Prior to seeing a new student/client, we read through their records to develop a picture and to make a group of questions that we may have about this student or client. We may further refine this picture by talking to the family or previous teachers or clinicians. However, it is always important to make our own observations and to gather baseline data to develop our treatment plan. These are typically done the first couple of times we meet with the student/client.
We use what we gathered then to narrow down our focus for our treatment.
Here is the data——–that tells us that this is this type of problem——— which means we will work on this skill———–.
Sometimes it is helpful to see examples of how this might be done. The below are examples from other clinicians to assist you. The names have been changed to protect the student’s privacy.
- James’s speech intelligibility was calculated to be 78/110 (71%), based on the analysis of an individual 110-word speech sample, in which an unfamiliar listener transcribed James’s speech as played on a voice recorder. James miss-produced several phonemes (e.g., the /l/ in “platform”), which compromised the listener’s understanding. He also struggled to articulate multisyllabic words (e.g., popsicle, vegetables, and listening), often rushing or omitting the medial syllable (i.e., telescoping of syllables). James is a good candidate for speech and language services to target articulation, as well as pacing and self-monitoring, to improve his overall intelligibility.
- Functional communication: Written functional communication: Maggie was informally assessed for her written functional communication skills using the job application worksheet that was previously used. Maggie wrote accurate responses for all eight items, but misspelled her hobby and needed a model to spell the name of her high school and the town she lived in. Further work on writing personal information was deemed necessary.Maggie was also asked to write the date on the job application. She did not know the date and was unsure what month it was. When given a calendar to assist her in locating and writing the date, Maggie was unsure how to use it. Therefore, a goal was set to increase Maggie’s knowledge about using a calendar. Oral functional communication In addition to writing personal identifying information on the job application, Maggie was also asked to write an emergency contact name and number. Maggie wrote her own name for the emergency name and “911” for the emergency contact number. Maggie was unsure of her mother’s first name. Maggie’s responses reflect that emergency contacts are a new concept for her. In order to increase Maggie’s safety and independence, a goal was set to help Maggie identify the appropriate action to be taken in life-threatening and non-life threatening situations.
- Executive Functioning Patrick was informally assessed to determine his executive functioning skills. A parent questionnaire from Executive Function Junction: Start2Finish Thinking (Bogen & Lindemuth) was given to Patrick’s parents to determine their perspective on Patrick’s relative strengths and weaknesses in self-regulation skills. Patrick was informally probed for various executive functioning skills during the completion of a hands-on project in which he was given a list of materials and instructions. He was rated on a 1-5 level of impairment scale, with 1 being no impairment and 5 being severe impairment. Relative strengths included an organized workspace and using self-talk to modulate work. Areas of weakness included identifying key information in materials and steps, identifying errors in work, and inhibiting external factors to maintain focus. Improving executive functioning skills was determined to be a necessary goal given the importance of executive functioning skills for organizing, carrying out, and monitoring the progress of tasks in an academic setting. Furthermore, progress made in executive functioning skills has the potential to carry-over into Patrick’s writing skills.
I hope that this is helpful to demonstrate how you take your data to assist you in developing a focus for treatment.