Case Study: An IPP Team Helps 6-Year-Old with Down Syndrome Improve Communication Skills

Work Setting: Schools Work Setting: Health Care

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Background

Angela is a 6-year-old girl with Down syndrome. She has a complex health history, which included dysphagia (G-tube dependent) and conductive hearing loss. She used a bone conduction hearing aid (the BAHA® Bone Conduction Implant System). Angela is mostly nonverbal and communicates with word approximations, gestures, and signs.

At school, Angela has an individualized education program (IEP) and receives speech-language pathology, physical therapy, and occupational therapy services. Her parents reported that she uses a device to communicate at school, but at the time of their report, they did not have one at home. Angela’s school program was conducted in English. Her father is bilingual (Spanish–English), but her mother speaks only Spanish. Her parents reported that their main concern was regarding Angela’s communication skills. They specifically asked when or if she would learn to talk.

The initial evaluation was part of Angela’s semi-yearly follow-up meeting at an interdisciplinary/IPP Down syndrome clinic at a local children’s hospital. This clinic had followed Angela since she was 1 year old. Her last evaluation in this clinic was 2 years ago.

Meet the Team

The IPP team included the following professionals:

How They Collaborated

At the initial IPP team meeting, with the hospital-based SLP serving as the team facilitator, the group discussed the case and each member’s role. For their initial assessment of Angela’s condition, all members decided to evaluate her on the same day.

At Angela’s appointment, the SLP assessed receptive and expressive language, speech sound production, and social communication skills. The audiologist looked into her speech perception with and without her hearing aid. The OT assessed Angela’s visual motor integration, sensory processing, neuromotor, upper extremity skills, and participation in activities of daily living. The PT evaluated her gross motor development, gait, and neuromotor functioning. The pediatric neurologist reviewed her medical history and did a physical exam. The CMA took Angela’s weight and measurements, and the Spanish language interpreter was present to help answer questions from Angela’s family.

During her assessment, Angela was playful and silly. She demonstrated communicative intent and engagement, communication with vocalizations, word approximations, facial expressions, and pantomimes. She used more than 25 American Sign Language (ASL) signs, which she learned at school. Her parents, who understood only about five of the signs, frequently missed the details of her communication attempts. Angela initiated communication frequently and responded accurately to simple directions in both English and Spanish. She demonstrated a restricted speech sound inventory with a limited variety of word shapes. Her parents reported that she used picture symbols and a communication device at school, but they did not use these at home.

Following the assessment, the team regrouped to share and discuss the evaluation results. The SLP advised the team that results of the communication evaluation indicated a severe expressive and receptive language disorder and a severe speech articulation disorder.

The audiologist reported that, with her hearing aid, Angela’s speech sound perception was accurate in the 30–40 dB range. The OT’s evaluation revealed hypotonia, deficits in visual motor integration, decreased independence with self-care skills, and decreased oral motor skills. The OT noted that Angela’s difficulty following complex oral directions may have impacted her performance on some tasks during her assessment. The PT’s evaluation revealed impairments in gross motor skills and hypotonia. Angela presented with a left head-tilt that her parents were previously told was related to visual impairments. The pediatric neurologist found that Angela was in good general health given her complex medical issues.

After discussing the results of the evaluations, the team provided Angela’s parents with additional resources, such as the contact information for a group of Spanish-speaking families with children who have disabilities. (Angela’s parents said that they were interested in meeting other families who have children with Down syndrome.) The SLP recommended the use of a speech-generating device with picture symbols at both home and school. This would help address the language differences and Angela’s restricted speech sound inventory. The IPP team recommended that Angela continue with her current school program under her IEP and return to the clinic in 1 year for a follow-up appointment.

Following this visit, the hospital-based SLP reached out to the school-based SLP regarding Angela’s use of a communication device at school. The hospital had a grant to help families purchase communication devices. Angela’s family used the grant funding to buy an AAC device, and the school-based SLP helped the family set it up at their home.

Outcome

Four months after the assessment, the hospital-based SLP checked in with Angela’s family. They reported that Angela was learning to use the AAC device at home, but it was “easier” for her to communicate vocally. However, Angela would use the device when prompted. On those occasions, it enabled her to communicate in one- to two-word utterances to clarify her vocalizations and gestures and respond to simple questions. Her father reported that the picture symbols on the device enabled his wife to understand more of what his daughter told her.

The family also reported that they had attended a meeting of the Spanish-speaking support group and met another family who has a child with Down syndrome. They also reported that Angela had an appointment regarding her neck tilt, which increased her likelihood of developing scoliosis.

With the family’s permission, the hospital-based SLP checked in with the school-based SLP, who reported that Angela used the AAC device at school and home. The school placed Angela in a group with other children who use AAC devices to help her use the device more frequently.

Ongoing Collaboration

Angela will return to the Down syndrome clinic in 1 year for her regular follow-up visit. In the meantime, the IPP team developed a follow-up plan that included bi-weekly conference calls. They also planned to meet in person at least quarterly.

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