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