to be at a two year age level. Though her parents have not yet heard Li-Li used present progressive verb tense markers, Li-Li was observed to imitate the word “sleeping” during play with dolls. Li-Li continues to use language for a variety of purposes. She requests information from her parents, including the names of things and the location of people, toys and pets. Li-Li was observed to request objects, request information and assistance, comment, describe the actions of dolls in play, respond to questions and to label objects and pictures. She communicated appropriate for a wide range of communicative functions.

On the MacArthur CDI, Li-Li’s expressive vocabulary in sign and spoken English consists of approximately 400 words. This vocabulary size is typical for a girl who is two years, six months of age. The following is a sample of the language Li-Li used. Words that were produced in Sign are represented in upper case. Spoken English utterances are represented in lower case.

“up Grendel” (Li-li says this as she puts a toy dog in a toy car.)
DADDY STUCK (Li-Li comments that the Dad doll is stuck in the car.)
“baby all done.” (Li-Li says this when she is finished playing with dolls.)
“more ball .M (Li-Li asks to play with a ball again.)
MORE MOUSE (Li-Li asked to play with a toy mouse again.)

Speech Production
Lili used many spoken English word approximations. A sample of her speech is included below:
/ba/ball
/i/ eat
/dEndl/ Grendel
/a: d^/ all done
/data/ dinosaur
/ae | deit^/ alligator
/bo^/ four
/dl/ six
/Ep/ help
Li-Li has made very good gains in her speech production abilities. She is using a greater variety of phonemes and spoken words than noted at her last visit in April. She deletes final consonants and unstressed syllables and makes consonant substitutions, all of which are typical patterns used by young children in general and by young children who are learning to listen with cochlear implants.

SUMMARY AND RECOMMENDATIONS:
Approaching three years of age, Li-Li Q- was seen for “follow along” through the Deaf and Hard of Hearing Program of the Children’s Hospital Boston at Waltham, accompanied by her parents (Elizabeth H- and John Q-). Li-Li is acquiring two languages, American Sign Language and Spoken English. Li-Li, a delightful and playful child, used both languages during this visit. When she was busy looking at and playing with toys, she tended to listen to and use spoken English. At other times, during a book reading activity, she attended to and used ASL. For today’s visit, Li-Li demonstrated language comprehension abilities that are clustering at the two year, six month age level with expressive language abilities clustering at the two year age level. Li-Li’s language abilities, as assessed here, are judged to be mildly delayed for her age. It is our impression that with continued access to both American Sign Language and spoken English, Li-Li’s language abilities will continue to expand and develop appropriately. Based upon these findings, the following recommendations are offered:

Li-Li requires a dual language, ASL and spoken English, educational program that is designed to foster the development of both of the languages she uses. In this setting, she will need to be taught by trained teachers of the deaf. Li-Li requires a small class size with a student-teacher ratio not exceeding 4:1.

As a child who is learning to listen with cochlear implants, Li-Li requires educational environments that have been treated acoustically to reduce background noise. She also requires staff members who are able to conduct daily listening checks of her equipment and engage in troubleshooting of equipment as needed.

Li-Li requires speech, language and listening therapy for at least two hours each week. The goal of this therapy includes increasing Li-Li’s overall language comprehension and production abilities as well as her speech production abilities. In addition, the development of her auditory skills continues to be an important goal of her therapy.

In the context of speech, language and listening therapy, an emphasis on phonemic awareness and “playing with” the sound system of spoken English is recommended.  Li-Li enjoys looking at books, an excellent context for developing phonemic awareness, rhyming, letter·sound correspondence and vocabulary as well as language stimulation.

Li-Li requires auditory access to language and information, exploration of sound, and interaction through spoken language (supported by signing when necessary) throughout the day.

Li-Li’s first language is American Sign Language (ASL) She is acquiring many words and phrases in spoken English and making a natural transition towards speaking as she now has access to sound through use of her cochlear implants. A combination of both modes and both languages is required to ensure that her learning keeps pace with her potential.

It was our pleasure to see Li-Li and her parents for this follow along visit. We are delighted to participate in her care and believe that her parents’ high expectations and aspirations for her are appropriate.

Jennifer Johnston, Ed.D, CCC-SLP Speech/Language Pathologist
Terrell A. Clark, PhD, Pediatric Psychologist