Case Study: Social Communication Deficits

Associate’s Name & Discipline:
Andrea W. Pointer, MS, CCC-SLP

Name of Organization:
Kids Kount Therapy Services, LLC, Mobile, AL

Client:
“Aiden”, male, 7 years, 1 month of age

Background:
Born at 37 weeks gestation with a low birth weight, Aiden had a history of asthma, environmental allergies, a diagnosis of ADD, and chronic serous otitis media (fluid in the ears) which required placement of bilateral pressure-equalization tubes three times. Aiden had previously received occupational therapy for fine motor delays.

Presenting Problem:
Aiden was referred to our facility due to concerns with delayed development of articulation and social communication skills. His parents reported he had difficulty with transitioning and would “get stuck” on an activity, struggled to keep up with peers and did not interact well with others. Aiden’s teachers reported he exhibited sadness/depression and social delays.

Aiden presented with social communication deficits in the presence of average expressive and receptive language scores (Preschool Language Scale-5^th Edition). The Test of Pragmatic Language was utilized to assess Aiden’s social language skills. Aiden had a standard score of 74 with an age equivalent of 4 years, 0 months. A standard score of 90 to 110 is considered to be normal limits for peers of his same age/gender.

Difficulties presented included:

• Formulating questions (requests)
• Politely indicating or verbalizing dislikes
• Understanding sarcasm
• Verbalizing conflict resolution in an age-appropriate manner
• Heeding warning in various safety situations
• Interacting with less or unfamiliar individuals
• Making eye contact
• Joint play
• Impaired speech intelligibility, (/r/ distortions)

Based on results of this testing and our clinic’s recommendations for this iLs program, a functional vision exam and a full audiological examination were required. Hearing sensitivity was noted to be within normal limits bilaterally. A tympanogram of the right ear was Type A (normal), and the left ear was Type As (suggestive of a less compliant middle ear system, normally indicating a history of middle ear problems or childhood otitis media). The functional vision exam indicated 20/20 vision in right eye and 20/30 in left eye. He was also reported to close one eye when looking at things in distance. Further testing was recommended to rule out an accommodative dysfunction.

In reviewing Aiden’s iLs case history form, multiple references were noted with regards to his “difficulty following 2-step directions” as well as occurrences of him being bullied at school. Areas of weakness were reported to include frustration with tasks, memory problems, lack of determination, fear of trying new things, and anxiety. Aiden’s strengths were stated to include kindness towards others, being affectionate and loving, and demonstrating curiosity.

Prior to therapy, an iLs Checklist, SCAN-3:C, and Test of Auditory Processing Skills-3^rd Edition were utilized to gather baseline data. Aiden was reported to exhibit the following symptoms “often”: bothered by background noise or unexpected sounds, avoided movement activities, had difficulty sitting still, made disruptive noises or sounds, had poor balance and would fall easily, avoided balance-related activities, had difficulty learning new motor activities or activities that required more than one step, seemed clumsy, struggled with fine motor activities, disliked or avoided group sports, had difficulty identifying and distinguishing between different sounds or letters, had difficulty finding numbers or words on a page, confused words or sounds, mumbled, had a tendency to ramble, had difficulty with spelling, and had difficulty organizing personal spaces.

Aiden was also reported to “always” have difficulty following directions in a noisy environment, need instructions repeated with visual cues, have difficulty remembering sequential tasks, have difficulty making and keeping friends, become easily overwhelmed by daily activities, have poor short-term memory, and need to re-read homework several times in order to comprehend.

Therapeutic Goals:
Parental goals for therapy included “improving Aiden’s ability to focus and learn more efficiently in a classroom setting” as well as to “decrease anxiety and frustration with tasks and improve interactions with others.” The speech-language pathologist’s goals focused on strengthening the following skills: auditory memory, auditory cohesion, auditory figure ground, dichotic listening, following of multi-step directions, production of /r/, joint attention in play activities, verbalizing and performing appropriate conflict resolution, formulating grammatically correct questions and requests, and understanding multiple meanings and sarcasm. The therapist noted many of the difficulties in social communication were related to Aiden’s difficulty with processing auditory and possibly visual information in his environment.

iLs Program and Other Interventions Used:
iLs Reading & Auditory Processing Program (customized 20 sessions due to insurance constraints) with the iLs Interactive Language Program, two times a week.

Although occupational and speech therapy were the indicated and recommended interventions, this iLs program was paired only with speech therapy due to parental requests with their primary concerns of social and articulation development. The iLs Visual-Balance-Coordination activities (Playbook) were utilized during each session in combination with traditional speech-language therapy activities.

Summary of Changes:
Aiden made significant gains in therapy with additional reports of improvements noted in home and school environments. He was given a two-month break following his iLs program (where no intervention was provided). When he arrived for his reassessment, the therapist noted he was not feeling well and appeared to have a sinus infection. However, testing continued as planned.

Aiden engaged with two unfamiliar therapists in reciprocal conversations and was observed to maintain eye contact for greater than 75% of the conversation. He answered questions appropriately and with grammatically correct sentence structure and also recognized humor. He was also observed to be “less anxious.” His production of /r/ phonemes had improved significantly with minimal to no distortions. He did not mumble when talking, and he seemed more confident overall in the communication process. His parents also reported he had experienced successes in improved coordination and body balance and was now “riding his bike without training wheels.” Aiden also did not seem agitated by background noise within the clinic environment and was reported to be less sensitive to noise in the home environment.

Aiden made significant improvements in many of the standardized tests.  His Auditory Figure Ground score increased from 4 to 11 (borderline disordered to Normal) and both Sentence Memory and Auditory Comprehension increased from the 1^st percentile to the 50^th percentile.

Standardized test results are also included in the tables below:

SCAN-3:C (Scaled Scores 7 or greater = normal range)
SUBTEST	INITIAL TESTING SCALED SCORES	REASSESSMENT SCALED SCORES	CHANGE POST iLs
Auditory Figure Ground +8 (Words in background noise)	4	11	Borderline disordered to Normal
Filtered Words (Auditory Closure)	9	10	Normal range for both dates; increased
Competing Words-Directed Ear (Dichotic Listening)	4	6	Low Borderline disordered to Borderline disordered

 

Test of Auditory Processing Skills-3rd Edition (Scaled Average Scores 7 – 13)
SUBTEST	INITIAL TESTING SCALED SCORES	REASSESSMENT SCALED SCORES	CHANGE POST iLs
Word Discrimination	9	14	Increased to Above Average
Phonological Segmentation	8	9	Increased, Average
Phonological Blending	7	7	No change, Average
Number Memory Forward	10	12	Increased, Average
Number Memory Reversed	6	10	Increased to Average
Word Memory	5	6	Increased progress, still Below Average
Sentence Memory	3	10	Increased to Average (1st percentile to 50th percentile)
Auditory Comprehension	1	10	Increased to Average (1st percentile to 50th percentile)
Auditory Reasoning	2	3	Increased, still Below Average

The Number Memory Reversed progress indicates improvements in working memory function. Significant gains were also noted with Sentence Memory and Auditory Comprehension. Although some areas continue to show weaknesses, impressive gains have been noted overall with a 20-session program of intervention. Due to time constraints and Aiden not feeling well, the Test of Pragmatic Language was not able to be re-administered. However, noticeable gains in progress were evident during his social interactions with both familiar and unfamiliar therapists and per parental reports of interactions with peers.

Conclusions and Recommendations:
Aiden has made significant gains in his auditory processing, social communication, and articulation skills. His parents were so pleased with his progress, increased confidence, decreased anxiety, and improved academic performance that they have committed to a program of iLs incorporating both occupational and speech therapy which will focus more intensively on visual and auditory processing skills, bilateral coordination, fine motor skills, reading comprehension, auditory reasoning, dichotic listening and increased complexity of social interactions/conversations.

Comments by Ron Minson, MD, iLs Clinical Director:
A history of presenting problems and test results help us to identify the problems but tell us nothing about how deeply imbedded these problems might be, nor how fast they may respond to therapy.  The therapist created a short program that demonstrates the power and effectiveness of a well-designed multi-sensory intervention to address definite neurologically based problems in the most expedient manner possible. In this case, the clinician was very sensitive to the needs of the parents in designing a program that would be acceptable to the family, yet beneficial for the child. The very successful outcome allowed the parents to be comfortable in continuing therapy for further gains and integration of newly acquired skills.

Notwithstanding the impressive improvements in language, speech and social skills, we must also recognize the importance of improved balance and coordination in facilitating these cognitive and behavior improvements. Brain resources required to manage the body were freed up to focus on the higher learning requirements of the nervous system. Thus, including the Visual-Balance-Coordination activities and the Interactive Language Program were essential components to combine with the Speech Therapy and the iLs Reading & Auditory Processing Program.

Recall, too, how effective iLs is in reducing feelings of anxiousness. Anxiety from any source invariably interferes with the effectiveness of any therapy due to both behavioral and physiological causes. The reduction in anxiety opens the doors for the nervous system to change and grow.