Quality Assessment and Intervention with Infants and Toddlers

Quality Assessments and Interventions
with Infants and Toddlers
SCSHA 2016
Dawn Kearney, MA CCC-SLP
Danielle Varnadoe, MA CCC-SLP
 Disclosures/Introductions
 Review of Risk Factors for Speech and Language
Evidence-Based Assessments
Evidence-Based Interventions
 Non-Financial Disclosure:
 Michelle L. W. Dawson, MS CCC-SLP is VP of Governmental Affairs for
SCSHA, she is also Convention Co-Chair for the 2016 SCSHA Convention
 Financial Disclosure:
 Michelle L.W. Dawson, MS CCC-SLP is an employee of Sprout Pediatrics
and has a contract with NSS for development of a 6 hour webinar for
Infantile Spasms and Treatment of Oropharyngeal Dysphagia
 Biography:
 Michelle completed her MS in Communicative Sciences and Disorders from
James Madison University in Harrisonburg, VA in 2009. She has worked in a
variety of settings including the public schools, in-patient and out-patient
rehabilitative hospitals, as well as spent may years in early intervention. She
is currently working on her BCS-S licensure as treating feeding and
swallowing disorders across the life span is her first love within the SLP
Scope of Practice.
Dawn Kearney
Financial/Non-financial Disclosure Statement
Dawn is the Co-owner of Midlands Therapy Services (2003) based in
Lexington, SC and Southland Therapy Services (2006) based in Savannah,
GA. Both agencies provide early intervention services, speech/language,
feeding, OT and PT, to infants and toddlers in many parts of SC and GA.
Biographical Information
Dawn received her Master’s degree in Speech Pathology and Audiology
from South Carolina State University in 2000. She holds both the
certification of clinical competence (CCC-SLP) from ASHA and is licensed
in the state of South Carolina. Dawn also holds the South Carolina Part C
Credential through BabyNet. Dawn began providing speech and language
therapy to infants and toddlers in 2001 through the BabyNet system after
the premature birth of her oldest son. She has extensive experience in
many early childhood diagnoses and delays and is passionate about making a
difference in her patients and their families’ lives.
Danielle Varnedoe: Introduction and
Disclosure Statement
Financial/Non-financial Disclosure Statement
Danielle Varnedoe is not a service provider under Part C services in
the state. She is a non-paid consultant to BabyNet and reviews
speech-language evaluations when eligibility determination for Part
C services is in question. No relevant financial relationship with
BabyNet exists.
Biographical Information
Danielle Varnedoe is on faculty in the Department of
Communication Sciences and Disorders at the University of South
Carolina. She is the director of the USC Speech and Hearing
Research Center. Danielle has interests in both the early
identification of communication disorders in infants and toddlers and
in the differential diagnosis of speech sound disorders in children.
Review of Risk Factors and Red Flags for
Expressive Communication Disorders/Delays
What does a child with an Expressive
Communication Delay look like?
 “Generally these children are the toddlers who are slow at
producing first words and word combinations and may persist
in having grammatical errors as syntax develops. They are the
children who show no signs of developmental delays, such as
cognitive, emotional or sensory problems, but who are
demonstrating difficulty learning language” (Olswang,
Rodriguez, & Timler, 1998).
Most Speech Language Pathologists agree that a child with
less than a 50 word vocabulary and who is not yet putting 2
words together by age 2 is at risk for an Expressive
Communication Delay.
However, research and review of studies on “late talkers” have
provided SLPs with more diagnostic markers/red flags. These
red flags can help with the clinical decision making process in
differentiating between those children who may outgrow
their language delay from those who will most likely
continue to display deficits in expressive language
Red flags for expressive
communication delay:
Family History
A gap in receptive/expressive language skills on a
speech and language evaluation
Decreased vocalizations or lack/reduced babbling
Limited phonemic vocabulary
Inability or difficulties with imitating sounds, words
or word combinations
Decreased play skills
Reduced/delayed social skills
Behavioral issues
Family History
“Thirteen studies recorded family history of
speech, language and/or learning difficulties,
with 11 identifying this as a risk factor for
childhood speech and language impairment”
(Harrison & McLeod, 2010).
A gap in receptive/expressive
language skills on a speech and
language evaluation
“The consensus suggestions that toddlers with
significant expressive and receptive language
delays of 6 months or more are most at risk for
continued language delay. Further, for those
children delayed in both comprehension and
production, the larger the comprensionproduction gap, the poorer the prognosis”
(Oswnang, Rodriguez, Timler, 1998).
Decreased vocalizations or lack/
reduced babbling
“Children who show late canonical babbling
may also show a delay in their expressive
language ability, but not a delay in their
receptive language ability in understanding
individual words at 2 years of age” (Oller,
Eilers, Neal, & Schwartz 1999).
Limited phonemic vocabulary
“Various researchers have conducted in-depth analyses of the
phonological characteristics of samples of spontaneous language
collected from “late talkers” (L-T). In general the analyses of the
samples showed that L-T are less talkative than normal children of
the same age and that they have a smaller phonological inventory
for both vowels and consonants. In addition, various types of
analyses confirmed the presence of simpler syllabic structures
amongst L-T, characterized by a preponderance of open syllables
consisting of a single vowel or a ‘consonant plus vowel’ sequence”
(Chantel Desmarais et al, 2008).
Decreased play skills
“Late talkers seem to engage in higher frequency of
manipulations, handling, and grouping of toys &
objects than in combinatorial/thematic play and
symbolic play” (Olswang, Rodriguez, Timler, 1998).
Behavioral issues
Clinically, there appears to be a strong association
between language difficulties and behavior problems.
“Studies on subjects with Specific Language
Impairment have in fact demonstrated that the
presence of a language disorder constitutes a
moderately high risk i.e. 2.5-4.2 times greater, that
these children will also present with behavioral
problems” (Desmarais et al, 2008).
Is there a link between recurrent otitis
media and expressive communication
No, the research findings do not confirm a link
between children with recurrent otitis media &
vocabulary delay. However, studies are showing that
otitis media has an influence on articulation skills
(Desmarais et al. 2008).
Now that we know what the clinical evidence tells
us about the characteristics and red flags of an
expressive communication delay, Let’s talk
Evaluation and Assessment
Quality Assessment = Quality Intervention
Receptive and
Age Appropriate
Evaluation and Assessment
Common Screening Instruments
Battelle Developmental Inventory-2 Edition (ST) (2004)
Overall: Sensitivity: 0.72–0.93; Specificity:0.79–88
“considered “moderately accurate”.
Communication Domain: Sensitivity: .72; Specificity: 79 (Elbaum, 2010)
Battelle Developmental Inventory – 2nd Edition (BDI-2 ST)*
*Elbaum, 2010)
Battelle-2 (ST)
“The BDI-2 Screening Test accurately identified the children who are at risk in the
autistic and cognitive delay group better than in the other delay groups. The
developmental and speech and language delay groups had many fewer
children who were correctly identified as being at risk for developmental delay.
“For all groups, 79% or more children who were not at risk for developmental
problems were identified as not having developmental problems. The BDI-2
Screening Test accurately identified the children who were not in a risk
group in the motor and developmental delay group better than in the
other delay groups.
Reference: Early Childhood Developmental Screening: A Compendium of Measures for
Children Birth to Five. OPRE Report, November, 2014.
Common Evaluations
 Normed Referenced
 Preschool Language Scale -5 (2011) (English and Spanish)
Problem: Score skills as “present” or “absent” but does not
provide a description of what the child can do and how they do
e.g. “…uses 1 word”
“…uses 5 words”
The real question should be: how are they used? What is the
quality of these words?
Home Communication Questionnaire included
Preschool Language Scale - 5
*Total Language Score
Common Evaluations
 Receptive-Expressive Emergent Language Scale-3 (2003)
Sensitivity and specificity not stated in the manual.
More of a screening instrument; needs to be supplemented with
other assessment procedures.
Rule of Thumb Regarding Tests
 Supplement TESTS with ASSESSMENTS (What are the child’s abilities
and needs within his/her natural environment?).
 Tests should not be used to measure progress.
 Tests should not solely be used to qualify infant/toddlers for services.
-------------------------------------------Technical Information
• Providers should purchase and use the latest version within a year of
• Tests should be revised every 15 years.
Elements that go into ICO:
• Appropriate education and training
• Knowing normal development
• Knowing the evidence (because test scores do not always tell
the right story)
• Previous experience
• Sensitivity to cultural needs
• Family’s perceptions and needs
What the Evidence Says
• Late onset of canonical babbling (Oller, Eilers, Neal & Schwartz,
• Limited words or word attempts (Paul & Roth, 2011).
• Delayed development in the area of phonology
Restricted syllable structure (Pharr, Ratner, & Rescorla, 2000)
Small phonetic repertoires (Carson, Klee, Carson, & Hime,
2003; Paul & Roth (2011).
• Limited pragmatic efforts to manipulate environment (Paul &
Roth, 2011).
• Significant delay (>6 months) in comprehension and production
(Paul, 2007; Ellis & Thal, 2009).
Other Assessments
 MacArthur-Bates Communicative Developmental Inventories-2nd
Edition (Fenson, et.al., 2007)
Inventories: Words and Gestures (8-18 months); Words and Sentences 16-30
50th percentile-WNL
<10 percentile – significant delay
Up to the 11th percentile: good sensitivity and specificity
11th percentile: sensitivity - 0.68; specificity - 0.98
19th percentile: sensitivity - 0.81; specificity - 0.79
49th percentile: sensitivity - 1.00; specificity - 0.44
(Heilmann, et.al., 2005)
Other Assessments
Language sampling procedures; needs to be done over
Independent measures of phonology (quantity + quality);
needs to be done over time for reliability purposes
(Morris, 2009). See forms.
Pragmatic assessment (more detailed information)
Definite Yes:
Receptive and/or expressive language disorder
(F80.2) for mixed; (F80.1) expressive only
Phonological disorder (F80.0)
Definite NO:
Articulation Delay
Childhood Apraxia of Speech (CAS)
(Davis & Velleman, 2000; ASHA Practice Portal for CAS)
Case 1 - Diagnosis of CAS
Case 2- Battelle findings
Case 3- Lack of information
Case 4 – Really a lack of information
Review of EBP Interventions
Let’s begin with legal/policy review
What does IDEA Part C Say?
 Early Intervention Services in Natural Environments
Code 303.126
 Each system must include policies and procedures to ensure,
consistent with other provisions in the part, that early interventions
services for infants and toddlers with disabilities are provided
 A. To the maximum extent appropriate, in natural environments; and
 B. In settings other than the natural environment that are most appropriate, as
determined by the parent and the IFSP team, only when early intervention
services cannot be achieved satisfactorily in a natural environment
 Natural Environments Code 303.26
 “settings that are natural or typical for a same-aged infant or toddler
without a disability, may include the home or community settings,
and must be consistent with the provisions of code 303.126 (Early
Intervention services in natural environments).
What does Babynet Say?
 Family Outcomes:
 “ The Part C program recognizes that families play a crucial role in
optimizing their child’s development and aims to enhance the capacity of
families to meet the special needs of their infants and toddlers. Services
are based on an Individualized Family Service Plan (IFSP) that is jointly
developed by family members and service providers, taking into account
the child’s developmental needs and the family’s concerns and priorities.
Part C also recognizes that infants and toddlers with disabilities
have a right to receive services as part of family and community life
within the context of everyday routines, experiences, and activities
with familiar people. Early development is best supported when
services are provided in the child’s home or in places or programs where
young children play.”
Babynet General Assembly Report December 2015
What does DEC Say?
 8 Guiding Principles: Leaders, Assessment, Environment, Family,
Instruction, Interaction, Teaming and Collaboration, Transition
 E1: Practitioners provide services and supports in natural and inclusive
environments during daily routines and activities to promote the child’s access to
and participation in learning environments
F1: Practitioners build trusting and respectful partnerships with the family
through interactions that are sensitive and responsive to cultural, linguistic, and
socio-economic diversity
F6: Practitioners engage the family in opportunities that support and strengthen
parenting knowledge and skills and parenting competence and confidence in
ways that are flexible, individualized, and tailored to the family’s preferences
INS5: Practitioners embed instruction within and across routines, activities, and
environments to provide contextually relevant learning opportunities
INT3: Practitioners promote the child’s communication development by
observing, interpreting, responding contingently, an providing natural
consequences for the child’s verbal and non-verbal communication and by using
language to label and expand on the child’s requests, needs, preferences, or
ASHA continued
 Technical Report: Roles and Responsibilities of
Speech-Language Pathologists in Early Intervention
Great Resource!!!
Characteristics of Infants/Toddlers who receive EI
4 Guiding Principles:
Services are family centered and culturally and linguistically responsive
Services are developmentally supportive and promote children’s
participation in their natural environments
Services are comprehensive, coordinated, and team based
Services are based on the highest quality of evidence that is available
ASHA continued
 Technical Report: Roles and Responsibilities of
Speech-Language Pathologists in Early Intervention
 Functions of SLP
 Prevention
 Screening, Evaluation, and Assessment
 Planning, Implementing, and Monitoring Intervention
 Consultation and Collaboration with the Family and Other Team
 Service Coordination
 Transition Planning
 Advocacy
 Awareness and Advancement of the Knowledge Base in Early Intervention
ASHA continued
 Position Statement: Roles and Responsibilities of
Speech-Language Pathologists in Early Intervention
 Our Roles should be implemented in accordance with these guidelines:
1. Services are family centered and culturally/linguistically responsive
2. Services are developmentally supportive and promote children’s
participation in their natural environments
3. Services are comprehensive, coordinated, and team based
4. Services are based on the highest quality of evidence that is available
What does ASHA say?
 IDEA Part C Issue Brief: Natural Environments
 Implications for ASHA Members: “Natural environments” and
“family-centered” practices involve helping families learn how to
encourage their children’s participation in everyday situations
and are the focus of members’ intervention in Part C
That leaves EI SLP’s where?
Intervene in Natural Environments
But Also Acceptable
 Living Room
 Daycare
 Kitchen
 Clinic
 Backyard
 Hospital Out-Pt
 Wal-Mart
 Grocery Store
 Park
 Mall
 Chick-fil-a
 not ideal but for some
circumstances only
 Rural Settings
 Therapist Safety
Interventions in a Natural Environment
 Bringing an object outside of their SES for
tx and take it away:
 Examples: Tablets and expensive toys
 Bringing in foreign objects to medically
fragile homes
 If you use OME tools, do not share between
Leave That Bag At Home!
How about Co-Treatments?
ASHA Technical Report,
Guiding Principle Three:
“Services are Comprehensive,
Coordinated, and Team Based”
DEC TC2: “Practitioners and
families work together as a team
to systematically and regularly
exchange expertise, knowledge,
and information to build team
capacity and jointly solve
problems, plan, and implement
So… Do this “Thang”!
Even with ABA!!!
Let’s look at
EBP Interventions to Incorporate
First 100 Words
These are
happens on the
No Flashcards
Sign Language
 Use in conjunction with the
spoken word
 SLP and Family Model
 Hand over hand with the Pt
 Focus on the Core Vocabulary
 Fine Motor/Gross Motor
deficits can hinder this tool
Does the Child have
the prerequisite
skills for the task?
•Gross Motor Skills
•Fine Motor Skills
•Head/Neck Control
Remember Consult
the TEAM!!
AAC should
teaching the
child to say
what they
want to say
than saying
what we
want them to
 AAC means learning
language, NOT operating
 Core Vocabulary plus fringe
vocab 80/20 approximate
 Motor Memory…
Trial and error is how we
 AAC has to be multimodal
 Not hand over hand, but
we should model instead
with aid of gestures, facial
expressions, and our
posture…engage their
AAC device in language
Just Say No to NSOMEs
Transference of Part to Whole
2. Strength
3. Task Specific Brain Organization
4. Lack of Effect on Mouth Awareness
5. Lack of Evidence
Lof, G., Watson, M. (2010). Five Reasons why Nonspeech Oral Motor Excrises (NSOMEs)
Do Not Work. (SIG 16 Perspectives on School-Based Issues, 11, 109-117.
 Home Exercise Program
 Not just for insurance
 Family/Caregivers help to
create this, but they rely on
the guidance of the
Make Interventions Fun!
Balance with Tough Love
Let’s Try a Few
Targeted Language
Core Vocab:
Fringe Vocab:
Targeted Language:
Core Vocab:
All Done
Fringe Vocab:
Considerations for Special
How does this work with Medically
Complex Pts?
American Academy of Pediatrics:
 “Create frequent opportunities that
allow for ‘learning in the natural
environment’ rather than in simulate
‘treatment’ situations”
 “Utilizing methods of ‘coaching’ as a
model for families
Remember their unique ADL
needs require FXNL ST
How does this pertain to
Feeding/Swallowing Pts?
•Practice within your
Scope of Practice
•This is NOT OMEs
•CSE vs. Instrumental
•Billing/Coding concerns
exist within Babynet…
however SCSHA is working
to address this issue
Tiny Soap Box
If it’s not functional,
not part of their
natural environment,
then why are we
introducing it?
Food is Not Plastic
Food does Not
 The diagnosis is made by more then just the numbers.
Look for the waving red flags!
 Use the evidence and provide details – make it count!
 Family Centered, Fxnl ADL’s, Natural Environment!
Adams, R. C. MD., Tapia, C. MD., and The Council on Children with Disabilities. (2013). Clinical Report: Early
Intervention, IDEA Part C Services, and the Medical Home: Collaboration for Best Practice and Best Outcomes.
Pediatrics, 132 (4), 1073-1086.
Childress, D. C. (2004). Special Instruction and Early Intervention: Best Practices in Early Intervention. Infants
andYoung Children, 17(2), 162-170.
DEC Recommended Practices in Early Intervention/Early Childhood Special Education 2014. (2016, April 14).
Retrieved February 01, 2016, from http://www.dec-sped.org/recommendedpractices
BabyNet: Ensuring Quality Services for Infants and Toddlers with Disabilities and their Families within the
BabyNet Early Intervention System: An Analysis of Current and Needed Resources. (December 2015).
IDEA Part C Issue Brief: Natural Environments. (n.d.). Retrieved February 01/2016, from
Interventions for children with speech, language and communication needs: An exploration of current practice
Child Language Teaching and Therapy October 2012 28: 325-341,
Lof, G., Watson, M. (2010). Five Reasons why Nonspeech Oral Motor Excrises (NSOMEs) Do Not Work. (SIG 16
Perspectives on School-Based Issues, 11, 109-117.
Roles and Responsibilities of Speech-Language Pathologists in Early Intervention: Position Statement. (n.d.).
Retrieved February 01/2016, from http://www.asha.org/policy/PS2008-00291/
Roles and Responsibilities of Speech-Language Pathologists in Early Intervention: Technical Report. (n.d.).
Retrieved February 01, 2016, from http://www.asha.org/policy/TR2008-00290/
 Desmarais, C., Sylvestre, A., Meyer, F., Bairati, I., and Rouleau,
N. (2008). Systematic review of the literature on characteristics of
late-talking toddlers. International Journal of Language and
Communication Disorders, 43, 361-389.
 Harrison, L.J. and McLeod, S. (2010). Risk and Protective Factors
Associated With Speech and Language Impairment in a Nationally
Representative Sample of 4- to 5-Year-Old Children. Journal of
Speech, Language, and Hearing Research, 53, 508-529
 Oller, D.K., Eilers, R.E., Neal, R.A., & Schwartz, H.K. (1999).
Precursors To Speech in Infancy: The Prediction Of Speech and
Language Disorders. Journal of Communication Disorders, 32, 223245.
 Oswang, L.B., Rodriguez, B., Timler, G. (1998). Recommending
Intervention for Toddlers With Specific Language Learning
Difficulties: We May Not Have All the Answers, But We Know a Lot.
American Journal of Speech-Language Pathology, 7, 23-32.