Language Disorders in Children with Other Disabilities: Autism, Mental Retardation & Multiple Severe Disabilities TSHA Convention Short Course March 25, 2010 Leslie Armbruster, MA, CCC-SLP Alison 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) with Mental Retardation and/or Multiple Severe Disabilities

Definitions Mental Retardation Multiple Disabilities Speech Impairment DSM IV-TR IDEA 2004 Multiple Disabilities 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 Disabilities Typical 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.) Check here to see if participants agree – or have other descriptors for this group of students

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 indefinitely disabilities 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 Impairment IDEA 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 Therapy Related 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 Therapy Related 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 Therapy Related 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? Basic communication goals should be included in the (instructional) specially designed instruction. S-L Therapy adds to the basic language and communication instruction that is delivered through the curriculum

Multi-Disciplinary Team Evaluations Key Components Multi-Disciplinary Team Evaluations

Key Components SLP’s Role in MDT Evaluations Evaluation Procedures for the Multi-Disciplinary Team Evaluation Plan Evaluation Tips Evaluation Flow Chart Communication Model – for consistent decision making Adverse Effect Rubric Academic achievement Functional 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 when Review existing information Teacher interview Other school staff interviews Parent interview Classroom observation Other observations Direct Testing Parent Conference School 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 Use Handout 4 …this is the second part of the template. Go through the flowchart. Point out that method 1 is the current Cognitive referencing. If it qualifies a child, go ahead and make them eligible. If it doesn’t, then you would go to a cross battery analysis of your data. If you don’t have enough information, you need to get more.

Communication Model See Handout

SI Eligibility Guidelines Disability 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 Guidelines Disability 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 Guidelines Disability 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 Framework Eligibility 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

Autism Areas 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 Therapy Related 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 Autism Guiding 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 Retrospective diagnosis – onset prior to age 3…(i.e., before they get to school)

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 Use Handout 4 …this is the second part of the template. Go through the flowchart. Point out that method 1 is the current Cognitive referencing. If it qualifies a child, go ahead and make them eligible. If it doesn’t, then you would go to a cross battery analysis of your data. If you don’t have enough information, you need to get more.

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 Individuals begin to organize their actions within an activity using language Metacognition: ability to reflect on own experiences and behavior and the perspectives of others to plan, prepare, execute, and negotiate in familiar, new and changing situations Self-Organization: formulation of thoughts and ideas, problem solving, planning future events, managing complex information

Social Communication & Behavior Core Characteristics Autism 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 Rubric 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 – 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 Supplement Autism 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: Extended Educational Programming 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 Interventions Sample 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 Interventions Sample Wording The following language form/s are recommended to enhance effective communication: objects/pictures; signs; voice output device picture communication system; words; other Speech therapy services are needed. See SOS page

Case Study