Clinical Case History Assignment

Client: Ezekiel Benser Gender: M Age: 28 months and 15 days

Client/family concerns:

Ezekiel's mother expressed concern that Ezekiel has a very limited number of words in his vocabulary and that he does not spontaneously-produce two- or multiple- word utterances. His mother also expressed concern that he "is very aggressive with [their] dogs," which hits, bites, & pinches, at times in relation to irritability and at time for no apparent reason. His mother also expressed concern that "he falls a lot" when walking & running and sometimes "walks with his heels off the floor." His mother also expressed concern that his sleep cycle is such that he is awake through the night and sleeps during the day. His mother does not have concerns about any additional developmental delays or sensory difficulties.

Remarkable Medical History:

oInjuries, illnesses, surgeries,

oDiagnosis of Sickle Cell Anemia. Ezekiel is being monitored for possible asthma. Ezekiel is allergic to egg & shellfish consumption; he also may be allergic to pet dander. Ezekiel was hospitalized for two nights at Children’s Hospital of Los Angeles in January 2022 due to stomach flu.

oMedications the client is currently taking

oThe client is currently using medications Albuterol and EpiPen.

oFamily history of a speech or language delay or disorder?

oFamily history of special needs includes Ezekiel’s brother who had speech therapy as a child; mother’s cousins who were diagnosed with autism and biological father’s sister who had speech issues.

oIs the client receiving any other therapeutic services (e.g. PT, OT)?

oThe client is not receiving any other therapeutic services.

For clients that are under the age of 5.

oHistory of ear infections? If so, how frequent/ how many?

oNo history of ear infections.

oHas hearing been tested? When? By Whom?

oHearing was tested in February of 2022. Results indicated there are no hearing concerns.

oWere developmental milestones achieved within age-appropriate limits?

oDevelopmental milestones were not achieved within age-appropriate limits. Milestones that fell below his age include communication development, physical development, social-emotional development and adaptive development. Gross motor skills, fine motor skills, expressive language, social-emotional skills, and adaptive/self-help skill are below average for Ezekiel’s chronological age.

Social History:

oWho lives in the home?

oEzekiel lives with his mother, Daysi Gonzalez, 20 year-old brother, maternal grandmother, grandfather, aunt and uncle.

oInterests: sports, instruments, pets, activities, language school (e.g. Korean school), and favorite games/TV shows/movies – these may lead to topics of conversation or motivation during treatment.

oEzekiel enjoys playing with a variety of toys including cars, dinosaurs and balls.

Behavioral Observations:

Ezekiel was initially shy but soon warmed-up to the evaluator once the evaluation began He did not display any atypical fears, maladaptive/perseverative behaviors, ongoing apprehension of participatory impairment, sensory difficulties, or tactile defensiveness. He did not demonstrate any difficulty transitioning from one activity to the next and maintained age-appropriate eye- contact throughout the evaluation.

Speech and Language History:

Began treatment in: May 2022 Semesters in treatment at LSHC: Summer

Has treatment been consistent?: Yes/No; If no, explain. Ezekiel is a new client.

Ezekiel’s first speech and language evaluation was done by Rebecca O’Brien M.A., CCC-SLP in April, 2022. He was administered the Communication Evaluation Chart from Infancy to Five Years; REEL-3 Receptive-Expressive Emergent Language Scale; Oral Motor Screen; Clinical Observations and Parent Interview. Results of testing indicated Ezekiel’s developmental levels for receptive language skills were within normal limits at 25 months and expressive language skills were delayed at 12 months.

Ezekiel’s recommended goals and objectives from his initial assessment report included the following:

Receptive Language

1.Ezekiel will follow simple one-to-two step directions (e.g. “Give me the [object]”, “Come here and sit on the chair”) while fading out the use of gestures as a prompt.

2.Ezekiel will demonstrate an understanding of common nouns (e.g.

animals, food items, vehicles, toys, body parts, clothing, shapes, household items) and verbs (e.g. eating, sleeping, walking, running, jumping, playing).

3.Ezekiel will demonstrate an understanding of “wh” questions (e.g. “What is it?”, “Where is it?”).

4.Ezekiel will demonstrate an understanding of prepositions (e.g. “In”, “Under”, “Over”, “On”, “Behind”, “In front”); quantity concepts (e.g. “Some”, “All”, “One”), and descriptive concepts (e.g. “Big”, “Little”).

Expressive Language

1. Ezekiel will imitate sounds, consonant sounds and consonant-vowel combinations and final consonant production after being modeled by the therapist.

2. Ezekiel will imitate the names of new and familiar objects after being modeled by the therapist.

3. Ezekiel will name familiar objects (e.g. animals, food items, vehicles, toys, body parts, clothing, shapes, household items) upon verbal request, as well as, spontaneously.

4. Ezekiel will consistently produce single words to communicate wants and needs with 80% accuracy and minimal cueing. Ezekiel will then produce two+ word combinations to communicate his wants and needs once single word production has been met.

Summary of LSHC treatment goals from client’s file:

SOUND PRODUCTION

Sound Error

Goal

Semester Treatment Began

Semester Treatment Ended

The client will imitate consonant sounds after being modeled by the therapist in 8/10 opportunities.

Summer, 2022

N/A

The client will imitate consonant-vowel combinations after being modeled by the therapist in 8/10 opportunities.

Summer, 2022

N/A

RECEPTIVE LANGUAGE

Skill

Goal

Semester Treatment Began

Semester Treatment Ended

Comprehension of spoken language

The client will follow simple one-to-two step directions without gestural cueing in 8/10 opportunities

Summer, 2022

N/A

The client will demonstrate and understanding of “wh” questions in 8/10 opportunities.

Summer, 2022

N/A

EXPRESSIVE LANGUAGE

Skill

Goal

Semester Treatment Began

Semester Treatment Ended

The client will imitate the names of new and familiar objects after being modeled by the therapist in 8/10 opportunities.

Summer, 2022

N/A

The client will name familiar objects upon verbal request in 8/10 opportunities.

Summer, 2022

N/A

Progress: Make notes on client’s progress.

Note: Look at the skill areas addressed not just the goals. Has the client demonstrated consistent progress? Are there areas of progress that have been more significant than others? Are there skills that have not shown progress? Are there goals that that not been met over multiple semesters?

Therapeutic Methods:

Read through the therapeutic methods from previous reports and make note of the following:

oDelivery Schedule

oPractice variability (number of different targets that are practiced)

Variable: different targets in different contexts

oPractice Schedule (order that the targets are practiced)

Random: multiple targets practiced, limited trials per target

oDescribe type and level of cues used. Provide examples of cues.

oType: Visual, Verbal, Gestural, Imitative model, Kinesthetic

oLevel: Minimal

oReinforcement schedule

oEffective treatment materials and how they were utilized:

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