Pediatric SLP Assessment Report

Date of Birth: 14/05/2021

10/10/2024

Added by: Sarah Jenkins, M.Sc., R.SLP, Reg. #4821, Speech-Language Pathologist

License #4821

Electronically Signed

Chronological Age: 3 years, 4 months

Accompanied by

• Mother (Claire Vance)

Note

Location

• In-clinic (Halifax Pediatric Therapy Centre)

Consents

• Explanation provided to the healthcare decision-maker regarding assessment procedures, benefits, risks, side effects, alternative options, and probable consequences of not receiving the service, with verbal consent obtained for the assessment as described.
• Fee schedule previously explained and accepted, with this documented in the chart notes.
• Online Intake consent signed for the collection, retention, and maintenance of health information in accordance with PHIPA.
• Online Intake email waiver signed, permitting email communication about the client.
• N/A - Email waiver was signed.
• Online Intake consent to exchange information with the insurance company, where applicable.

Written consent obtained to exchange information with the following parties

• Dr. Alan Grant (Family Physician) and Bright Beginnings Daycare

Additional Notes

• Mother requested a copy of the report be sent directly to the daycare resource teacher.

Background Information

• Birth History: Full-term (39 wks), SVD, birth weight 3.4 kg. No NICU stay.
• Medical History: Recurrent acute otitis media (3 episodes in past yr); bilateral tympanostomy tubes inserted 02/2024. Currently taking cetirizine (Reactine®) 2.5 mg PO daily PRN for seasonal allergies.
• Developmental Milestones: Sat at 6 mos, walked independently at 13 mos. Fine motor skills WNL.
• Speech and Language Milestones: First words at 16 mos. Slow vocabulary growth noted until tube placement. Recently started combining 2-3 words.
• Daily Program: Attends Bright Beginnings Daycare FT (08:30 to 16:30).
• Languages at home: English only.
• Hearing: Passed newborn hearing screen. Post-tube audiological eval (03/2024) confirmed WNL hearing thresholds bilaterally.
• Other Services Involved or Waiting for: None.
• Siblings: Older sister, age 6 yrs, no Hx of speech/language delays.

Reported Concerns

• Mother reports reduced speech intelligibility (~50% to unfamiliar listeners) and frustration when not understood. Expressive vocabulary and sentence length appear behind peers.

Method of Assessment

• Parent interview, informal play-based observation, spontaneous language sample, and standardized testing.

Socio-Communication Skills

• WNL. Consistently responded to name, maintained appropriate eye contact, and demonstrated joint attention. Engaged in reciprocal turn-taking during play.
• Test Administered and results: Informal clinical observation only; no standardized test required.

Play Skills

• Age-appropriate functional and symbolic play observed (e.g., feeding doll, pretending to cook with toy food, crashing toy cars).

Behaviour

• Cooperative, separated easily from mother. Required occasional verbal redirection to transition between structured assessment tasks.

Receptive Language Skills

• Demonstrated understanding of core vocabulary, basic spatial concepts (in, on, under), and 2-step related commands without gestural cues.
• Test Administered and results: Preschool Language Scales, Fifth Edition (PLS-5) - Auditory Comprehension (AC): Standard Score 98, 45th percentile (Average).

Expressive Language Skills

• Communicates primarily in 2-to-3-word phrases. Uses early pronouns (I, me, you) and present progressive (-ing), but omits auxiliary verbs and regular past tense (-ed).
• Test Administered and results: Preschool Language Scales, Fifth Edition (PLS-5) - Expressive Communication (EC): Standard Score 81, 10th percentile (Mild-to-Moderate Delay).
• Language Sample: 50 spontaneous utterances collected during free play with farm set.
• MLU: 2.3 morphemes (expected for age: ~3.0-3.5).
• Sample: "Cow go in", "Me want big tractor", "Doggie eat food", "Where piggie go?"

Articulation/Phonology/Motor Speech

• Oral mech exam WNL for structure and function. Phonological processes active: consistent final consonant deletion, velar fronting (/k, g/ -> [t, d]), and cluster reduction.
• Test Administered and Results: Goldman-Fristoe Test of Articulation, Third Edition (GFTA-3): Standard Score 74, 4th percentile.

Fluency of Speech

• WNL. No atypical disfluencies or secondary behaviours observed.

Voice

• WNL for pitch, loudness, and vocal quality. Mild hyponasality noted secondary to seasonal allergies.

Recommendations & Summary

• Weekly 45-minute individual speech-language therapy sessions recommended to target phonological processes and expressive morphosyntax. Home programming provided.
• In summary, child presented with: a moderate phonological delay and a mild-to-moderate expressive language delay, alongside age-appropriate receptive language and socio-communication skills.

Tentative Goals for Therapy

• Goal: Client will produce final consonants (/p, b, t, d, m, n/) in CVC words with 80% accuracy across 3 consecutive sessions given minimal visual/tactile cues.
• Goal: Client will produce velar plosives (/k, g/) in the initial position of words with 80% accuracy during structured play tasks.
• Goal: Client will expand utterance length to 4-word phrases (e.g., Subject + Verb + Object + Location) during play with 75% independence.
• Goal: Client will accurately produce auxiliary verb "is" + verb-ing in structured sentence tasks with 80% accuracy.
• Goal: Caregiver will implement auditory bombardment and recasting strategies at home during daily routines.

Plan/Follow-UP

• Assessment results, clinical impressions, and therapy recommendations were discussed in detail with the client's mother at the end of the session; she expressed agreement with the proposed treatment plan and booked the initial therapy block.