Initial Speech-Language Evaluation Note

Initial Speech-Language Pathology Evaluation

Client Information

• Name: Lucas James Vance
• Date of Birth: 14/05/2019
• Age: 5 years, 5 months
• Gender: Male
• Address: 42 Banksia Street, Heidelberg VIC 3084
• Contact Information: 0412 345 678 (Mother: Sarah Vance), sarah.vance88@email.com.au
• Date of Assessment: 24/10/2024

Referral Information

• Referred by: Dr. Priya Patel, General Practitioner, Heidelberg Medical Centre (Ph: 03 9459 1234)
• Reason for Referral: Evaluation and management of reduced speech intelligibility and expressive grammar delays prior to primary school entry.

Background Information

Medical History

• Relevant medical diagnoses: Recurrent acute otitis media (AOM) between 2021 and 2023. Mild asthma diagnosed 03/2022.
• Previous surgeries or hospital admissions: Bilateral myringotomy and grommet insertion (12/08/2023 at Austin Hospital) for chronic otitis media with effusion (OME).
• Medications: salbutamol (Ventolin®) 100 mcg INH PRN for wheeze.
• Hearing status and history of ear infections: History of conductive hearing loss secondary to OME. Post-grommet audiology review (15/02/2024) confirmed normal hearing thresholds bilaterally.

Developmental History

• Milestones (for example, speech and motor development): Gross and fine motor milestones WNL (walked at 13 months). First words delayed (18 months); slow to combine words (30 months).
• Developmental delays identified: Expressive speech and language delay noted by Maternal and Child Health Nurse at 3.5-year key ages and stages visit; monitored until ENT intervention completed.

Family History

• Family history of speech, language, or learning difficulties: Paternal uncle had childhood speech sound disorder requiring SLP intervention. No known history of dyslexia or ASD.

Educational or Occupational History

• Current school or workplace: Little Explorers Kindergarten (4-year-old kinder program)
• Level of education: Preschool
• Support services received (for example, special education or occupational therapy): Nil formal therapy received to date. Kinder inclusion support educator assists with peer interactions 2 hours/week.

Communication Concerns

Reported by Client or Family

• Mother reports unfamiliar listeners understand approx. 60% of Lucas's speech.
• Frustration when not understood by peers, leading to withdrawal.
• Difficulty retelling events from kindergarten using correct tense and pronouns.

Clinician Observations

• Intelligibility decreases significantly in connected speech compared to single words.
• Frequent phonological errors (velar fronting and cluster reduction).
• Short mean length of utterance (MLU) with grammatical omissions.

Assessment Components

Speech Assessment

• Articulation: Phonological processes persisting beyond expected age: velar fronting (/k/ -> [t], /g/ -> [d] in initial/final positions, e.g., "tat" for "cat") and consonant cluster reduction (/s/ clusters reduced, e.g., "poon" for "spoon"). Stimulable for /k/ and /g/ in isolation with visual/tactile cues.
• Fluency: Smooth, effortless flow of speech; no stuttering behaviours observed.
• Voice: Vocal quality, pitch, loudness, and resonance all WNL.

Language Assessment

• Expressive Language: CELF-P3 Core Language score indicates mild-to-moderate expressive delay. Errors in pronoun use ("him" for "he") and omission of regular past tense "-ed" and auxiliary verbs ("boy running").
• Receptive Language: Receptive skills WNL. Followed 2- and 3-step novel directions accurately and demonstrated age-appropriate vocabulary comprehension.
• Pragmatics: Appropriate eye contact, joint attention, and conversational turn-taking with clinician. Initiates play and communication appropriately.

Cognitive-Communication Assessment

• Attention and Memory: Sustained attention for 20-minute structured tasks; required minimal redirection. Working memory adequate for following multi-step instructions.
• Problem Solving: Age-appropriate reasoning demonstrated during play-based tasks (e.g., matching shapes, resolving toy conflict scenario).

Swallowing and Feeding Assessment (when applicable)

• Oral Motor Function: Oral structure and function WNL on informal examination. Normal labial seal and lingual range of motion. Adequate mastication and bolus control with snack (crackers and water).
• Feeding Habits: Mother reports age-appropriate diet with no choking, gagging, or food aversions.

Assessment Tools Used

• Diagnostic Evaluation of Articulation and Phonology (DEAP) – Phonology Subtest: To evaluate speech sound production and identify phonological error patterns.
• Clinical Evaluation of Language Fundamentals – Preschool, 3rd Edition (CELF-P3): To assess receptive and expressive language structures.
• Informal Play-Based Language Sample and Oral Peripheral Examination: To evaluate functional communication, pragmatics, and oral-motor structure/function.

Summary of Findings

• Strengths: Age-appropriate receptive language, strong social-pragmatic engagement, and high stimulability for target speech sounds.
• Areas of Concern: Moderate phonological disorder (fronting, cluster reduction) impacting intelligibility, alongside mild-to-moderate expressive morphosyntactic delay.

Recommendations

Intervention Plan

• Weekly 45-minute individual SLP sessions utilizing a minimal pairs phonological approach and narrative-based grammatical modelling.
• Short-term goals (3 months): Produce /k/ and /g/ in CV/CVC words with 80% accuracy; use subjective pronouns (he, she, they) in structured sentences with 80% accuracy.
• Long-term goals (6 months): Eliminate velar fronting and /s/ cluster reduction in conversational speech; use age-appropriate past tense morphemes in spontaneous narrative retell.

Referrals

• Return to GP (Dr. Patel) to initiate a Chronic Disease Management (CDM) plan for Medicare-rebated allied health sessions.

Home Strategies

• Auditory bombardment: Read lists of /k/ and /g/ words to Lucas for 2 minutes daily to build phonological awareness.
• Recasting: Repeat Lucas's grammatically incorrect sentences back to him with the correct structure emphasized, without forcing him to repeat (e.g., Child: "Him felled down", Parent: "Yes, he fell down!").

Clinician's Signature

• Name: Emma Thorne, CPSP, MSPath
• Title: Speech-Language Pathologist
• Contact Information: 03 9455 9876, e.thorne@melbspeechclinic.com.au
• Date of Report Completion: 25/10/2024