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2 Zohran Speech & Language Assessment Report

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52 views

2 Zohran Speech & Language Assessment Report

Uploaded by

MN Khan
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Early Learning Centre for Special Needs

Al-Rakah Janubia

Speech & Language Assessment Report

Demographic Details:

 Date: June 27, 2024


 Patient Name: Zohran Ali
 Age: 4 years, 7 months
 Gender: Male
 Date of Birth: September 29, 2019
 Ethnicity: Pakistani
 School: Preschooler
 Date of Referral: June 24, 2024

Reason for Evaluation: Concerns regarding speech regression, issues with expressive and receptive language,
and behavioral problems.

Chief Complaint:

 Zohran primarily communicates through signs and gestures, occasionally using jargon and very few single words.
 Limited social interaction with peers.
 Specch regression ( could say words like "Mama," "Water," and "Apple at 2yrs of his age )
 Engages in head-banging and self-harming behaviors.

Presenting Problem: Parents have noted regression in Zohran's speech and difficulties in being understood by
others.

Medical Diagnosis: No formal diagnosis of developmental disorder, but parents suspect regression and speech
delay.

Medications: Zohran is not currently taking any medications.

Allergies: No known allergies.

Past Medical History: No significant medical events or surgeries.

Family History: No known family history of speech or language disorders.

Social History: Lives with parents in a nuclear family. Limited progress in preschool, with minimal peer
interaction.
Developmental History: Achieved developmental milestones within the normal range, but speech
development has been slower compared to peers.

Assessment:

General Observation:

 Prelinguistic skills are below average.


 Joint play and attention are below average.
 Deficits in social approaches.
 Emerging object permanence and use.
 Average eye contact and hand-eye coordination.
 Inconsistent pointing.
 Poor turn-taking and attention.
 Average imitation.

Oral Mechanism Examination:

 Facial Structure: Symmetrical with slightly retracted lips at rest, limited lip closure.
 Lips: Limited mobility, decreased ability to round for bilabial sounds, retraction observed during speech.
 Hard Palate: Normal appearance and intact.
 Soft Palate: Intact with appropriate movement.
 Teeth: Normal dental occlusion.
 Mandible: Normal jaw movement with symmetrical opening and closing.
 Tongue: Limited lateral mobility and coordination, affecting articulation precision, with lingual protrusion
observed during speech attempts.
 Vegetative skills : Impaired blowing

Expressive Language:

 Understands and follows directions well.


 Identifies body parts and objects (e.g., transportation items, fruits, shapes).
 Good receptive language, understands syntax.
 Limited understanding of pronouns and prepositions.
 Follows verbs with physical and visual prompts.
 Expresses needs and wants by pointing.

Receptive Language:

 Responds well to name and simple instructions.


 Uses non-verbal communication to answer WH questions.
 Points to objects when named from flashcards.
 Follows two-step directions.
 Can wait for about 5 minutes in turn-taking tasks.
 Transitions well between activities.
Behavioral Observations:

 Issues with headbanging, expressing emotions, and responding to sounds.


 Fixated behavior on certain toys.
 Confusion with daily routines and inappropriate emotional responses.
 No functional or vowel sounds produced during assessment.
 Appears non-verbal but has good receptive skills.

Diagnostic Impressions :

 Delayed Expressive & Receptive language


 Social Communication disorder

Intervention Plan:

Objectives:

 Improve jaw stability and movement.


 Enhance understanding and use of pronouns and prepositions.
 Develop initial verbal communication skills.
 Reduce problematic behaviors (e.g., headbanging).
 Improve emotional recognition and response.

Short-Term Goals:

 Jaw Stability and Movement:

o Introduce jaw exercises with physical and visual prompts.


o Utilize bite blocks and chewy tubes to enhance jaw strength.

 Pronouns and Prepositions:

o Use visual aids and modeling.


o Practice through structured play and daily routines.

 Initial Verbal Communication:

o Begin with imitation of vowel sounds using physical prompts.


o Use picture exchange communication system (PECS) to initiate requests.

 Reduce Problematic Behaviors:

o Implement a sensory diet.


o Use a visual schedule to reduce confusion with daily routines.

 Emotional Recognition:

o Use social stories and role-playing to teach appropriate emotional responses.


o Practice identifying emotions in pictures and real-life scenarios.

Long-Term Goals:

 Verbal Communication:

o Develop functional use of basic words and simple sentences.


o Increase verbal communication to express needs and wants.

 Comprehension and Usage of Language:

o Enhance understanding and appropriate use of pronouns and prepositions.


o Improve ability to follow multi-step directions independently.

 Behavioral Regulation:

o Reduce frequency and intensity of headbanging.


o Improve emotional regulation and appropriate responses to emotions.

Plan of Care:

 Intensive Speech Therapy: Focus on oral motor skills, articulation, phonological awareness, and language
development.
 Oral Motor Exercises: Improve lip, tongue, and jaw strength, mobility, and coordination.
 Parent Education: Provide strategies and techniques for supporting Zohran's speech and language development
at home.

Assessment Tools Used:

1. Oral Peripheral Mechanism Examination (OPME)


2. Receptive-Expressive Emergent Language Test (REEL-3)
3. Peabody Picture Vocabulary Test (PPVT-4)
4. Preschool Language Scale (PLS-5)
5. Behavior Assessment System for Children (BASC-3)
6. Social Responsiveness Scale (SRS-2)

Assessed & Administered by:

Dr. Mehvish Khan

PhD Clinical Neuropsychologist

Autism Specialist / SPED / Brain & Behavior Analyst

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