| 59055 | | Plan Date: 03-23-2026 | | Speech Assessment Summary: Based on clinical observation, caregiver interview, and standardized assessment, this 6-year, 4-month-old male presents with a severe speech sound disorder, a severe mixed receptive-expressive language disorder, and a pragmatic language disorder. During the evaluation, the patient exhibited significant distractibility, impulsivity, and a high activity level that required numerous prompts to maintain cooperation. These behavioral factors precluded the valid administration of a comprehensive standardized language assessment; therefore, language abilities were assessed via dynamic observation and caregiver report. Functionally, the patient demonstrates profound difficulty with communication across all domains. Receptive language is significantly impaired, as evidenced by his inability to consistently follow commands and answer questions. Expressive language is characterized by a limited vocabulary and the use of jargon, rendering him largely unintelligible to unfamiliar listeners. Socially, his communication deficits prevent him from participating in reciprocal conversations, engaging in appropriate turn-taking, or utilizing conversational repair strategies. These impairments directly impact his academic readiness and social participation, limiting his ability to access the school curriculum and form meaningful peer relationships. Objective assessment of articulation using the Clinical Assessment of Articulation and Phonology, Second Edition (CAAP-2) confirmed a severe speech sound disorder, with standard scores of Skilled Speech-Language Pathology services are medically necessary to address these severe and pervasive communication deficits. The patient’s inability to be understood, follow directions, and express himself effectively places him at significant risk for academic failure, social isolation, and behavioral challenges stemming from frustration. Given the severity of his multi-faceted delays, which fall more than -3.0 standard deviations below the mean, and the profound functional impact on his daily life, a treatment frequency of two sessions per week is recommended. This intensity is required to provide sufficient therapeutic intervention to remediate the severe speech sound disorder while simultaneously building foundational receptive, expressive, and pragmatic language skills. Postponement of intensive treatment would lead to a widening of the developmental gap between the patient and his peers, further compromising his educational progress and overall functional independence.
| | Speech Progress to Date: Baseline is currently at 0. | | Speech Rehabilitation Potential: Excellent. with consistent Speech Therapy and parental support. Mateo will be discharged when she receives a standard score above 1.5 standard deviations from the mean for all impairments, indicating that his speech and language skills will be in the mild to average range. | | 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. | | Receptive Language | In 6 months, Mateo will demonstrate improved receptive language skills by understanding age-appropriate vocabulary, basic concepts, and directions (e.g., WH-questions, spatial/quantitative concepts, and multi-step directions) with 60% accuracy given minimal cues, in order to increase comprehension for functional communication across home, school, and community settings. | | Expressive Language | In 6 months, Mateo will demonstrate improved expressive language skills by using age-appropriate vocabulary, grammar, and sentence structures (e.g., 3-4+ word utterances, answering WH-questions, and expressing wants/needs) with 60% accuracy given minimal cues, in order to effectively communicate across home, school, and community environments. | | Oral Motor/Articulation | In 6 months, Mateo will produce age-appropriate speech sounds in words and phrases with 60% accuracy given fading verbal, visual, and tactile cues, in order to improve overall speech intelligibility and functional communication. |
| | Speech and Language Short Term Goals: | | Category | Goal Description | | Receptive Language | Within 6 months, Mateo will follow simple one-step directions (e.g., “give me,” “sit down,” “come here”, "stop", "pick up") during structured and play-based activities with 50% accuracy given fading verbal and visual prompts/cues, in order to improve receptive language skills for functional participation. | | Expressive Language | Within 6 months, Mateo will answer simple WH-questions (e.g., who, what, where) during structured and play-based activities using speech with 50% accuracy given fading verbal and visual prompts/cues, in order to improve expressive language skills for functional communication. | | Oral Motor/Articulation | Within 6 months, Mateo will produce multisyllabic words (2 to 3 syllables) with appropriate syllable sequencing and reduced omissions during structured and play-based tasks with 40% accuracy given fading verbal, visual, and tactile cues, in order to improve intelligibility in connected speech. | | Oral Motor/Articulation | Within 6 months, Mateo will accurately produce age-appropriate consonant clusters (e.g., l-blend, s-blends, r-blends) at the word level during structured and play-based tasks with 40% accuracy given fading prompts/cues, in order to increase overall speech intelligibility. | | Oral Motor/Articulation | Within 6 months, Mateo will produce fricative and affricate sounds (e.g., /f, v, s, z, sh, ch, j/) in words during structured and play-based activities with 40% accuracy given fading verbal, visual, and tactile cues, in order to improve speech intelligibility. | | Oral Motor/Articulation | Within 6 months, Mateo will produce target speech sounds in the final position of words (e.g., /p, t, d, k, g, -ing/) during structured and play-based activities with 40% accuracy given fading verbal, visual, and tactile cues, in order to improve overall speech intelligibility. |
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