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What are Brutus' communication strengths and areas of need?

Brutus areas of needs consistent of

-speech produciton

-reading

-limited attention span

-excutivie functioning

-word finding deficits

. He demonstrated many strengths in his communication abilites such as independently engaged in conversation and shared infomation related to his personal life and experinces.

How might his ADHD and TBI influence language performance?

Brutus current conditions (e.g., ADHD and TBI) may influence langauge performance beucase of decreased attention span and exectutive functioning. This also ties onto planning, organization, and inhibition difficulties.

What additional information do you need?

-Teacher report and classroom observation

-Parent goals and priorities

-Additional information about his QOL and functional impact

-Current IEP goals and documentation

How would you begin intervention?

-dynamic assessment (e.g., SLAM cards, non word book)

How can the patient plan and strucutre sentences, what words are being choosen, and how the patient articulaties his utterances.

-Trial startgies and build a functional report in order to increase motivation

-Thje first session I would began with articulation and building reading/writing strategies.

How would you collaborate with other rehabilitation professionals (e.g., occupational

therapy, physical therapy, psychology, neuropsychology) to support Brutus and his

family

In order to support Brutus and his family I will collaborate with other rehabiliation professioanals by mianitaing effective communication regarding the patients goals and construct a personalized/ functional plan of care. Due to his ADHA diagnosis, OT/PT can integrate a squishy pillow or visual compoent to faciliate the clients needs.

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Standardized and Informal Assessment

2 SD below mean for core language

1 SD below for formatting sentences and recalling sentences

Below average for sentence comprehension

Goals: Cognitive

Brutus will utilize visual organizers to sequence tasks and assist in working memory with min-mod cues in 4/5 opportunities across 3 data points.

Goals: Language

Brutus will follow EET sequencing to expand on specificity, elaboration, and narrative details with min-mod cues in 4/5 opportunities across 3 data points.

Goals: Artic

Brutus will decrease instances of tongue protrusion with 80% accuracy across 3 consecutive sessions with minimal cueing.

Goals: Literacy

Brutus will break up 3 phoneme words and identify their individual sounds with 80% accuracy across 3 data points with moderate cues.

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Case history

4 year old TBI patient fell of tractor in 2023

ADHD and TBI and fine motor deficits

Recieved services from an SLP because the SLP deemed his behavior developmentally appropriate but parent concerns persist.

In terms of his language  her shared personal information, answer wh questions, has emerging infrencing skills. He was able to identify emotions and generate appropriate hypotheital rtesponces

In terms of his execuative function there is a notable deficit in his attnention span and he is unable to read/ recognize letters

• Interpret standardized and informal assessment findings.

CELF: Core language is 66

Expressive language:

1. A. Formulated sentences: Received a scaled score of 4. He demonstrated difficulting target words into gramatically complete and meaningful sentences. He would make up a sentence without the target words. He lacked cohesion throughout his productions. He benefited from visual supports and extended time accomidations

2. Word dtructure: Received a scaled score of 3 score.

Receptive language:

1. Recalling sentences: Scaled score of 4, As complexity of stimuli increased accuracy decreaseed.

2. Sentence comphrension: Received a scale score of 5

GFTA

Received a standard score of 61indiciating that his speech sound production fell below 2 standard deviations of the mean. He demonstrated cluster redution, stopping. He exhibited inconsistant incinsistant sound substitutions and intermittant frontal tongue protrusion

NOTE: Clinicians suggested that Brutus's attention deficitis, working memory deficits and occasional comprehnesion errors contributed to his low scores'

Differentiate language impairment from executive functioning and attention-related challenges.

-the TILS will help to differentiate

Memmory assessments

Identify additional assessments or information needed.

TILS for reading

NIH tool box

Informal memory assessment

Develop an initial outpatient intervention plan with functional goals.

Reading intervention  for early litereracy strategies ( engaging in a book, answering comprhension questions, identifying letters)

Articulation intervention adressing stopping first then cluster reduction as treatment prgoresses

Functional working memory strategies : rehersal, visualization, advance organizers, graphic organizers

Support your recommendations using current evidence from the assigned readings.

It is critical for the SLP to target working memory "When it comes to intervention, then, working memory must be treated as an element in a biological system that is sensitive to the efficiency of other systems for its integrity." ( Singr et al 2018)

Singer emphasizes the functionality of these strategies.

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Intervention: Implementation of classroom supports; visual schedule, visual timers, reminders, built-in movement, organizers to support completion of assignments, management of environmental stimuli, and a model of what work may look like.

Begin incorporating metacognition of supports needed through heavily supported social autopsies and reflection. This will begin to develop his use/awareness of self-monitoring.

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Strengths: friendly, engaged in conversation, retell personal story, sequenced 3-step events, answered a variety of wh- questions

Weaknesses: attention, receptive/expressive language articulation, executive function (organization, planning, impulsivity)

ADHD was said to possibly impact his CELF-5 score, as he could not attend to task and maintain focus.

Additional Information:

-Medical Management?

-Interview with teacher.

-Strategies used in the classroom

-Had support?

-Parent Interview

-What resources have you been given?

-What strategies do you use?

-How does his personality change from school/other environments to home

Additional Assessment: PTBI, SFAVRS

Intervention:

Attention/Impulsivity and executive functioning to promote learning and success in the classroom

-Focus on task

-Maintain attention

-reduce impulsivity

Expressive Language

-focusing on morphology and the structure/meaning of words

-Formulating more complex and complete sentences

Collaboration:

Neuropsych

OT

-he benefited from visual supports and additionally processing time

Goals:

Client will use compensatory strategies (e.g., graphic organizers, advanced organizers, sequencing organizers) to improve working memory and attention to tasks.

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Executive Functioning and Attention-Related Challenges

Attention and impulsivity influenced CELF-5 scores. Misunderstanding directions during the CELF-5. As the evaluation points out speech production and executive functioning should be the greatest areas of concerns.

Information Needed

Reading and writing sample

Classroom participation - how is he doing in school, what does he remember in lessons, how does he transition between activities, awareness of deficits. Can he follow multi-step directions.

Plan for Outpatient

Target executive functioning and speech sound production. Utilize visual schedules and self-talk. Also work on phonological awareness to strengthen literacy skills. Multi-step directions as well.

Questions

how to address attention skills as an outpatient clinician?

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What are Brutus' communication strengths and areas of need?

- Strengths: Overall communication of messages across contexts (explanation, personal narratives, sequencing three-step events), conversational abilities

- Areas of need: Verbal working memory, attention, impulsivity, speech production, planning & organization, vague responses

How might his ADHD and TBI influence language performance?

Executive functioning deficits (attention, impulsivity) likely affected Brutus' language performance by impacting his responses to answers. These deficits resulted in rushed and incorrect answers. Additionally, deficits in organization and planning impact his overall language by affecting sentence cohesion.

Identify additional assessments or information needed:

NIH toolbox findings, classroom observations, informal language sample measures, test/homework performance at school

How would you begin intervention?

Begin with executive functioning goals (e.g., sustained attention on a task, organization and planning, working memory strategies)

Possible Goals:

By the end of 8 weeks, Brutus will demonstrate improved organization and planning by successfully alerting clinicians when to switch between tasks within a session in 80% of opportunities, with the support of a visual schedule and minimal verbal cues from clinicians across 3 consecutive sessions.

By the end of 8 weeks, Brutus will demonstrate increased narrative cohesion and description by retelling a story from a short video clip using a graphic organizer with 80% accuracy across 3 consecutive sessions with minimal clinician cues.

How would you collaborate with other rehabilitation professionals (e.g., occupational

therapy, physical therapy, psychology, neuropsychology) to support Brutus and his family?

Collaborate with psychology and neuropsychology to address cognitive needs

Consistent check-ins with parents/family about performance at home

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1. What are Brutus' communication strengths and areas of need?

Strengths

Friendly, engaged, and eager to participate in conversations.

Independently shares personal experiences and discusses familiar topics.

Responded to WH- questions with consistency.

Identifies emotions and explains characters' actions during social scenarios.

Uses complete sentences in conversation and can sequence simple events.

Responds well to supports, including visual cues, graphic organizers, repeated instruction, and assistive technology. During his reading evaluation, text-to-speech and look-back strategies improved his comprehension.

Areas of Need

Significant receptive and expressive language weaknesses, including grammar, sentence formulation, verbal working memory, and recalling increasingly complex verbal information.

Narratives often lack detail and organization and require prompting for elaboration.

Reading difficulties, including decoding, fluency, and comprehension of more complex text.

Executive functioning weaknesses, including attention, working memory, planning, organization, self-monitoring, impulse control, and problem solving.

Reduced speech intelligibility due to persistent speech sound errors.

2. How might ADHD and TBI influence language performance?

Brutus's ADHD likely contributes to reduced sustained attention, distractibility, and impulsive responding, all of which were observed during testing and likely affected his standardized scores. His TBI likely contributes to executive functioning weaknesses, including planning, organization, processing verbal information, and verbal working memory. These challenges make it more difficult to formulate organized responses, follow complex directions, and retain longer verbal information.

Language, working memory, attention, and executive functioning work together during learning. Rather than attempting to improve working memory in isolation, intervention should support language processing within meaningful academic activities.

3. What additional information is needed?

Teacher report and classroom observations

Current IEP goals and accommodations

Parent priorities and concerns

Current OT and neuropsychological information

Functional communication across home, school, and community settings

Additional information regarding social participation and peer relationships

4. How would you begin intervention?

Use a functional, strengths-based approach targeting language, literacy, and executive functioning while incorporating the supports that were successful during his evaluation.

Intervention would include:

sentence formulation, vocabulary, grammar, and narrative organization

reading comprehension strategies (ex., look-back strategies)

visual supports, graphic organizers, and repeated verbal directions

self-monitoring and organizational strategies

continued use of assistive technology, including text-to-speech and word prediction

Use visual supports, rehearsal strategies, and meaningful language activities to reduce working memory demands rather than relying on isolated memory training.

5. How would you collaborate with other professionals?

Collaborate with:

Occupational Therapy to support executive functioning, organization, fine motor skills, and assistive technology.

Psychology/Neuropsych to address ADHD, executive functioning, and behavioral regulation.

Teachers and the school team to ensure consistent accommodations, visual supports, organizational strategies, and assistive technology across settings.

Family to provide education, promote carryover of strategies, and support consistent implementation at home.

This approach is consistent with the framework discussed in class, which targets the learner, communication partners, and the communication environment.

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It should be noted that Brutus' TBI occurred in 2023 from a fall. This affected his frontal cortex and was in in a coma for 8 days. He has attentional deficits and gets distracted easily. On the CELF-5, Brutus performed below average scoring a 66 on core language and was below the average range on all subtests (Sentence Comprehension: 5, Word Structure: 3, Formulated Sentences: 4 , and Recalling Sentences: 4). Compared to others his age he demonstrated significant language difficulties across receptive and expressive language abilities. It was also noted that his lack of sustained attention contributed to his performance. Additionally, maximum prompting was required due to this.

In conversational contexts, Brutus demonstrated several strengths when describing familiar routines, explaining game rules, and retelling personal experiences. However, the conversation sample lacks specificity and elaboration. Mild grammatical errors were observed during this as well including occasional overgeneralization of past tense form (this will be monitored with time).

It was observed that Brutus was engaged in conversations and independently shared personal experiences. He answered a variety of WH- questions with occasional attentional difficulties.

During standardized testing, his deficits were more apparent due to executive functioning deficits such as lack of attention. This likely impacted scores on the CELF-5, as his conversational language skills were more acceptable.

What else? An executive functioning or TBI to better understand the root of his CELF-5 performance. An informal assessment would be the best fit for this specific client (p[pediatric test of brain injury designed to assess functional and cognitive-linguistic skills). This will allow clients to pin point primary deficits. Was it really a language impairment? Or, is it a result of attentional deficits? Assess during every day tasks (at home and at school) rather than in a structured environment.

Intervention plan:

Assessment (Pediatric Test of Brain Injury)

Goals:

Following-directions

1. Brutus will follow two-step directions with a verbal cue in the classroom using self-cueing strategies with 90% accuracy across 3 sessions

Rationale: Addressing attentional deficits and executive functioning are common difficulties that can impact school adjustment and academic success sow e should focus on these skills

Impulsivity

2. During a use taught strategies to think about actions and verbally identify his current feelings before initiating a response in 90% of opportunities across 3 sessions

Rationale: To address EF skills and emotional regulations/impulsivity since Brutus struggles with responding impulsively prior to fully thinking before responding. This would be an effective strategy because during eval, it showed he benefitted form reminders to slow down and think.

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Collaboration: Use EF strategies in a variety of therapy settings (OT,PT, NPsych) to support generalization while still in a controlled environment with fewer demands. Strategies (compensatory and developmental) could be trialed in these various settings to identify potential barriers to use that only emerge under specific demands.

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Communication strengths&areas of need:

There are many strengths in his communication abilities while also exhibiting areas of need related to speech production, executive functioning, and attention.  He’s able to answer a variety of wh-questions, discuss personal experiences and identify character’s emotions. He describes familiar routines and explains game rules. However, additional prompting was frequently needed to expand his ideas and provide more complete information.

ADHD and TBI influence language performance:

ADHD and TBI may have influenced his performance because his body experienced highly traumatic events. His injury occurred in the frontal cortex and was put in an induced coma for 8 days. Frontal lobe injuries can often cause executive function problems, including poor attention plan which makes him more distractible than children.

Without treatment for his ADHD and TBI, he will struggle absorbing material in class. Difficulties with attention, working memory, processing speed, and executive functioning would affect his ability to follow direction, retain new information, organize thoughts, and comprehend academic language.

Additional info:

More information from teachers about behavior and performance in an academic setting. A dynamic assessment would also be helpful information to get a potential spontaneous language sample instead of expecting him to perform well in a standardized and structured assessment. Obtain information from the FAVRES to measure executive functioning in a less structured environment.

How would you begin intervention:

With executive functioning intervention that focuses on maintaining attention and regulating emotional impulsivity. Co-treatment with OT is a high priority as language and fine motor skills are reported as the biggest concerns.

Collaboration:

OT: Ask what goals other rehabilitation professionals are working on and collaborate on integrating fine motor and other ADLs into daily communication activities. Fine motor challenges can inhibit Brutus’ abilities to participate in daily activities at home and in school, working with psychology can help get ahead of any mental health related effects of this. Speech being included along the way is important in making sure Brutus feels consistently understood.

Neuropsychology: Express our concerns on Brutus’ executive functioning skills to ensure he is given the correct treatment for his ADHD and other symptoms as a result of his TBI.

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Comm strengths:

Friendly, engaged, motivated to participate. Personal experiences, very social, answers WH- questions + demonstrated emerging picture based lang activities.

How might his ADHD and TBI influence language performance?:

Poor sustained attention, impulsive responses (poor inhibition), difficulty with planning, organizing, verbal working memory. All of these EF are critical to developing and using age-appropriate language and literacy skills.

What additional information do you need?

Functional EF performance observation. I would like to observe Brutus completing a functional task (e.g.; please help me clean up these toys by putting them into the appropriate bins. Then we will get out and set up new game to play with). Given these instructions, which steps/what order does he perform the task? What cues help him to remain on task? How is he organizing the toys/games?

How would you begin intervention?

I would ideally target EF skills (likely starting with attention) that need boosted in order for Brutus to assist him with language skills.

How would you collaborate with other rehabilitation professionals (e.g., occupational therapy, physical therapy, psychology, neuropsychology) to support Brutus and his family?:

OT- Functional every day occupations (hygienic, play, social, family) and fine motor skills.

Psychology- EF skills, social-emotional impacts