Case 3:
Alejandro

BACKGROUND:

  • Alejandro is a 24-month-old boy who comes to see you for a well-child check.  He was born at full-term after an uncomplicated pregnancy and has been entirely healthy since birth.  His parents mention that he speaks only “a handful” of words.  They remember their older daughter speaking much more when she was two.
  • Alejandro’s parents wonder whether they should be concerned about his speech. Relatives have told them that boys often speak later than girls and that “he probably doesn’t get a chance to talk because his older sister always speaks for him.” Dad also notes that the family speaks both English and Spanish.  He has heard that children who grow up in bilingual households are often late to speak.

QUESTION 1: What would you tell Alejandro’s parents about the impact of gender, presence of siblings, and exposure to a bilingual environment on speech and language development?

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ANSWER:

  • Boys progress more slowly than girls at the initial stages of language development but usually lag by only 1-2 months. 
  • Boys are more likely to have language disorders than girls.
  • The presence of older siblings and exposure to more than one language are not a reason for speech and language delay.

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BACKGROUND:

  • On further history, you learn that Alejandro speaks about 10 single words, mostly in Spanish.  He does not use any two-word phrases.  He frequently uses pointing to communicate.  His parents think he hears well and note that he responds to two-step commands. 
  • Your history, exam, and developmental screening confirm that Alejandro is attaining developmental milestones appropriately in other domains.  He is socially engaging during your interaction.  He demonstrates age-appropriate symbolic play as he moves toy cars around the floor of the exam room.  His physical and neurological exam are entirely normal.

 

QUESTION 2: What would be your next step(s)?

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ANSWER:

  • You decide to refer Alejandro for a hearing evaluation and a speech and language assessment. 

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QUESTION 3: Which agencies or community resources would you use?

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ANSWER:

  • Audiology at LPCH or the family's local medical center.
  • Early Start program through the Regional Center for the family’s county.
  • LPCH Speech and Language Pathology Services or other private speech and language center.

 

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QUESTION 4: How would your plan change if Alejandro were 36 months old?

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ANSWER: 

  • Refer to the local school district instead of the Regional Center.

 

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BACKGROUND:

  • Alejandro’s family contacts the Early Start program for an evaluation.  His expressive language is judged to be at a 18-month level (25% delayed), making him eligible for services.  The Regional Center works with the family to develop an Individualized Family Service Plan (IFSP).  Part of Alejandro’s plan will be to work with a speech- language pathologist twice a week. 
  • The family is told that there is no Spanish-speaking speech-language pathologist available. Alejandro is on a waitlist for services. 

 

QUESTION 5: What would be your next step?

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ANSWER:

  • Contact the Legal Aid Society of San Mateo County- Family Advocacy Program (FAP) for assistance.
  • According to California law, once a child is determined to be eligible, services must begin as soon as possible.  Putting a child on a waiting list for services is explicitly prohibited. 

 

END OF CASE:

  • Alejandro begins working with a speech- language pathologist twice a week.  When he returns for a check-up at 30 months of age, his parents note that he uses more than 200 words.  He uses two-word phrases to express what he wants and to label and comment on what he sees.

 

 

 

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