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Language Disorders in Children with Other Disabilities:
Autism, Mental Retardation &Multiple Severe Disabilities
TSHA Convention Short CourseMarch 25, 2010
Leslie Armbruster, MA, CCC-SLPAlison Barton, MA, CCC-SLP
OUTLINE OF TRAINING
Mental Retardation/Multiple Severe Disabilities
• SI as a Related Service
• Key Components – MDT Assessment
• Determining Disability Condition (SI)• Stage 1 – Communication Disorder
• Stage 2 – Adverse Effect
• Report Recommendations• Stage 3 – Need for SLP Services
OUTLINE OF TRAINING
Autism Spectrum Disorders
• SI as a Related Service
• Key Components – MDT Assessment
• Determining Disability Condition (SI)• Stage 1 – Communication Disorder
• Stage 2 – Adverse Effect
• Report Recommendations• Stage 3 – Need for SLP Services
SI (Language) withMental Retardation
and/or Multiple Severe
Disabilities
Definitions
Mental Retardation•DSM IV-TR
•IDEA 2004 Multiple Disabilities
•IDEA 2004
•Texas Commissioner’s Rules Speech Impairment
Mental Retardation – DSM-IV-TR
Significantly sub average general intellectual functioning AND significant limitations in adaptive functioning in at least two areas:• Communication, self-care, home living, social/
interpersonal skills, self-direction, functional academic skills, work, leisure, health, safety
Presenting symptoms are in the areas of adaptive functioning
Mental Retardation – DSM-IV-TR
Adaptive functioning: how effectively an individual copes with common life demands and how well s/he meets the standards of personal independence expected for age, sociocultural background and community setting.
Interesting Trivia
The recent draft of the DSM-V changes the term “mental retardation” to “intellectual disabilities”
Watch for the wording change in the next reauthorization of IDEA and/or Texas Commissioner’s Rules!!!
Mental Retardation – DSM-IV-TR
Prevalence: 1% of general population Mild MR – 50-55 - approx 70; 85% of MR pop
Mod MR – 35-40 – 50-55; 10% of MR pop
Severe MR – 20-25 – 35-40; 3-4% of MR pop
Profound MR - <20-25; 1-2% of MR pop
Mental Retardation – IDEA 2004
“Mental retardation means significantly sub average general intellectual functioning, existing concurrently with deficits in adaptive behavior and manifested during the developmental period, that adversely affects a child’s educational performance.”i.e. adverse affect on academic achievement and adverse affect on functional performance
Multiple Disabilities – IDEA 2004
Multiple disabilities means concomitant impairments (such as mental retardation-blindness, mental retardation-orthopedic impairment, etc.), the combination of which causes such severe educational needs that they cannot be accommodated in special education programs solely for one of the impairments. The term does not include deaf-blindness.
Severe Multiple DisabilitiesTypical Student Profile
Measured IQ in the severe to profound range Often non-ambulatory Often limited use of hands/arms for self-care
purposes Often does not have a symbol system in place Often nonverbal Often – procedures in place (feeding tube,
trach, etc.)
Multiple Disabilities – Texas Commissioner’s Rules
A student who meets the criteria for multiple disabilities in IDEA and who meets all of the following:disability is expected to continue indefinitelydisabilities severely impair performance in two of the following:
psychomotor skills, self-care skills, communication, social and emotional development, cognition
Mental Retardation Section – DSM-IV-TR
“A Communication Disorder can be diagnosed in an individual with Mental Retardation if the specific deficit is out of proportion to the severity of the Mental Retardation.” (p. 47)
This means…
A communication disorder co-occurs with mental retardation when specific communication skills are out of proportion with the severity of the mental retardation
Tip: compare communication skill levels to over-all functioning, especially adaptive behavior
Tip: stay away from IQ score and language score comparisons
Speech-Language ImpairmentIDEA
Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance [emphasis added] 34CFR 300.101 (c)(11)
Critical Concepts
Communication Disorder such as…
Adverse effect on educational performance = • Adverse affect on academic achievement
• Adverse affect on functional performance
• Per IDEA 2004
SI with Other Disabilities
When SI is a second or third disability condition, speech-language services become a related service provided to help the student benefit from his/her special education program
Speech-Language Therapy
Instructional Service• When SI is only disability
• Purpose: progress in the general ed curriculum
Related Service• S-L Therapy is a related service when there
are other disabilities
• Purpose: benefit from special ed program
Speech-Language TherapyRelated Service ARDC considers eligibility categories ARDC outlines specially designed
instruction/special education program ARDC determines whether related services
are needed to help student benefit from special education (including speech-language therapy)
ARDC determines frequency, location, duration, and type (direct or indirect) of all IEP services
Speech-Language TherapyRelated Service
Purpose of S-L Therapy as related service is to help student benefit from special education program
When student has MR or Multiple Severe Disabilities, specially designed instruction focuses on• Work based learning outcomes
• Independence: self-care, communication, interpersonal
• Functional academics
Speech-Language TherapyRelated Service
How does Speech as a related service change…• Goals and objectives?
• Frequency of services?
• Location of services?
• Duration of services?
• Description of direct & indirect services?
Key Components
Multi-Disciplinary Team Evaluations
Key ComponentsSLP’s Role in MDT Evaluations
1. Evaluation Procedures for the Multi-Disciplinary Team
Evaluation PlanEvaluation Tips
2. Evaluation Flow Chart3. Communication Model – for consistent decision
making4. Adverse Effect Rubric
Academic achievementFunctional performance
General Principle (IDEA)
The assessment of language and communication status for students with other disabilities is one part of a comprehensive, multi-disciplinary team evaluation §300.532 (h)
Communication and interpersonal skills are areas of adaptive functioning that must be addressed for MR
Note to MDT…
Evaluation of students with significant disabilities often includes reliance on informal measures rather than on standardized tests
Other Notes to MDT…
Adaptive behavior/functioning level is the determining factor in identification of mental retardation
Use scores from language standardized tests to corroborate adaptive behavior standard scores and cognitive ability scores
Use data from informal measures, observations, functional communication profile to identify a language/communication disorder
Multidisciplinary Teamwork
Balanced work distribution Active participation – all team members Evaluation Action Plan – spells it out Parents and Teachers – partners in the
process
Evaluation Plan
Consistently provide comprehensive evaluations
Address/Assess all areas Reminds team to answer the evaluation
question/s Delegates responsibility for data collection Allows for individualized evaluations (vs.
“boiler-plate” approach)
Evaluation Team Action Plan
Specify who will do what by whenReview existing information
Teacher interviewOther school staff interviews
Parent interviewClassroom observation
Other observationsDirect Testing
Parent ConferenceSchool Team Conference
IEP Team Meeting
Quality Evaluation:Assumptions
Useful Clear Guides instruction/intervention Identifies learning targets Includes broad based information Includes reports from parents Is completed over multiple occasions
IDEA 2004 Flex Points
Comprehensive evaluations• Variety of tools and strategies
• Gather functional, developmental, academic information
• Assess in all areas related to suspected disability
• Must include information from parent
Comprehensive Evaluations Provide sufficient information for academic and functional
goals
Specify supports for school personnel: Should be listed specifically in the IEP – including staff development, AT/AC training for teachers and paraprofessionals, other indirect services and activities needed for full IEP implementation
Identify all special education and related services needs (i.e. don’t fragment evaluation among assessment professionals)
One child: One evaluation report: One IEP
Comprehensive Evaluations Variety of assessment tools and strategies
• Standardized instruments• Naturalistic observation• Language sample• Communication sample• Parent interview• Teacher interview• Clinical interview• Play-based assessment• Records review• Consideration of student’s learning profile• Responsiveness to interventions
Variety of Evaluation Instruments
Norm-referenced Criterion-referenced Dynamic evaluation Ecological evaluation Rating Scales Observation Notes Screening Scales Interview Notes/Anecdotal Information Medical and Developmental History
Dynamic Evaluation(measure teachable moments)
Considers learning demonstrated during evaluation process
Variations of the test – teach – test – teach model Observations in functional context-bound activities
in multiple settings What the child is able to do with some adult
support Similar to Patterns of Strengths and Weaknesses
Dynamic Evaluation Categories(Highly important in autism evaluations)
Attention Discrimination Planning Self-regulation Transfer Motivation Interaction
Ecological Evaluation(Highly important for developing IEP and BIP)
Informal testing Effects of context on performance Observe child in daily activities Includes insights, knowledge, impressions of
parents and professionals who know the student
Helps team identify supports and compromises faced by child/family in areas most important to them
Ecological Evaluation Categories
State Environment Posture Sensory Motor/Integration Social Exploration/Play Communication Response to Cues Performance Facilitated Performance Compromised
Flowchart
See Handout
Communication Model
See Handout
SI Eligibility GuidelinesDisability Condition & Adverse Effect
Develop MDT Evaluation Plan to answer referral (or re-eval) questions
Gather Assessment Data Analyze Assessment Data
• Complete Summary Profile of Performance• Cognitive/intellectual abilities
• Adaptive Behavior levels
• Communication levels
• Language levels
SI Eligibility GuidelinesDisability Condition & Adverse Effect
If Cross Battery Analysis is used• Look for low scores across all cognitive
processes
• Look for Gc lower than other processing areas
• XBA can help determine if language is a relative weakness, aligned with other areas, or a relative strength
SI Eligibility GuidelinesDisability Condition & Adverse Effect
Compare communication and language level/s with adaptive behavior levels and over-all functioning level
Interpret data and document presence/ absence of communication disorder• See Handout
Adverse Effect Rubric
See Handout
Positive Indicators: Adverse Effect Student has no communication system Student is younger than 9 years with no long history of
direct SLP services Evidence of response to direct SLP services and is
making progress in special education program Student has not received direct SLP services and
demonstrates:• Joint attention• Signaling behavior (vocal or motor)• Attention span of 5 seconds• Emerging motor imitation skills• Beginning cause-effect awareness
The Eligibility Process Disability Condition & Adverse Effect
• Stage 1 - Is a Communication Disorder present? That is, are communication skills out of proportion with severity of the mental retardation?
• Stage 2 - Is there an adverse effect on educational performance that arises from the communication disorder?• Adverse affect on academic achievement
• Adverse affect on functional performance
Need for S-L Therapy as Related Service• Stage 3 - Are speech-language pathology services needed
as a related service to help the student benefit from special education?
Case Study
Autism Spectrum Disorders
Who Is Autistic?…educationally speaking, that is…
In Texas, a student with autism is one who meets the federal criteria for autism as stated in 34 CFR §300.7(c)(1)
Students with pervasive developmental disorders are included in this category
TAC §89.1040
Legal FrameworkEligibility Definition
Federal • Autism means a developmental disability
significantly affecting verbal and nonverbal communication and social interaction, generally evident before age 3, that adversely affects a child’s educational performance
State Add-on: Other Characteristics• Engagement in repetitive activities, resistance to
change, unusual responses to sensory experiences
• PDDs included in this category
Interesting Trivia
The recent draft of the DSM-V removes Asperger’s and PDD-NOS as separate diagnostic categories…
It’s all “just autism”
Should not be big wording changes… the disability category for the Autism Spectrum has been Autism
AutismAreas of Interest for SLP
Qualitative Impairment in Social Interaction
Qualitative Impairment in Communication
Communication Skills
in
Autism
Qualitative Impairment in Social Interaction Communication Overlay
• Marked impairment in the use of multiple nonverbal behaviors such as eye-to-eye gaze, facial expression, body postures, and gestures to regulate social interaction
• Failure to develop peer relationships appropriate to developmental level
Qualitative Impairment in Social Interaction Communication Overlay
• lack of spontaneous seeking to share enjoyment, interests, or achievements with other people (e.g., by a lack of showing, bringing, or pointing out objects of interest)
• lack of social or emotional reciprocity (will impair ability to communicate reciprocity)
Qualitative Impairment in Communication
• delay in, or total lack of, the development of spoken language (not accompanied by an attempt to compensate through alternative modes of communication such as gesture or mime)
• in individuals with adequate speech, marked impairment in the ability to initiate or sustain a conversation with others
Qualitative Impairment in Communication
• repetitive use of language or idiosyncratic language
• lack of varied, spontaneous make-believe play or social imitative play appropriate to developmental level
Autism and Communication
Qualitative impairment in communication is a core feature in identification of autism
If a student is on the Autism Spectrum (for educational purposes), by definition, the SLP will have evidence of a communication disorder
SLP’s Role on MDT: describe the communication disorder in relation to the autism
Stage 1 Answer: Yes
If the child meets eligibility for autism, there will be evidence of a qualitative impairment in communication.
SLP describes the communication disorder relative to autism and any other disability conditions
SI with Other Disabilities
When SI is a second or third disability condition, speech-language services become a related service provided to help the student benefit from his/her special education program
Speech-Language Therapy
Instructional Service• When SI is only disability
• Purpose: progress in the general ed curriculum
Related Service• S-L Therapy is a related service when there
are other disabilities
• Purpose: benefit from special ed program
Speech-Language TherapyRelated Service ARDC considers eligibility categories ARDC outlines specially designed
instruction/special education program ARDC determines whether related services
are needed to help student benefit from special education (including speech-language therapy)
ARDC determines frequency, location, duration, and type (direct or indirect) of all IEP services
Key Components MDT Assessments
Comprehensive evaluation includes assessment of: • Areas affected in Autism (social,
communication, sensory responses)
• Learning areas affected in Autism (cognition, thinking, problem-solving, executive functioning, attention, behavior)
• Adaptive behavior
MDT Assessment for AutismGuiding Principles
Retrospective diagnosis – need information from parents
Variety of assessment tools, strategies procedures (qualitative not score-bound)
• Tests, observation screening scales
• Adaptive behavior rating scales
• Observations, clinical interview
• Parent interview, teacher interviews
Multidisciplinary Team Evaluation Models
Many districts operate one or more central autism assessment teams
Coordination may be needed between autism team and campus SLP
Autism Team: looks at characteristics of autism including language and communication (documents communication disorder to answer Stage 1)
Campus SLP: looks at language and communication in relation to functional and academic performance (to answer Stage 2 adverse effect question)
Flowchart
See Handout
Evaluation Plan
Communication Model
See Handout
Language and Communication Team Expert: SLP
Reciprocity and shared meaning Ability to handle the social, ever-
changing aspects of communication Language is an abstract code Presuppositional knowledge Communicative functions Discourse management Figurative language
Developmental Assessments(Autism Team)
Cognition Adaptive Behavior Sensory Responsiveness Learning Style Learning Profile (educational achievement) Behavior Language
Executive Functioning Assessment(SLP and Autism Team)
Ability to problem solve and self-monitor future, goal-directed behavior
Requires the development of symbolic language
Meta-cognition Ability to Self-Organize
Social Communication & BehaviorCore CharacteristicsAutism Spectrum Disorders
Joint Attention • Social orienting
• Establishing joint attention
• Considering another’s intentions
Social Reciprocity
• Initiating bids for interaction
• Taking turns
• Responding to others
Language & Related Cognitive Skills
• Understand/use verbal & nonverbal communication
• Symbolic play
• Literacy skills
• Executive functioning Behavior & Emotional
Regulation
• Regulation of Self
• Regulation of Others
Language and Communication Assessment
Assessment should
• Systematically look at each component of the Communication Model
• Analyze preverbal/nonverbal communication (gestures, gaze, vocalizations)
• Assess social-affective signaling
• Profile social, communicative and symbolic abilities
Language and Communication Assessment
Assessment should• Directly assess the child and not only
rely on parental report
• Permit observation of initiated and spontaneous communication
• Permit observation across multiple contexts with a variety of communication partners
Parent and Teacher Interviews
A gold mine of information…
Early Indicators of Autism(may be retrospective information)
Failure to establish joint attention
No shared delight/ pleasure in experiences
Delay/absence of pointing (will hand lead)
Unusual hand or finger mannerisms
Absence of symbolic play
Inability to understand words out of context
Failure to use words meaningfully
Cessation of talking after saying at least 3 meaningful words
Adverse Effect RubricHandout
Positive Indicators: Adverse Effect Student has no communication system Student is younger than 9 years with no long history of
direct SLP services Evidence of response to direct SLP services and is
making progress in special education program Student has not received direct SLP services and
demonstrates:• Joint attention• Signaling behavior (vocal or motor)• Attention span of 5 seconds• Emerging motor imitation skills• Beginning cause-effect awareness
The Eligibility Process
Disability Condition & Adverse Effect• Stage 1 – Describe communication disorder i.e. qualitative
impairment in communication
• Stage 2 - Is there an adverse effect on educational performance that arises from the communication disorder?
• Adverse affect on academic achievement
• Adverse affect on functional performance
Need for S-L Therapy as Related Service• Stage 3 - Are speech-language pathology services needed
as a related service to help the student benefit from special education?
Stage 3
Consider the student’s special education program. What SLP services are needed to help the student benefits from special education?
Consider the 11 items in the Texas Autism Supplement
Texas IEP SupplementAutism
The following strategies shall be considered based on peer-reviewed, research-based educational programming practices to the extent practicable…and included in the IEP when needed:
1. Extended Educational Programming
2. Daily Schedule (minimal unstructured time)
IEP Supplement
3. In-Home and Community-Based Training or Viable Alternative
4. Positive Behavior Support Strategies
5. Futures Planning
6. Parent/Family Training and Support
IEP Supplement
7. Staff-to-Student Ratio
8. Communication Interventions
9. Social Skills Supports and Strategies
10. Professional Educator/Staff Supports
11. Teaching Strategies
#8 Communication InterventionsSample Wording
“The ARD committee considered information about communication interventions, including language forms and functions that enhance effective communication across settings and determined the following:• Student is making progress in the general
education setting without specific targeted communication interventions
#8 Communication InterventionsSample Wording
ORThe following language form/s are
recommended to enhance effective communication:objects/pictures; signs; voice output devicepicture communication system; words; other
ORSpeech therapy services are needed. See SOS
page
Case Study