Table of Contents s448

BOONE COUNTY SCHOOLS

STUDENT SERVICES DIVISION

SPECIAL EDUCATION DEPARTMENT

SPEECH / LANGUAGE SERVICES

Procedures Kathleen G. Reutman Executive Director, Student Services

Karen Snelling Special Education Director

Boone County Schools 5942 North Orient Burlington, KY 41005

(859) 334-4455 Revised 09/04 TABLE OF CONTENTS

I. REFERRAL PROCESS

II. ASSESSMENT PROCEDURES Speech Sound Production/Use/ Severity Rating Scale Language/Severity Rating Scale Fluency/Severity Rating Scale Voice/Severity Rating Scale Moderate to Profound Disabilities/Severity Rating Scale

III. ELIGIBILITY GUIDELINES

IV. PROGRAM COMPLETION CRITERIA

V. AUDIOLOGICAL PROCEDURES FOR HEARING SCREENING I. REFERRAL PROCESS BOONE COUNTY SCHOOLS SPECIAL EDUCATION DEPARTMENT SPEECH/LANGUAGE SERVICES COMMUNICATION DISORDERS REFERRAL PROCESS

1. Classroom teacher brings concerns to ARC. ARC Chairperson initiates a SIT I (Student Intervention Team) Meeting. The "Team" includes Classroom Teacher, ARC Chairperson, Speech/Language Pathologist (SLP), and the following disciplines, as warranted: Psychologist, if academic concerns; Special Education Teacher OT, if fine motor concerns; PT, if gross motor concerns; VI Consultant, if visual skills concerns; HI Consultant, if audiological skills concerns; Autism Consultant, if autism/PDD concerns; Nurse, if medical issues; etc. Teachers concerns are discussed with Team and interventions are developed at the SIT I. Interventions may be employed for 4-6 weeks for language concerns. SIT also determines appropriate communication screening measures.

2. Prior to SIT II, SLP will conduct Communication Screening and prepares written screening report.

3. At SIT II, the Team reconvenes with parents and discusses results of all screenings and interventions. The committee can then take one of two routes. 1) The Team can continue to assist student with focused interventions; the process of referral is stopped; or 2) The Team can determine there is enough concern to warrant an evaluation.

4. If the evaluation process is initiated, the Team becomes an ARC team, the Evaluation Planning Form is completed and Consent for Evaluation is signed by parent/guardian. Focused Interventions continue while the evaluations are being completed. Parent Rights are reviewed by ARC Chairperson with parents and a copy provided to them. Medicaid Notification is also given.

5. For speech/language only referrals, the SLP completes evaluation, prepares Communication Written Report, Eligibility Form and Severity Rating Scales Matrices.

For referrals that include other areas of evaluation, evaluation written reports are prepared by each team member as appropriate and an integrated report is written by the School Psychologist. The ARC reconvenes to discuss evaluation results, determine eligibility for Special Education and related services and plan appropriate programs to meet the student’s needs.

An Individual Education Plan (IEP) is developed with parent involvement and Consent for Specially Designed Instruction ( ) is signed.

The Staff Support Assistant is responsible for sending all paperwork to the Special Education Director. STUDENT INTERVENTION TEAM PROCESS (SIT)

SIT I Concerns brought to ARC Screenings conducted. Interventions designed

SIT II ARC reviews Screening results and interventions, makes referral for Communication Evaluation, receives parent consent for evaluation.

Speech-Language Pathologist: follows due process procedures suggests most appropriate evaluation procedures to determine rating:

Standardized, norm-referenced tests, Functional Communication and non-standardized procedures Assessment

Communication Rating Scales: Speech Sound Production & Use Communication Rating Scale for Language students with Moderate Fluency to Severe Disabilities Voice

ARC decides service needs

The student is determined eligible to The student does not meet eligibility receive speech-language services. for speech services IEP is developed and service delivery is determined. Boone County Schools Student Services Division Special Education Department Speech/Language Services SCREENING REPORT

NAME: ______SCHOOL: ______DATE OF BIRTH: ______EXAMINER: ______GRADE: ______DATE OF SCREENING:______TEACHER: ______DATE OF REPORT: ______HEARING: Date of Screening: ______Results: ______passed ______failed ______GENERAL OBSERVATIONS:

______ARTICULATION WNL further Eval Indicated ______LANGUAGE WNL further Eval Indicated ______VOICE WNL further Eval Indicated ______FLUENCY WNL further Eval Indicated ______RECOMMENDATIONS

______Speech/Language Pathologist Date

Revised 10/04 Boone County Schools EC 5A Student Services Division Special Education Department Speech/Language Services COMMUNICATION EVALUATION WRITTEN REPORT NAME ______SS# ______DOB ______AGE ___ SEX ___ SCHOOL ______GRADE ____ TEACHER ______DATE OF EVALUATION ______DATE OF REPORT ______EVALUATOR ______AREAS OF EVALUATION ARTICULATION/PHONOLOGY Satisfactory ______Unsatisfactory ______CONVERSATIONAL SPEECH Intelligible ______Some words unintelligible ______Intelligible if topic known ______Unintelligible ______EVALUATION RAW STANDARD PERCENTILE MEAN INSTRUMENT(S) SCORE SCORE RANK

COMMENTS: ______

ORAL SPEECH MECHANISM AND MOTOR FUNCTIONING

Satisfactory for speech production ______Unsatisfactory for speech production ______Comments ______HEARING SCREENING Passed ______Failed ______(Right ear ______, Left ear ______) Comments: ______VOICE SCREENING satisfactory unsatisfactory EVALUATION satisfactory unsatisfactory QUALITY INTENSITY PITCH INFLECTION satisfactory satisfactory satisfactory satisfactory unsatisfactory unsatisfactory unsatisfactory unsatisfactory nasal/denasal too loud too high monotonous/ too soft too low exaggerated breathy/ hoarse rising/ falling

COMMENTS: ______

SCREENING satisfactory unsatisfactory EVALUATION satisfactory unsatisfactory ______FLUENCY

Repetitions (Part word ______Whole word ______) Prolongations ______Hesitations ______Interjections ______Struggle ______Associated behaviors observed ______Number of dysfluencies per minute: Oral Reading ______Monologue ______Conversation ______Rate: Satisfactory ______Unsatisfactory ______Too Rapid ______Too Slow ______Comments: ______LANGUAGE Screening: Satisfactory ______Unsatisfactory ______Evaluation: Satisfactory ______Unsatisfactory ______

EVALUATION Raw Standard Percentile EVALUATION Raw Standard Percentile Score Score Rank Score Score Rank INSTRUMENT(S) INSTRUMENT(S)

Comments: ______

______

CLASSROOM OBSERVATION SUMMARY ______

SEVERITY RATING SCORE: Voice _____ Fluency ______Articulation _____ Language ______Total Severity Rating ______

RECOMMENDATIONS

Respectfully submitted, ______Speech/Language Pathologist Date

Revised 10/04 BEHAVIOR OBSERVATION Child/Youth ______Date ______Site of Observation ______Observer ______Person responsible for student during observation ______Title ______Observation Time ______Beginning Ending

I. Target behavior of concern identified in referral: ______

II. Physical environment: _____ at desk _____ on chairs in a group _____ playground _____ at listening center _____ on the floor _____ cafeteria _____ at learning center _____ at chalkboard _____ gym _____ at table _____ other ______

III. Task (defined by the teacher) for the student to perform:______

III. Observation method to be used: A. _____ Interval recording of targeted or academic engaged time. B. _____ Frequency/Duration of targeted behavior. C. _____ Anecdotal

A. Interval recording (you should use stopwatch or watch with a second hand). Interval length: _____ 15 seconds _____ 20 seconds _____ 30 seconds _____ Academic engaged time (on-task) _____ Targeted behavior (i.e. out-of-seat, verbal interruptions, etc.) ______

______

Mark “+” when student or peer is on-task or when the targeted behavior occurs. Mark “-” when student or peer is off-task or when the targeted behavior does not occur.

Student Peer

% of “+” responses for student ______% of work completed by student ______% of “+” responses for peer ______% of work completed by peer ______Observer comments: ______

In the teacher/supervisor/caregiver’s judgment, was the student’s behavior typical? ___ Yes ___ No (please explain) ______The Boone County Board of Education does not discriminate on the basis of race, color, national origin, age, religion, marital status, sex or disability. B. Frequency recording of targeted behavior. Record the number of times the behavior occurs during a specific period of time. Time period _____ minutes Frequency/duration for student ______Frequency/duration for peer ______

In the teacher/supervisor/caregiver’s judgment was the student’s behavior typical? ___ Yes ___ No (please explain) ______

C. Anecdotal observation. Record below (and on additional pages if necessary) all pertinent behaviors occurring during the observation period. ______Comments/Summary ______In the teacher/supervisor/caregiver’s judgment, was the student’s behavior typical? ___ Yes ___ No (please explain) ______

______Signature (of person completing form)

Cc: Central Office White – Due Process Yellow – Central Office Observation Requirements

Observation and analysis of the student’s language skills within his/her everyday contexts and environments provide essential information about language strengths and possible area(s) of weakness. Information gained within functional settings and contexts may be used not only as partial documentation of a language disorder, but also to learn more about the patterns/areas of the language disorder and to assist in intervention planning. Functional data should also be used to validate the results of standardized tests.

While not inclusive of all possibilities within the school and home settings (especially for preschoolers), some examples of sources of functional assessment are listed below:

. Language sampling/narratives The informal language sample may be a key component of the functional assessment for preschool and/or severely language delayed students. Analysis of the language sample to validate standardized assessment data relies upon the use of developmental scales in the areas of phonology, morphology, syntax, semantics and pragmatics. For older students, an oral narrative may be an appropriate tool for functional analysis.

. Classroom observation The speech-language pathologist should observe how the student’s language disorder affects his/her involvement and progress in the general curriculum (Program of Studies). This information assessment of the student’s language skills may be used to validate the results of standardized tests. It may also help to support a teacher’s description of the student’s communicative behaviors.

The observation should assess how well the student is able to follow classroom routine, interact with his/her teachers and peers, respond to and participate in classroom discussion or other activities needed to progress in the general curriculum.

. Teacher/parent interviews Information gathered from parents and/or teacher(s) about the student’s language performance in familiar settings can be used by the speech-language pathologist to verify the student’s language performance.

. Criterion referenced activities (e.g., student telling a story) Criterion referenced measures indicate ability with respect to specific skills. Such measures aid in the understanding of a student’s abilities and needs by complementing findings from norm-referenced measures, and by providing a means of describing the student’s strengths and needs in terms of actual performance. II. ASSESSMENT PROCEDURES SEVERITY RATING SCALE

RANGE OF SEVERITY NON-DISABLING MILD MODERATE SEVERE

STANDARD DEVIATION X -1 1/3 -1 2/3 -2

STANDARD SCORE 100 80 – 75 74 – 70 ▼69

PERCENTILE 50 9TH – 5TH 4TH – 2ND ▼2

EXAMPLES: (X = 100, SD = 15) 100 80 74 69 CELF 4

(X = 10, SD = 3) 10 6 5 4 CELF 4 Subtests SPEECH SOUND

Suggested Instruments

I. Articulation: Goldman Fristoe Test of Articulation Arizona Test of Articulation Revised Spontaneous Speech Sample

II. Phonology: Phonological Awareness Test Analysis of Phonological Processes Revised Clinical Probe for Articulation Consistency

Speech Sound Screening: Speech Ease Screening Inventory (K-1) Joliet Fluharty Spontaneous Speech Sample

Supplementary Instruments: Test of Oral Motor Skills TOLD P-3, Articulation, Subtest DEVELOPMENTAL NORMS FOR ARTICULATION

Sound Age Sound Age

m 3 1/2 j 5 n 3 1/2 k, g 5 h 3 1/2 l 6 b,p 3 1/2 , 3 6 d,t 4 s, z 7 4 r 7 w 4 7 f,v 5 Ә, ♂ 7

Appendix A - Cross Listing of Consonant Sound Classification.

/p/ /b/ /t/ /d/ /k/ /g/ /f/ /v/ /s/ /z/ /d3/ /m/ /n/ /r/ /l/ /w/ /j/ /h/ Obstruents √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Sonorants √ √ √ √ √ √ √ Stops √ √ √ √ √ √ Fricatives √ √ √ √ √ √ √ √ √ Affricates √ √ Liquids √ √ Nasals √ √ √ Glides √ √ Stridents √ √ √ √ √ √ √ √ Sibilants √ √ √ √ √ √ Labials √ √ √ √ √ √ Interdentals √ √ Alveolars √ √ √ √ √ √ Palatals √ √ √ √ √ √ √ Velars √ √ √ Glottals Voiced √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ √ Voiceless √ √ √ √ √ √ √ √ Boone County Schools Student Services Division Special Education Department Speech/Language Services

Student: ______DOB: ______Grade/Program: ____ SLP:______Date: ______

COMMUNICATION RATING SCALE: SPEECH SOUND PRODUCTION AND USE

Non-Disabling Mild Moderate Severe 0 4 6 8 Intelligibility Connected speech Connected speech Connected speech Connected speech is intelligible. is occasionally is frequently is unintelligible or unintelligible unintelligible. only intelligible and/or noticeably when listener has in error. knowledge of the context. 0 3 4 6 Sound System Scores on Scores on Scores on Scores on standardized standardized standardized standardized *See NOTE instruments are instruments are 1 instruments are 1 instruments are 2 within 1 1/3 SD’s 1/3 to 1 2/3 SD’s 2/3 to 2 SD’s below or more SD’s below the mean or below the mean or the mean or from below the mean or above the 9th from the 9th to the the 4th to the 2nd below the 2nd percentile. 5th percentile. percentile. percentile.

0 3 4 5 Error Types No significant errors Productions reflect Productions reflect Productions reflect are present. common atypical a limited phonetic Differences may be phonological phonological inventory and/or typical or recognized processes or processes or sound numerous atypical dialectal patterns. sound errors. errors. phonological processes. 0 2 4 5 Speech Structure and/or Structure and/or Structure and/or Structure and/or Mechanism function are function difficulty function difficulty function are Structure and adequate for mildly affects affects speech. inadequate for Function speech. speech. speech.

0 4 6 8 Adverse Effect No interference with Minimally impacts Moderately Seriously limits on Educational performance in the performance in the interferes with performance in the Performance educational setting. educational performance in the educational setting. educational setting. setting.

Total Score 0 – 10 11 – 17 18 – 25 26 – 32 Rating Scale Non-Disabling Mild Moderate Severe Severity Rating 0 1 2 3

Comments: ______

______

* NOTE: Not all standardized measures have a consistent correlation among standard deviations, standard scores, and percentiles. This section should only be marked after the standard score or percentile has been compared to the standard deviation according to the test manual for that specific test. ASSESSMENT PROCEDURES FOR LANGUAGE DISORDERS

Review Hearing Status

Collect Spontaneous Language Sample and/or Behavior Observation

Administer Broad-based and Component Specific Standardized Norm-referenced Tests of Language

and/or

Collect Criterion Referenced and Non-standardized Assessment Data

Document Adverse Effect (Teacher/Parent Interview and Behavior Observation)

Complete Assessment Summary

Complete Matrix to Assign Severity Rating

Complete Communication Written Report LANGUAGE EVALUATION

For language evaluations the SLP will use one age appropriate comprehensive language instrument or one of each receptive and expressive instruments.

AGE RANGE Comprehensive Test Pre. Prim. Inter. Adoles. PLS3   CELFpre  CELF4    OWLS     TELD   TOLDP3   TOLDI3  TOAL3  BLT  REEL CASL Functional Communication Scale

SUPPLEMENTARY INSTRUMENTS AGE RANGE AREA EVAL.

PPVT3 Semantics EVT3 Semantics ROWPVT Semantics EOWPVT Semantics ASSET Semantics WORD TEST Semantics WORD TEST ADOL Semantics CREVT Semantics TACLR Semantics TEEM Morphology BOEHM R PRE Basic Concepts BOEHM 3 Basic Concepts TOPS Problem Solving TAPS-R Auditory Percept TAPS Upper Level TOWL Written Language LISTENING TEST Listening TEST OF WORD FINDING Word Finding TEST OF PRAGMATIC LANGUAGE Pragmatics LANGUAGE PROCESSING TEST (LPT)

PREVERBAL ASSESSMENT INTERVENTION PROFILE EXPRESSIVE TEST

LANGUAGE SCREENING INSTRUMENTS CELF PRE CELF 3 SCREENING TEST FLUHARTY BANKSON SPEECH EASE INVENTORY (K1) BANKSON-LANG TEST (SCREEN) (BLT) Boone County Schools Student Services Division Special Education Department Speech/Language Services

COMMUNICATION RATING SCALE: LANGUAGE

Non-Disabling Mild Moderate Severe 0 4 6 8 Functional Language skills are Language skills are Language skills are Language skills are Assessment within expected mildly impaired moderately impaired. severely impaired. range. __ Form/structure __ Form/structure __ Form/structure __ Form/structure __ Content/semantics __ Content/semantics __ Content/semantics __ Content/semantics __ Use/pragmatics __ Use/pragmatics. __ Use/pragmatics __ Use/pragmatics

0 3 4 6 Standardized/ Scores on Scores on standardized Scores on Scores on Norm standardized instruments are 1 1/3 to standardized standardized Referenced instruments are within 1 2/3 SD’s below the instruments are 1 2/3 instruments are 2 or Assessment 1 1/3 SD’s below the mean or from the 9th to to 2 SD’s below the more SD’s below the mean or above the 9th the 5th percentile. mean or from the 4th to mean or below the 2nd *See NOTE percentile. the 2nd percentile. percentile.

0 4 6 8 Adverse Effect No interference with Minimally impacts Moderately interferes Seriously limits on Educational performance in the performance in the with performance in performance in the Performance educational setting. educational setting. the educational setting. educational setting.

Total Score 0 – 7 8 – 12 13 – 17 18 - 22 Rating Scale Non-Disabling Mild Moderate Severe Severity Rating 0 1 2 3

Comments: ______

______

* NOTE: Not all standardized measures have a consistent correlation among standard deviations, standard scores, and percentiles. This section should only be marked after the standard score or percentile has been compared to the standard deviation according to the test manual for that specific test. ASSESSMENT PROCEDURES FOR FLUENCY DISORDERS

Review Hearing, Vision and Communication Screening

Collect and Assess Samples of Communicative Behaviors in Structured and Unstructured Situations

Document Adverse Effect (interview/observations)

Complete Fluency Assessment Summary

Complete Fluency Rating Scale and Assign a Severity Rating

Complete Communication Written Report Boone County Schools Student Services Division Special Education Department Speech/Language Services

COMMUNICATION RATING SCALE: FLUENCY

Non-Disabling Mild Moderate Severe 0 2 3 4 Frequency of 10 or fewer per 100 11 to 12 per 100 words 13 to 14 per 100 words 15 or more per 100 Dysfluencies words in conversation in conversation in conversation. words in conversation.

Type(s) of 0 2 4 6 Dysfluencies Mostly whole Mostly whole Mostly part-word syllable Frequent part-word multisyllabic word monosyllabic word repetitions. Occasional speech sound repetitions. repetitions. speech sound repetitions. Frequent repetitions. prolongations and Occasional whole-word Repetitions are rapid, Prolongations and broken words. interjections and tense and irregularly broken words noted. Repetitions are rapid, phrase/sentence paced. tense and irregularly revisions. Repetitions are rapid, paced. Pitch rise may be tense and irregularly present. paced. Pitch rise may be present. Pitch rise may be present Long, tense blocks, some with noticeable Blocks in which sound tremors. and airflow are shut off. Phonatory 0 4 6 8 Arrest/Sustained None observed or less 0.5 to 2.0 seconds in 2.1 to 3.0 seconds in 3.1 or more seconds in Articulatory Posture than .5 seconds duration duration duration duration Speech Sound 0 4 6 8 Prolongations None observed or less 1.6 to 3.0 seconds in 3.1 to 4.0 seconds in 4.1 or more seconds in than 1.5 seconds duration duration duration duration Schwa Replacement 0 0 0 6 Not perceived Not perceived Not perceived Perceived Physical 0 2 4 6 Concomitants None perceived. Only noticeable to Noticeable to casual Distracting or obvious trained observer. observer. to the listener. Awareness and 0 2 4 6 Emotional Reactions Student is neither aware Student is occasionally Student is often aware Student is always of, nor concerned about, aware and mildly of dysfluencies. aware of dysfluencies. dysfluencies. frustrated by dysfluencies. Negative emotions are Negative emotions are often observed/reported. frequently obs/reported Avoidance Behaviors 0 2 4 6 and Peer Reactions No verbal or situational Verbal or situational Verbal or situational Verbal or situational avoidance observed or avoidance occasionally avoidance frequently avoidance consistently reported. observed or reported. observed or reported. observed or reported.

Peers appear unaware Peers are aware of Frequent teasing noted Considerable teasing of dysfluencies. dysfluencies; some or reported. requiring strong adult teasing noted reported. intervention. Adverse Effect on 0 4 6 8 Educational No interference with Minimally impacts Moderately interferes Seriously limits Performance performance in the performance in the with performance in the performance in the educational setting. educational setting. educational setting. educational setting. Total Score 0 – 16 17 – 27 28 – 40 41 - 58 Rating Scale Non-Disabling Mild Moderate Severe Severity Rating 0 1 2 3

Comments: ______

______ASSESSMENT PROCEDURES FOR VOICE DISORDERS

Review Hearing, Vision and Communication Screening

Collect and Assess Speech and Phonation Samples

Secure Medical Findings from Appropriate Physician Referral

Document Adverse Effect

Complete Voice Assessment Summary

Complete Voice Rating Scale And Assign a Severity Rating

Complete Communication Written Report Boone County Schools Student Services Division Special Education Department Speech/Language Services

Student: ______DOB: ______Grade/Program:______SLP: ______Date:______

COMMUNICATION RATING SCALE: VOICE

Non-disabling Mild Moderate Severe Pitch 0 1 2 3 Normal for age, gender Noticeable abnormality Intermittent abnormality Persistent abnormality and culture. perceived by trained perceived by untrained for age, sex and/or listener. listener. culture. Loudness 0 1 2 3 Within normal limits Noticeable abnormality Intermittent abnormality Persistent abnormality perceived by trained perceived by untrained for age, sex and/or listener. listener. culture. Quality 0 1 2 3 Within normal limits. Noticeable abnormality Intermittent abnormality Persistent breathiness, perceived by trained perceived by untrained glottal fry, harshness, listener. listener hoarseness, tenseness, stridency, aphonia or other abnormal vocal qualities. Resonance 0 1 2 3 Within normal limits. Noticeable abnormality Intermittent abnormality Persistent abnormality. perceived by trained perceived by untrained listener. listener Vocal 0 2 3 4 Abuse/ Not observed. Limited to specific Observed intermittently Persistent throughout Misus situations. throughout the day. the day. e Medical Findings 0 2 4 6 No laryngeal pathology Minor laryngeal Laryngeal pathology Persistent physical reported by physician. pathology reported by reported by physician. conditions reported by physician. physician. Physical conditions Pathology may include influencing pitch, Pathology may include nodules, polyps, ulcers, Pathology may include loudness, quality or vocal fold thickening, edema, partial paralysis unilateral or bilateral resonance may include edema or nodules. of vocal folds, enlarged paralysis of vocal folds, allergies, colds, or insufficient tonsils neuromotor involvement abnormal tonsils and/or and/or adenoids. of laryngeal/ adenoids. velopharyngeal muscles, etc. Adverse Effect on 0 4 6 8 Educat No interference with Minimally impacts Moderately interferes Seriously limits ional performance in the performance in the with performance in the performance in the Perfor educational setting. educational setting. educational setting. educational setting. mance Total Score 0 – 8 9 – 15 16 – 23 24 – 30 Rating Scale Non-disabling Mild Moderate Severe Severity Rating 0 1 2 3

Comments: ______Boone County Schools Student Services Division Special Education Department Speech/Language Services ORAL SPEECH SCREENING CHECKLIST

Student: ______Age: ______Date: ______

I. Lips A. Structure at rest: B. Function: Rounding Smiling Smacking Puffing Biting Lower Lip II. Tongue A. Structure: Surface Frenum B. Function: Tip Up Tip Down Tip Right Tip Left Tip on Palate III. Jaw A. Occlusion: Molars Incisor B. Function: Open/Close (TMJ) Forward/Backward Side to Side IV. Teeth A. Condition: Decay Caries Gaps B. Alignment: Crowding Crooked V. Hard Palate A. Height B. Width VI. Soft Palate (Uvula) A. Symmetry at rest: B. Movement during “ah” production VII. Velopharyngeal Mechanism: A. Voice quality during “u” production (nostrils open) B. Same with nostrils occluded VIII. Diadochokinetic Rate A. P^ 16 ____ B. t^ 16 ____ C. k^ 16 ____ D. p^t k 8 ____ IX. Breathing A. Mouth Breathing: SUMMARY AND RECOMMENDATIONS: ______Speech/Language Pathologist Date Revised 10/04 Boone County Schools Student Services Division Special Education Department Speech/Language Services ORAL EXAM

Student: ______Date: ______

I. Muscular Coordination ______speech mechanism ______General

II. Oral Examination

Lips Teeth Mandible Tongue ___ Normal ___ Normal ___ Normal ___ Normal ___ Cleft ___ Misaligned ___ Overbite ___ Restricted ___ Paralized ___ Jumbled ___ Underbite Movement ___ Frenum ___ Spaced ___ Openbite ___ Control ______Other ___ Other

Soft Palate: Hard Palate: ___ Normal ___ Normal ___ Sluggish ___ Narrow ___ Paralized ___ High ___ Cleft ___ Cleft

III. VOICE

Pitch Intensity Quality ___ Normal ___ Normal ___ Normal ___ High ___ Loud ___ Hoarse ___ Low ___ Soft ___ Harsh ___ Monotone ___ Uncontrolled ___ Nasal ___ Pattern ___ Pattern ___ Denasal ___ Breathy

RATE: ___ Normal ___ Rapid ___ Slow

Revised 10/04 Boone County Schools 10A Student Services Division Special Education Department Speech/Language Services LARYNGOLOGICAL REFERRAL

Name ______Age ______Date ______Address ______Phone ______School ______Grade ______Referring Speech Language Pathologist ______Examining Laryngologist ______

Nose: Is there obstruction in the nasal passages?______If so, please explain. ______Is there sinus infection or nasal allergy? ______

Pharynx: Is there any asymetry of muscle contraction? ______Are there any growths or other abnormalities: ______Larynx: Examination by indirect laryngoscopy ______direct laryngoscopy ______

Presence of Vocal Pathology: Please indicate location on diagram. Nodules ______Polyps ______Ulcer ______Other ______None ______

Epiglottis Size:______Anterior 1/3 Appearance: Hard ______Medium 1/3 Soft ______Other ______Posterior 1/3

Arytenoid Process FINDINGS: Does this patient have allergies, hypothyroidism, anemia, or any other chronic condition which might contribute to the abnormal voice quality______Has this patient’s misuse of voice contributed to abnormal structure or function?______Do your findings explain the abnormal voice quality?______In your opinion, it is possible that a continuation of present voice use may contribute toward future or increased disorders of the mechanism? ______

RECOMMENDATIONS: Do you recommend any of the following: Silence ______Duration ______Limited use of voice ______Duration ______Training by a speech clinician to help patient establish easy, efficient use of the vocal mechanism______Other recommendations______Please return to: ______Physician’s Signature Date Revised 10/04 Boone County Schools 10b Student Services Division Special Education Department Speech/Language Services REFERRAL – VELOPHARYNGEAL CLOSURE

NAME ______AGE ______DATE ______ADDRESS ______REFERRED BY ______SCHOOL ______REFERRING SPEECH LANGUAGE PATHOLOGIST ______EXAMINING LARYNGOLOGIST ______DATE OF EXAM ______

1. Please check below the method(s) you used to determine whether the velopharyngeal closure is adequate or not, and comment on your observations. [ ] Visual [ ] Adequate closure [ ] Inadequate closure Comment:______[ ] Cline Studies [ ] Adequate closure [ ] Inadequate closure Comment:______[ ] X-Ray (Stationary Plate) [ ] Adequate closure [ ] Inadequate closure Comment:______[ ] Other [ ] Adequate closure [ ] Inadequate closure Comment:______2. Visual Exam: A. Is the soft palate of normal proportions and length? ______B. Is the hard palate of normal proportions and length? ______C. Is the color of the palatal tissues normal? ______D. Is there any asymmetry of the palate?______E. Does the uvula appear normal in size and function?______F. Does the pharynx appear deep? ______Comment: ______G. Is there evidence of a submucous cleft? ______H. What is the condition of the nasal and sinus areas regarding obstructions, infections, allergies, etc.? ______I. Has the child had the tonsils or adenoid mass removed?______J. Other related physical anomalies noted: ______3. Surgical procedures recommended: ______4. Is speech therapy recommended:______Please return to: ______

______Physician’s Signature Date

Revised 10/04 Boone County Schools Optional Student Services Division Special Education Department Speech/Language Services VOICE EVALUATION FORM

Student: ______Age: ______Date: ______

1. Describe the vocal characteristics in spontaneous conversation:

2. Is the problem constant or variable? Describe variations.

3. Does the student have any allergies?

Is the student on any medications?

4. Note breathing habits including type, rapidity, and changes during the evaluation:

5. Listen to the length and quality of “ah” or “m” as the child takes a deep breath and holds it as long as he can. (About 12 seconds is average for a child)

6. Observe the child for evidence of tension. Watch and listen for tension increase as he counts from a whispered 1 to a shouted 10.

7. Have the child produce both /s/ and /z/ as long as possible. Repeat this several times recording the length of utterances. Divide the /s/ time into the /z/ time. A score below 80% may indicate vocal cord pathology. /s/ /z/ percentage

8. Listen for hard glottal attacks during counting from 80 – 90.

9. Listen for evidences of vocal fatigue as the child counts from 1 to 250 or 300. 10. Vary the voice and listen for changes:

Louder voice:

Softer voice:

Higher pitch:

Lower pitch:

Other:

11. List vocal abuses observed or reported.

12. How does the child feel about his voice?

Rate: Intensity: Pitch:

___ Fast ___ Loud ___ High ___ Slow ___ Soft ___ Low ___ Normal ___ Normal ___ Monotone ___ Variety

Resonance: Quality:

___ Denasal ___ Hoarse ___ Hypernasal ___ Breath ___ Normal ___ Aphonic ___ Normal

Revised 10/04 Boone County Schools Student Services Division Special Education Department Speech/Language Services OROFACIAL EXAMINATION CHECKLIST

Client Name: ______Age: ______Date: ______

Examiner: ______

I. Facial Characteristics A. General appearance: normal color ______, normal symmetry ______, adenoid facies ______Other: ______B. Frontal view: 1. eye spacing: normal (one eye apart) ______, hypertelorism ______, other: ______2. zygomatic bones: normal ______, hypoplasia ______, other ______3. nasal area: septum (straight) ______, or deviated ______, nares ______, columella _____, septum/turbinate relationship ______, turbinate color ______, other notations ______4. vertical facial dimensions: a. upper (40% of face) ______; other notations ______b. lower (60% of face) ______; other notations ______5. lips: cupid’s bow present ______; muscular union ______; neuromotor functioning -/i/ ______, /u/ ______, /p-p-p/ ______, other notations ______

C. Profile 1. normal (straight or convex) linear relationship between bridge of nose, to base of nose, to chin_____, maxilla ______, maxilla ______, retrusion protrusion mandible ______, mandible______,

2. mandibular plane: normal ______, steep ______, flat ______) D. General notations:

II. Intraoral Characteristics A. Detention 1. general hygiene: good ______, needs improvement ______, caries ______, gingival hyperplasia or recession ______2. occlusal relationships (“bite on your back teeth” and separate cheek from teeth with tongue depressor) a. first molar contacts: Class I – normal molar occlusion (normal molar relationship with variations in other areas of detention) ______Class I malocclusion (maxillary ahead of mandibular first molar) ______Class II malocclusion (maxillary ahead of mandibular first molar) ______Class III malocclusion (mandibular molar more than one-half tooth ahead of maxillary molar) ___ b. biting surfaces: normal vertical overlap (overbite) ____, excessive vertical overlap A____/P____, normal horizontal overlap (overjet) ______, excessive horizontal overlap A _____/P______, crossbite (mandibular tooth or teeth outside or wider than maxillary counterpart, or maxillary tooth or teeth inside mandibular counterpart) ______, notation of teeth involved ______, open bite (gap between biting surfaces) A ______/ P ______c. sibilant production with teeth in occlusion: normal /s/ ______, /z/ ______, /f/ ______, /v/ ______

B. Hard palate (“extend your head backward”) 1. midline coloration: normal (pink and white) _____, abnormal (blue tint) ______2. lateral coloration: normal ______, sorus palatinus (blue tint surrounding a raised midline bony growth)______3. posterior border and nasal spine: normal ______, short ______4. general bony framework: normal ______, submucous cleft ______, cleft _____, repaired clef ______, other______5. palatal vault: normal relationship between maxillary arch/vault ______, narrow maxillary arch/high vault____, wide maxillary arch/flat: vault ______, other______6. general notations______C. Soft palate or velum (Examiner’s eye level should be at client’s mouth level. Client’s head erect, mouth three- fourths open, and tongue not extended out of mouth). 1. midline muscle union (say “ah”): normal (whitish-pink tissue line) ____, submucous cleft (blue tint with A-type configuration during phonation) _____, cleft _____, repaired cleft ______2. length: effective (closure of nasopharyngeal port possible during phonation) _____, ineffective hypernasality noted) ______3. velar dimple (where elevated soft palate buckles during phonation): normal 80% of total velar length (or 3-5 mm above tip of uvula)_____, other notations______4. velar elevation: normal (up to plane of hard palate) ______, reduced ______, other______5. range of velar excursion (up and back stretching during phonation): excellent ______, moderate ______, minimal ______6. presence of hypernasality during counting: 60s_____, 70s_____, 80s_____, 90s______7. general notations: regarding air loss on unphonated sounds (nasal emission) and nasal resonance on phonated sounds ______

D. Uvula 1. shape: normal ______, bifid ______, other ______position: midline ______, lateral ______

E. Fauces 1. open isthmus ______, tonsillar obstruction or isthmus ______2. tonsil coloration: normal (pinkish) ______, inflammed ______

F. Pharynx 1. depth between velar dimple and pharyngeal wall on “ah”: normal _____, deep _____, other______2. Passavant’s pad: present during physiologic activity? ______3. Adenoidal surgery (ask client): intact ______, removed ______, date of tonsil/adenoid removal ______4. Gag response: positive ______, negative ______, weak ______5. General notations ______

G. Tongue 1. size: normal _____, macroglossia (rare) _____, microglossia ______2. diadochokinetic rate—an estimate of neuromotor maturation for speech (observe consistency and pattern of rapid movements during the 15 repetition sequence) a. normal movement patterns: tuh _____, juh _____, kuh _____, puh-tuh-kuh _____, describe variations ______b. mandibular assist: normal (until age seven and one-half) _____, possible neuromotor delay for speech (after seven and one half) ______3. lingual frenum: normal (tongue tip to alevolar ridge when mouth is one-half open) ______, short ______4. general notations: ______

III. General Observations and Other Findings:

______Examiner Signature Date

Revised 10/04 Boone County Schools Student Services Division Special Education Department Speech/Language Services

Name of Child:______Date:______School:______Grade:______

Dear Doctor:

The Exceptional Children Division of the Kentucky Department of Education requires a child to have a written recommendation from an Otolaryngologist before receiving therapy for a voice disorder. For this reason, would you complete this information after your examination of this child.

In the evaluation by the Speech/Language Pathologist the following was noted: ______

Thank you,

______Speech Language Pathologist

Return To: ______Boone County Schools Student Services Division Special Education Department Speech/Language Services VOICE ASSESSMENT SUMMARY Student: ______DOB: ______C.A.: ______SLP: ______Grade/Program:______Date:______

1. PITCH 2. LOUDNESS ___ normal ___ normal ___ too high ___ too low ___ pitch breaks ___ too loud ___ too soft ___ perceived by trained listener only ___ perceived by trained listener only ___ intermittent; perceived by others ___ intermittent; perceived by others ___ persistent; inappropriate for age and sex ___ persistent; inappropriate for age and sex

Description: ______Description:______

3. QUALITY 4. RESONANCE ___ normal ___ normal ___ breathy ___ harsh ___ hoarse ___ aphonic ___ too loud ___ too soft ___ perceived by trained listener only ___ perceived by trained listener only ___ intermittent; perceived by others ___ intermittent; perceived by others ___ persistent; inappropriate for age and sex ___ persistent; inappropriate for age and sex

Description (glottal fry, tense, strident, etc.): ______Description:______

5. VOCAL NOT OBSERVED SITUATION BOUND INTERMITTENT PERSISTENT ABUSE/MISUSE Shouting Loud talking Loud whispering Hard glottal attack Inhalation phonation Excessive throat clearing Excessive loudness Inappropriate pitch Talking in noisy environment

6. MEDICAL FINDINGS ___ no laryngeal pathology reported ___ laryngeal pathology reported: ___ vocal fold thickening ___ edema ___ nodules ___ polyps ___ ulcers ___ enlarged tonsils/adenoids ___ insufficient tonsils/adenoids ___ partial paralysis of vocal folds ___ complete paralysis of vocal folds ___ neuromotor involvement of laryngeal/velopharyngeal muscles ___ other (describe below)

Comments: ______

7. ADDITIONAL ASSESSMENT INFORMATION (from case history, interview, etc.): ______

______Examiner Signature Date

Revised 10/04 ASSESSMENT PROCEDURES FOR MODERATE TO SEVERE DISABILITY

Assessment Procedure for Moderate to Severe Disability

Review Hearing, Vision, Communication Screening/Observation

Functional Assessment conducted using option one or two plus referral to Assistive Technology Team, as appropriate

Complete Rating Scales

Complete Communication Evaluation Written Report COMMUNICATION EVALUATION FOR STUDENTS WITH MODERATE TO SEVERE DISABILITIES

For students who exhibit severely limited or no functional oral communication skills and/or are severely limited in their fine motor/manipulative skills, the Speech-Language Pathologist has two options:

Option 1 Students are assessed using the Communication Rating Scale(s) which provide specific procedures for assessing one or more of the communication areas of speech sound production and use, language, fluency and voice. Students for whom these Scales are appropriate possess sufficient communication strategies for application of the procedures, and the speech-language pathologist judges that these scales are appropriate to the needs of the student.

 Follow assessment procedures for Speech Sound Production and Use and Language, making adjustments as necessary for students with severely limited oral expression.  Complete the matrix in the Communication Rating Scale(s), as appropriate, and assign a severity rating.

Option 2 For students who exhibit severely limited or no functional oral communication skills and/or are severely limited in their fine motor/manipulative skills the speech-language pathologist may use the Communication Rating Scale for Students with Moderate to Profound Disabilities. The speech-language pathologist uses assessment data to provide input on communicative intent, symbolic communication and oral-motor skills. It is important to note that students rated with this scale in almost all cases will have already met the eligibility requirements for special education based on a primary disability.

 Follow appropriate assessment protocols for evaluating communication skills for students with moderate to profound disabilities. Data secured through standardized and non-standardized assessment procedures should allow the speech-language pathologist to assign the student a severity rating based on his/her functioning in communicative intent, symbolic communication, oral- motor skills and adverse effect.  Complete the Communication Rating Scale for Students with Moderate to Profound Disabilities and assign a severity rating.

SUGGESTED FUNCTIONAL ASSESSMENT INSTRUMENTS: . COACH (Clinical Observation ______) . Functional Communication Profile . Referral to Assistive Technology Team, as appropriate Boone County Schools Student Services Division Special Education Department Speech/Language Services

Student: ______Date: ______School: ______SLP: ______

Communication Rating Scale for Students With Moderate to Severe Disabilities

Students in these Locution Level Illocution Level Perlocution Level populations have already Intent is expressed in a Intent is expressed in a Expressive output is met the eligibility standardized and mutually regularized, non-standard, observable, but the intent requirements for a primary understood system. but understandable form of or meaning is interpreted disability. Communicative output, (for example: a by the listener, and the Intent point, a reach, an eye gaze.) speaker is not credited with having communicative intent.

(Reference: Kentucky System Change Project 1987)

4 5 8 Use of objects, pictures, Emerging with use of words, Absent signs and/or words are objects and/or pictures Symbolic consistent and appropriate Communication to situation.

Severity Rating Speech production Oral motor skills with Lack of integration of Directions: Circle a number intelligible at word level but adequate phonation to primitive oral-motor in each section of Oral-Motor oral-motor difficulties may support sounds and speech reflexes inhibiting the Communication Skills be present production development of speech Assessment, add to reach a 2 3 4 rating. Total Points=Severity Rating Adverse Effect Level of communication Level of communication Level of communication This relates to the impact of disorder minimally affects disorder moderately affects disorder maximally 14-18 points = 4 the student’s communicative the student’s educational the student’s educational affects the student’s 19-23 points = 5 skills on the educational program. program. educational program. 24-27 points = 6 program and the need for SLP services. 4 6 8 Student’s Rating = ______III. ELIGIBILITY GUIDELINES

Adapted from: “Eligibility Guidelines for Communication Disabilities” (Kentucky Department of Education Division of Exceptional Children’s Services – 1993)

Revised 9/98 IV. PROGRAM COMPLETION CRITERIA Program Completion Criteria

Only the ARC may recommend dismissal of a student from the communication disorders program. It is essential that all ARC members provide input related to the student’s communication functioning, for the most appropriate recommendation to be made. This decision is considered when a student meets one or more of the program completion criteria described below, or there are compelling reasons to consider discontinuation of services, also described below.

It is necessary that ARC members provide documentation in support of the recommendation for dismissal/discontinuation of services. Such documentation may be based on complete evaluation information, for example at the three year evaluation, or may be based on evidence of IEP goals and objectives achieved, observation of appropriate communication effectiveness in functional settings, successful program modifications, and/or related factors such as attendance records, etc.

When it is necessary to discontinue services even though the student may still exhibit a communication disorder, the student and parents should be advised that re-referral for services of the communication disorders program may be made at any time.

General Criteria to Determine Program Completion

. Communication disorder is no longer a disabling condition

. Communication disorder no longer adversely effects the student’s educational performance including academic, and/or vocational functioning (See Teacher/Parent Interviews, Appendix B, and Observation Guidelines, Appendix C, for documentation)

. Given current medical, dental, neurological, physical, emotional, and/or developmental factors, the student’s communication functioning is within his/her expected performance range.

Considerations for Discontinuation of Services

. The student has made minimal or no measurable progress over a period of at least one year of consecutive management strategies. During this time, program modifications and varied approaches have been attempted unsuccessfully, documented and a second opinion has been obtained.

. Student exhibits behaviors (over time) that are not conducive to success in therapy such as lack of cooperation or refusal to attend. Behaviors and interventions have been documented. Attendance records and any pertinent clinical observations must be included with documentation that indicate a variety of motivators were used to improve cooperation.

. An alternative education instructional service or program is deemed more appropriate to meet the student’s communication needs.

For additional resources on Program Completion Criteria for Speech Sound Disorders, see Appendix L. V. AUDIOLOGICAL PROCEDURES for HEARING SCREENING Boone County Schools Student Services Division Special Education Department Speech/Language Services Hearing Screening Procedure

The Speech/Language Pathologists or trained volunteer will screen all students Pre-K – 3rd, 5th and 7th and any other grade/student as referred.

Hearing Screening should be conducted within a quiet environment at 20 dB (25 dB in noisy environments) HL, frequencies of 500, 1k, 2k, 4k.

Any child unable to detect a given tone in either ear, will be rescreened within a 3 – 6 week period. If student continues to detect: a) two tones in one ear, or b) one tone in both ears, they are referred for further examination.

Appropriate Parent Notification Letter and Physician Report form are sent to parent. Boone County Schools Student Services Division Special Education Department Speech/Language Services

HEARING REFERRAL LETTER

Date: ______

Dear Parent;

A hearing screening project has been conducted. This is a screening process used for identifying those students who may be having some hearing difficulties and is not meant to be of a diagnostic nature.

Your child’s score in the hearing screening test given at ______School seems to indicate that an ear, nose, and throat examination would be advisable. We are, therefore, suggesting that you take ______to your doctor or ENT for an examination.

Please give the enclosed form to your doctor or ENT and ask him/her to complete, sign and return to me as soon as possible.

If your child is presently under doctor’s care for hearing/ear problems, please request a report to be sent to the school.

Sincerely,

______Speech/Language Pathologist

______School

Revised 10/04 Boone County Schools Student Services Division Special Education Department Speech/Language Services HEARING REPORT FORM

Name: ______Date: ______School: ______Grade: ______To be Completed by Physician:

Was treatment for the hearing problem necessary for this child? ______YES ______NO

Do you wish to see this child again? ______YES ______NO ______WHEN

Summary of hearing problem and diagnosis if indicated: ______Recommendations for parents or schools (preferential seating, speech and hearing therapy, avoid swimming, etc.): ______Other comments: ______Signed by: ______M.D. ______Address ______Date

Please return this form to: ______

Revised 10/04 HEARING EVALUATION OPTIONS

The following is a list of possible locations to have your child’s hearing evaluated:

Children’s Special Clinic St. Elizabeth Medical Center, (Head and Neck Surgery) Audiology Dept. Office of Dr. Kratz 1 Medical Village Drive 7210 Turfway Road Edgewood, KY 41017 Florence, KY 41042 578-5740 525-1511 St. Luke Hospital, Audiology Dept. Hearing Screening Program 7380 Turfway Rd. (Head and Neck Surgery) Florence, KY 41042 215 Thomas More Park, Suite C 962-5386 Crestview Hills, KY 41017 Dr. Ted Miller 20 Medical Village Drive Edgewood, KY 41017 341-6888

Check the Yellow Pages for other listings.

Additional Information:

 Please be sure to inform the person you talk with that your child failed the school’s hearing screening.

 Have the results sent to your child’s school to be put on record.

. Commission for Children with Special Health Care Needs 982 Eastern Parkway, Louisville KY 40217 Phone (800) 232-1160 (502) 595-4459 FAX (502) 595-4673 Boone County Schools Student Services Division Special Education Department Speech/Language Services HEARING SCREENING School ______Teacher ______Grade_____ Date ______Name 500 1000 2000 4000 6000 Comments R L R L R L R L R L 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.