1. 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

2. 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

3. 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

4. SI (Language) with Mental Retardation and/or Multiple Severe Disabilities

5. Definitions Mental Retardation Multiple Disabilities Speech Impairment
DSM IV-TR
IDEA 2004
Multiple Disabilities
Texas Commissioner’s Rules
Speech Impairment

6. 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

7. 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.

8. 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!!!

9. Mental Retardation – DSM-IV-TR
Prevalence: 1% of general population
Mild MR – approx 70; 85% of MR pop
Mod MR – – 50-55; 10% of MR pop
Severe MR – – 35-40; 3-4% of MR pop
Profound MR - <20-25; 1-2% of MR pop

10. 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

11. 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.

12. 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

13. 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

14. 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)

15. 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

16. 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 (c)(11)

17. Critical Concepts Communication Disorder such as…
Adverse effect on educational performance =
Adverse affect on academic achievement
Adverse affect on functional performance
Per IDEA 2004

18. 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

19. 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

20. 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

21. 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

22. 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

23. Multi-Disciplinary Team Evaluations
Key Components
Multi-Disciplinary Team Evaluations

24. 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

25. 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 § (h)
Communication and interpersonal skills are areas of adaptive functioning that must be addressed for MR

26. Note to MDT…
Evaluation of students with significant disabilities often includes reliance on informal measures rather than on standardized tests

27. 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

28. Multidisciplinary Teamwork
Balanced work distribution
Active participation – all team members
Evaluation Action Plan – spells it out
Parents and Teachers – partners in the process

29. 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)

30. 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

33. Quality Evaluation: Assumptions
Useful
Clear
Guides instruction/intervention
Identifies learning targets
Includes broad based information
Includes reports from parents
Is completed over multiple occasions

34. 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

35. 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

36. 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

37. 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

38. 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

39. Dynamic Evaluation Categories (Highly important in autism evaluations)
Attention
Discrimination
Planning
Self-regulation
Transfer
Motivation
Interaction

40. 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

41. Ecological Evaluation Categories
State
Environment
Posture
Sensory Motor/Integration
Social
Exploration/Play
Communication
Response to Cues
Performance Facilitated
Performance Compromised

42. 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.

43. Communication Model
See Handout

45. 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

46. 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

47. 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

48. Adverse Effect Rubric
See Handout

51. 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

52. 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?

53. Case Study

54. Autism Spectrum Disorders

55. 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 §

56. 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

57. 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

58. Autism Areas of Interest for SLP
Qualitative Impairment in Social Interaction
Qualitative Impairment in Communication

59. Communication Skills in
Autism

60. 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  

61. 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) 

62. 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 

63. 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  

64. 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

65. 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

66. 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

67. 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

68. 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

69. 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

70. 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)

71. 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)

72. 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.

73. Evaluation Plan

76. Communication Model
See Handout

78. 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

79. Developmental Assessments (Autism Team)
Cognition
Adaptive Behavior
Sensory Responsiveness
Learning Style
Learning Profile (educational achievement)
Behavior
Language

80. 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

81. 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

82. 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

83. 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

84. Parent and Teacher Interviews
A gold mine of information…

85. 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

86. Adverse Effect Rubric
Handout

89. 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

90. 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?

91. 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

92. 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)

93. 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

94. IEP Supplement 7. Staff-to-Student Ratio
8. Communication Interventions
9. Social Skills Supports and Strategies
10. Professional Educator/Staff Supports
11. Teaching Strategies

95. #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

96. #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

97. Case Study