In this presentation, we discuss speech and language in school-age youth, identify when referral for Speech-Language Evaluation and Therapy would benefit the patient, and explain utilization of Alternative and Augmentative Communication (AAC).

1. Making the Best Use of Speech-Language Therapy
Celia Neavel, MD, FSAHM
Lee Anne Holmberg M.A., CCC-SLP
Ellen S. Kester, Ph.D
Jon Yates, AAC Specialist
2012, Dell Children’s Hospital, Austin, TX

2. OBJECTIVES
1. Discuss speech and language in school-age
youth.
2. Identify when referral for Speech-Language
Evaluation and Therapy would benefit the
patient.
3. Explain utilization of Alternative and
Augmentative Communication (AAC).
4. Describe community resources for youth with
speech and language delay and their families.

3. STRUCTURES INVOLVED IN SPEECH
AND VOICE PRODUCTION.

4. PREVALENCE SPEECH PROBLEMS
REPORTED BY PARENTS

5. ALL OF THE DOCUMENTS AND CHARTS IN THIS
PRESENTATION CAN BE DOWNLOADED FROM OUR
FREE RESOURCE LIBRARY.
Click here to visit the Resource Library

6. LANGUAGE DISORDERS
 Language
 Shared system for communicating
 Involves sounds, signs, gestures, and/or spoken or
written words
 Specific Language Impairment
 Absence other developmental problems
 Other language disorders assoc. with
 Hearing impairment
 Autism
 Mental retardation
 Congenital or acquired disorders of brain
development
 Head injury, brain tumors.

7. MEAN LANGUAGE SCORES AND
NON-VERBAL I.Q.SCORES

8. PREVALENCE HAVING READING
DISABILITY

9. NORMAL LANGUAGE DEVELOPMENT IN
CHILDREN AND ADOLESCENTS
 Verbal AND non-verbal; follows predictable
course
 4-5 y.o.
 200-300 words; can describe, define, answer why; tell
simple story; understandable to all
 5-6 y.o.
 Understands > 2000 words, sequencing, rhyming;
creates stories; carries out series 3 directions
 School Years;
 Huge demand on skills for school and social
acceptance; emerging figurative language

10. WARNING SIGNS SCHOOL-AGED CHILD
 Phonological awareness problems
 New inattentive or not well-controlled ADHD
 Problems reading, writing, understanding social
interactions
 Feelings hurt or gets angry/frustrated
 Trouble learning second language
 Parents with language/literacy problems

11. LANGUAGE AND COGNITIVE DEVELOPMENT IN
ADOLESCENTS
 Core language skills established.
 Semantics, syntax, language concepts and basic pragmatic skills
 Early adolescents more concrete
 Adult pragmatic and social language skills being refined,
including ability to:
 Interact with adults and peers in classroom and social
activities
 Maintain or shift topic of the conversation; participate
appropriately in conversation
 Take another person’s point of view to know what information
is needed during a communication event
 Incorporate subtle variations in tone, word usage, rhythm
depending on situation

12. IMPLICATIONS OF VOICE, SPEECH,
AND LANGUAGE DISORDERS
 Need to communicate to function in our society
 Affect emotional and social life, education and job
 Substantial cost in life quality and human
potential
 Number will likely increase
 Improved survival for medically fragile infants and
individuals who sustained injury or acquired disease

13. GOALS FOR
INTERVENTIONS
 Help with developmental trajectory
 Maintain or improve self-esteem
 Maximize function
 Decrease anxiety
 Educate other important adults so can:
 Understand youth’s weaknesses
 Make appropriate modifications and contribute
further to interventions

14. IDENTIFYING VOICE, SPEECH, AND
LANGUAGE DISORDERS
 Suspected by family, physician, or educator
 Consider delayed versus disordered
 ASK FUNCTIONING AGE
 Speech-language pathologists evaluate &
diagnose
 History, exam, comparison to standardized norms
 Voice assessment
 Speech assessment
 Motor speech disorders and/or stuttering
 Language assessment
 Formalized questionnaires; direct observation;
testing vocabulary, understanding, word and
sentence production, language in social situations
 Must take into account the native language of the
speaker

15. BILINGUAL CHILDREN
Ellen S. Kester, Ph.D
President, Bilinguistics Speech and Language
Services
5766 Balcones Drive, Suite 205
Austin, TX 78731
(512) 480-9573 Phone (512) 458-9573 Fax
www.bilinguistics.com

16. EXAMPLES FROM BILINGUISTICS
 4-year-old Spanish-speaking child with a
total of approximately 20 words, who
could follow one-step commands with
gestures but not without gestures.
Intelligibility of 30-40%.
 3-year-old bilingual child who has
difficulty following simple directions with
gestures. He uses single words and two-
word utterances. Intelligibility is 40-50%.
 Neither of these children had been
referred for a speech-language evaluation
previously.

17. WHY DO WE GET REFERRALS LIKE
THIS?
 Misconceptions about bilingual development
 Mobility of population
 Parents don’t understand “no cost” options
 Parents not comfortable expressing concerns
 Parents not aware of developmental differences
 Parents may be aware of differences, but not
know value of early intervention
 Language barriers may impede referral process

18.  Children code switch between languages because
they don't know either language well.
 Raising children with two languages will confuse
them.
 Children with language impairment should not
learn more than one language at a time.
 Children who use the sentence structure of one
language when speaking the other likely have
language impairment.
 We should expect bilingual children to be delayed
in developing communication skills

19.  Bilingual children develop early
vocabulary at the same rate as
monolingual children (Pearson, 1993).
 Early language milestones are similar
(single words, lexical spurt, 2-word
phrases, following directions) (Pearson and
Fernandez, 2001).
 Conceptual scores are similar (Pearson, 1998).

20. DETERMINING SPEECH-LANGUAGE
IMPAIRMENT IN BILINGUALS
EnglishEnglish
Spanish
OK
Spanish
OK
NormalNormal
English
OK
English
OK
SpanishSpanish
NormalNormal
EnglishEnglish SpanishSpanish
Impaired*Impaired*

21.  Difficulty learning both languages, even with adult
assistance
 Family history of language/learning disabilities
 Slower development than siblings
 Difficulty interacting with peers
 Inappropriate pragmatic/social language skills (i.e.,
turn-taking, topic maintenance, considering listener
needs, non-verbal communication)
 Difficulty with language in many routines
 Idiosyncratic error patterns
 Language performance unlike others with similar
cultural/linguistic experiences
Click here to visit the Resource Library

22. LEE ANNE HOLMBERG M.A., CCC-
SLP
SPEECH-LANGUAGE
PATHOLOGIST
EASTER SEALS OF CENTRAL
TEXAS

23. SPEECH-LANGUAGE PATHOLOGY YOU
SHOULD KNOW
• Language Disorders:
– Receptive Language Disorder
– Expressive Language Disorder
– Pragmatic Language Disorder
• Articulation Disorders:
– Oral Apraxia
– Stuttering-
– Voice Disorder
• Feeding Disorder:
– Dysphasia

24. A FEW DIAGNOSIS THAT WARRANT
REFERRAL TO SPEECH-LANGUAGE
PATHOLOGIST
 Children with ADD or ADHD
 Hearing Loss or Chronic Ear Infections
 Cleft Palate or other Craniofacial Anomalies
 Difficulty Feeding and Swallowing
 Autism Spectrum Disorders
 Variety of Syndromes including- Down Syndrome, Fragile X
Syndrome, Turner’s Syndrome, etc.
 Children with Cerebral Palsy

25. OTHER SITUATIONS THAT WARRANT
REFERRAL TO SPEECH-LANGUAGE
PATHOLOGIST
 Children that schools discharged from speech therapy
 Learning disabilities or children struggling in school
 School-aged and cannot identify significant details in story or
situation and then sequence them in understandable way
 2 – 5 y.o. with very small vocabulary and having difficulty
stringing words together in phrases and sentences
 When parent of a 2 y.o. or older says, “My child is not talking and
using words, and does not seem to understand me.”
 When parent says, “I do not understand what my child says.”
Please do not tell a parent who is concerned to wait until child is 4
or 5 y.o. A lot of speech-language development goes on before then!!!!

26. TESTS MOST COMMONLY USED
FOR EVALUATIONS
 Language Tests:
 Preschool Language Scale 4 (PLS4)
 Clinical Evaluation of Language Functioning (CELF)
 Clinical Evaluation of Language Functioning-Primary (CELF-
P)
 Test of Language Disorders (TOLD)
 Articulation Tests:
 Goldman Fristoe Test of Articulation

27. WHAT TO LOOK FOR IN SPEECH-LANGUAGE REPORT
 Speech-language diagnosis accompanies medical diagnosis,
if applicable
 Chronological age of child included
 Standard scores from formal testing (average range 85-
115)
 Language age levels in all subtests of formal testing
 Narrative discusses child’s strengths and weaknesses
 Specific recommendations
 Stated goals to be addressed in therapy

28. WHAT A SPEECH-LANGUAGE
PATHOLOGIST CAN OFFER
• Speech and language Screenings, evaluations,
and treatment.
• Recommendations for referrals to other therapies
i.e. OT, PT
• Collaboration with other service providers
(doctors, psychologists, other therapists, and
schools).
• Education on the child's communication issues
for parents, and other providers
• Parent training on communication and the
child’s needs and goals

29. WORKING WITH THE SCHOOLS:
WHAT SPEECH-LANGUAGE PATHOLOGIST
FOCUSES ON
 Collaboration with teachers, school speech-language
pathologists, and counselors
 Education and training on specific techniques that are
working well in the child’s therapy
 Opening a dialogue to share progress and difficulties the
child is experiencing

30. QUESTIONS TO SCREEN FOR
POSSIBLE SPEECH-LANGUAGE
DELAYS
Young Children:
 How much is your child talking?
 How many words is your child using?
 How many words is your child stringing
together?
 Is your child able to follow directions (Go
get your shoes.)?
 Does your child understand what your are
telling him/her?
 How much are you able to understand
your child?

31. QUESTIONS TO SCREEN FOR
POSSIBLE SPEECH-LANGUAGE
DELAYS
Adolescents:
 How is your child functioning in school?
 How much of what your child tells you are you
able to understand?
 Is your child able to use logical sentence?
 Is their spoken grammar correct?
 Is your child able to identify the main details in a
story?
 Then is your child able to sequence these main
details to retell the story?
 Can your child follow multi-step directions?
 Does your child have pronunciation difficulties?

32. WHAT IS AUGMENTATIVE ALTERNATIVE
COMMUNICATION (AAC)?
Augmentative and alternative communication
(AAC) includes all forms of communication
(other than oral speech) that are used to
express thoughts, needs, wants, and ideas.
asha.org

33. TYPES OF AAC
 Unaided AAC: Using body to communicate with
others. Includes, gestures, body language, and/or sign
language.
 Aided AAC: Using tools along with the body to
communicate with others. Tools can include:
 Pencil and paper.
 Communication boards or communication books.
 Electronic Voice Output Devices (VOD).
www.asha.org

34. TOTAL COMMUNICATION APPROACH TO
AAC
 Includes use of combination of speech, gestures, sign,
and AAC.
 Important because it gives person variety of methods
to use for successful communicate with others.

35. TYPES OF CLIENTS WITH AN AAC DEVICE
SEEN AT EASTERS SEALS
 Clients with Down Syndrome
 Clients with profound oral apraxia
 Autistic clients
 Clients with severe Cerebral Palsy

36. AAC 101
Jon Yates
AAC Specialist
DynaVox Mayer-Johnson

37. ASSESSMENT
 AAC Devices recognized as treatment by:
 American Medical Association
 American Academy of Neurology
 American Academy of Physical Medicine &
Rehabilitation
 American Speech-Language Hearing Association

38. CONDITION SETS THAT BENEFIT FROM THE
USE OF A COMMUNICATION DEVICE
•Cerebral Palsy
•Down Syndrome
•Mental Retardation
•Autism
•Muscular Dystrophy
Congenital/
Develop‐
mental
Acquired
Child Adult
•Traumatic Brain Injury
(TBI)
•Spinal Cord Injury
(SCI)
• TBI
• Stroke
• SCI
• Amyotrophic Lateral
Sclerosis (ALS)
• Parkinson’s Disease
• Huntington’s Disease
• Multiple Sclerosis (MS)
Degenerative
Acute
•Cerebral Palsy
•Down Syndrome
•Mental Retardation
•Autism
•Muscular Dystrophy

39. SOME INTERESTING FACTS
 8 out of 1000 people worldwide cannot use
speech to communicate.
 2‐3 million in U.S. could benefit from speech
generating devices.
 Only 5% of these people have a speech device.
 Funding is available.
Source: Univ of Nebraska
Lincoln Website

40. WHAT BENEFITS DOES AAC PROVIDE TO YOUR PATIENTS?WHAT BENEFITS DOES AAC PROVIDE TO YOUR PATIENTS?
 Improves overall quality of life
 Supports meaningful personal relationships
 Develops functional communication skills
 Improves Functional Communication Measures
 Reinforces traditional rehabilitation activities
 Schedules (appointments and daily activities)
 Reminders (medication and appointments)
 Videos (physical therapy examples)
 Helps patients communicate important medical and
personal information to healthcare teams

41. FUNDING: SHOW ME THE MONEY
 Medical Model
 Medicare
 Medicaid
 Private Insurance
 STAP
 Other Organizations
 ALS
 VA
 School
 IEP
 Third Party Billing
 Other
 Fund Raising

42. FUNDING: MEDICAL MODEL
Private Insurance
 Many insurers follow Medicare guidelines.
 Call insurance company and ask questions about
benefits. Confirm whether coverage available for Durable
Medical Equipment/Speech Generating Devices.
 Payment varies by policy.
 Ask if met deductible and Out of Pocket Maximum for
calendar year.
 Any co-payments or deductibles need to be
collected before device is shipped. Go through
STAP for this!!

43. FUNDING: MEDICAL MODEL
Texas Medicaid Assistance 100%
 Covers approved equipment with no out pocket cost to
client
 Does require 30-DAY trial period
 Process takes about 2 months with trial

44. FUNDING: STAP
 STAP stands for:
 Specialized Telecommunications Assistance Program
 Falls under umbrella of DARS
 Department of Assistive and Rehabilitative Services
This is a TAX that we pay for on our phone bills every month

45. FUNDING: STAP
 Process
 Fill out STAP application and provide small report.
Application must be accompanied by proof of TX
residency.
 Everyone in Texas with a dual diagnosis qualifies for
STAP.

46. FUNDING: STAP
 With this funding there is no reason why anyone in
Texas should be without a voice. 
 This is also a great alternative for schools!
 STAP timeline is about 4 weeks. Times do
fluctuate!! Follow up with STAP!!

47. RESOURCES
 0-3 y.o. Early Childhood Intervention
 =/ >3 y.o. Child Find through School/School District or
youth’s school if already enrolled
 Non-Profit Therapy Organization
 Private Therapy Organization
 Consider:
 Hours
 Location – home or center-based; family’s transportation
 Type Insurance Accepted
 If Youth-focused
 Waiting List
 Areas of Specialization
THANK-YOU DCMCCT speech therapists for sharing list!

48. REFERENCES
http://www.nidcd.nih.gov/health/voic
e/ National Institute on Deafness
and Other Communication
Disorders, National Institutes of
Health
asha.org American Speech-
Language-Hearing Association
 Crossed Wires: Identification, Impact, Management and Outcomes of
Language Disorders presentation by Lynn Wegner, MD at Texas Scottish
Rite March 6, 2010

49. CODING
 784.3 Aphasia
 784.40 Voice and
resonance disorder,
unspecified
 784.42 Dysphonia
 784.43 Hypernasality
 784.44 Hyponasality
 784.49 Other voice
and resonance
disorders
 784.59 Other speech
disturbance,NOS
 784.61 Alexia and
dyslexia
 783.42 Delayed
Milestones

50. CODING
 315.31 Expressive
language disorder
 315.32 Mixed
expressive-receptive
language disorder
 315.34 Speech and
language delay due to
hearing loss
 315.39 Other
language disorder
(phonologic,
articulation)
 315.5 Mixed
developmental
disorder
 315.8 Other specified
delays in development
 315.9 Unspecified
delays in
development/ learning
disorders NOS

51. Click to visit www.bilinguistics.com

52. Rapidly identify speech-
language patterns related to
second language acquisition to
distinguish difference from
disorder.
DIFFERENCE OR DISORDER: UNDERSTANDING
SPEECH AND LANGUAGE DEVELOPMENT IN
CULTURALLY AND LINGUISTICALLY DIVERSE
STUDENTS