| ID | Date | Type | Evaluation Diagnosis |
26444 | 03-17-2026 | Speech Initial Evaluation | F80.81 | | Speech Background History: Leonidas is a 3-year-old male (DOB: 02/22/2022) who was referred for a speech-language evaluation due to concerns regarding stuttering and fluency development. Per parent report, Leonidas was born full term following a prolonged labor and experienced oxygen desaturation at birth, requiring a neonatal intensive care unit (NICU) stay of approximately one week until oxygen levels stabilized. Parent reported that Leonidas has met all developmental milestones within expected timeframes.
Medical history is notable for frequent illnesses, including recurrent colds, flu, and hand-foot-and-mouth disease. Parent reported that Leonidas has recently experienced disrupted sleep patterns due to ongoing illness. Additionally, Leonidas is described as a mouth breather, which parent attributes to chronic congestion. He is currently taking Claritin to assist with mucus management.
Leonidas is currently enrolled in a 3-year-old program and is in the process of being evaluated for additional services. Parent reported primary concerns related to the onset and progression of stuttering, which has increased in frequency and severity over time. Parent expressed concern that the stuttering is now accompanied by secondary behaviors, including eye blinking, physical tension such as tapping, and pulling on clothing during moments of disfluency.
These concerns indicate a need for further evaluation of fluency skills and their impact on Leonidas’s functional communication and participation across environments |
| Speech Medical History: |
| Speech Medications: Claritin |
| Speech Behavioral Observations: Attending Skills: Alert, Response Rate: Impulsive, Level of Activity: WNL, Cooperation: WNL, Communicative Intent: With some prompts, Awareness of Others: Present, Reliability of Scores: Adequate, Awarencess of Environmental Events: Good, Social Interactions: Usually, Prognosis for Improved Communicative Functioning: Friendly, |
| Speech Communication Strengths: Interactive, Maintains topic, Responds to greetings, |
| Speech Communication Weaknesses: Poor vocabulary, Repetitiveness, Unintelligible, |
| Speech Background Summary: |
| Speech Diagnosis/Impressions: report, Leonidas presents with a moderate fluency disorder (stuttering) and mild to moderate articulation deficits, while receptive and expressive language skills are within functional limits for his age.
Leonidas demonstrated frequent stuttering-like disfluencies, including part-word and whole-word repetitions, accompanied by secondary behaviors such as eye blinking, looking away, and physical tension. These behaviors, along with reported increases in disfluency frequency and associated frustration, indicate a clinically significant fluency disorder that extends beyond typical developmental disfluency.
In addition, Leonidas presents with articulation deficits characterized by sound substitutions, distortions, and difficulty producing multisyllabic words, which contribute to reduced overall speech intelligibility. While familiar listeners are able to understand the majority of his speech with context, intelligibility is reduced for unfamiliar listeners and during more complex utterances.
The combined presence of fluency and articulation difficulties significantly impacts Leonidas’s ability to communicate clearly and efficiently, placing him at increased risk for communication breakdowns, frustration, and reduced participation in social interactions. Given the presence of secondary behaviors, reduced intelligibility, and increasing communication demands, skilled speech-language intervention is warranted to support the development of effective and functional communication skills. |
| Speech Diagnosis/Impressions: report, Leonidas presents with a moderate fluency disorder (stuttering) and mild to moderate articulation deficits, while receptive and expressive language skills are within functional limits for his age.
Leonidas demonstrated frequent stuttering-like disfluencies, including part-word and whole-word repetitions, accompanied by secondary behaviors such as eye blinking, looking away, and physical tension. These behaviors, along with reported increases in disfluency frequency and associated frustration, indicate a clinically significant fluency disorder that extends beyond typical developmental disfluency.
In addition, Leonidas presents with articulation deficits characterized by sound substitutions, distortions, and difficulty producing multisyllabic words, which contribute to reduced overall speech intelligibility. While familiar listeners are able to understand the majority of his speech with context, intelligibility is reduced for unfamiliar listeners and during more complex utterances.
The combined presence of fluency and articulation difficulties significantly impacts Leonidas’s ability to communicate clearly and efficiently, placing him at increased risk for communication breakdowns, frustration, and reduced participation in social interactions. Given the presence of secondary behaviors, reduced intelligibility, and increasing communication demands, skilled speech-language intervention is warranted to support the development of effective and functional communication skills. |
| Speech Recommendations: Speech Therapy: 2 time(s) a Week for 30 to 45 minute sessions |
| ID | Plan of Care |
| 59029 | | Plan Date: 03-17-2026 | | Speech Assessment Summary: report, Leonidas presents with a moderate fluency disorder (stuttering) and mild to moderate articulation deficits, while receptive and expressive language skills are within functional limits for his age.
Leonidas demonstrated frequent stuttering-like disfluencies, including part-word and whole-word repetitions, accompanied by secondary behaviors such as eye blinking, looking away, and physical tension. These behaviors, along with reported increases in disfluency frequency and associated frustration, indicate a clinically significant fluency disorder that extends beyond typical developmental disfluency.
In addition, Leonidas presents with articulation deficits characterized by sound substitutions, distortions, and difficulty producing multisyllabic words, which contribute to reduced overall speech intelligibility. While familiar listeners are able to understand the majority of his speech with context, intelligibility is reduced for unfamiliar listeners and during more complex utterances.
The combined presence of fluency and articulation difficulties significantly impacts Leonidas’s ability to communicate clearly and efficiently, placing him at increased risk for communication breakdowns, frustration, and reduced participation in social interactions. Given the presence of secondary behaviors, reduced intelligibility, and increasing communication demands, skilled speech-language intervention is warranted to support the development of effective and functional communication skills. | | Speech Rehabilitation Potential: Good. with consistent Speech Therapy and parental support. Prognosis for improvement is good given Leonidas’s age, family support, and emerging communication skills. Early intervention targeting both fluency and articulation is expected to support improved speech clarity, reduced physical tension during communication, and increased confidence during speaking tasks. Progress will depend on consistency of therapy attendance, caregiver involvement, and carryover of strategies across environments. | | Speech and Language Long Term Goals: | | Category | Goal Description | | Home Management Intervention Program | When counseled by the clinician, parents will incorporate the home management intervention program as a daily and weekly activity to transfer skills learned in therapy into the home environment. Home management training will optimize patients functional communication tasks in the home. | | Fluency | Within 12 months, Leonidas will improve speech fluency to communicate with reduced stuttering and decreased physical tension during speaking tasks across environments. | | Oral Motor/Articulation | Within 12 months, Leonidas will improve speech sound production to increase overall intelligibility during words, sentences, and conversational speech. |
| | Speech and Language Short Term Goals: | | Category | Goal Description | | Fluency | Within 6 months, Leonidas will use a slower, more controlled rate of speech (e.g., “slow talking”) during play-based speaking tasks in 4 out of 5 opportunities with moderate cues. | | Fluency | Within 6 months, Leonidas will use “easy” or “smooth” speech during words or short phrases in 4 out of 5 opportunities with moderate cues. | | Fluency | Within 6 months Leonidas will demonstrate knowledge of stuttering [e.g. speech mechanism, definition of stuttering, types of stuttering, feelings associated, etc.] as evidenced by [verbal teach-back, completed portfolio activities, etc.] with 60% accuracy across 4 consecutive sessions | | Oral Motor/Articulation | Within 6 months, Leonidas will produce multisyllabic words accurately with 60% accuracy across three consecutive sessions with minimal to moderate cues. | | Fluency | Within 6 months, Leonidas will use a relaxed body and voice (e.g., reduced blinking, less pulling on clothing, decreased tension) during speaking tasks in 4 out of 5 opportunities with minimal to moderate cues. |
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