What email address or phone number would you like to use to sign in to Docs.com?
If you already have an account that you use with Office or other Microsoft services, enter it here.
Or sign in with:
Signing in allows you to download and like content, and it provides the authors analytical data about your interactions with their content.
Embed code for: Case Study (1)
Select a size
Describe using evidence and rationale, the nursing interventions you could give to promote compassionate, competent and patient centre care. Within the discussion include a critical appraisal of the underlying evidence base and rationale for your interventions.
This case study will focus on the delay of speech development in a 3-year-old boy. It was seen that this could leave to behavioural issues. There was also a link to the patient’s inability to chew properly, as it may have left the patient with weaker muscle development in his jaw than considered normal for a child of a similar age. As part of the health visiting team, play therapy and a speech and language referral was made for the patient and his behaviour was observed. Throughout the patient’s journey with the health visiting team, the patient’s family were heavily involved in every step to promote care that is compassionate, competent and patient centred. This involved writing letters of support for education establishments and involving the patient and his family in the Triple P Parenting program.
Alalia is described as a delay or defect in the mechanisms required for speech and language (1). Speech is the process of making sounds, using organs and structures including the lungs, vocal cords, mouth, tongue and teeth. This is different to language delay which is a delay in the development or the use of language. During this case study we will be studying Daniel, a 3-year-old boy with alalia and behavioural issues.
Between 6-19% of toddlers suffer from speech delay. It is often associated with behavioural conditions due to frustration or a lack of understanding. Daniel is interesting to this case study as he seems to have a full understanding of language and seems more unwilling to speak rather than incapable. There is no correlation between social situation and his ability to communicate and is behaviour seems to be a result of his alalia rather than the cause.
Patient centred care (PCC) is defined in the NHS as the care given to patients which takes on a holistic approach, meaning it takes into consideration the patient as a whole person. It includes their physical and mental wellbeing, their social and familial considerations and the patient’s opinions and decisions on their own care to meet a common understanding. It is known that it can be more difficult to provide patient centred care in the community due to the restrictions of the health visiting team and the relationship between the patient and the health professional.
Daniel comes from a two parent family and has an older and younger sister. His family have good support from his grandparents and they have established routines. His mother is a healthcare professional and his family is a PhD student. Both parents are heavily involved in methods to improve Daniels speech and language. Daniels father has recently gone back to higher education and they have moved into a new area with all the children moving schools. Daniels parents have struggled to get him enrolled into nurseries due to a lack of places in nearby establishments.
Daniel and his parents have had many different diagnoses mentioned to them including the possibility of Daniel being on the autistic spectrum. This led to frustration on the mother’s side and a decrease in encouragement on the father’s side.
Typical speech and language development begins at birth with different cries for different needs. The first word is typically spoken around 12-13 months. The first word is described as any sound or set of sounds that is used consistently to refer to a thing, action or quality. From there the child begins to “holophrase” a term coined by professionals for the linking of words and gestures. An example to Daniel doing this is when he pulls on someone’s clothes, points to one of his toys and names it by the kind of vehicle it is – “car”, “train” or “plane” as a way of getting someone to play with him.
This is where Daniel’s speech and language development ends. He conveys all his messages through gesturing and manipulating his restricted vocabulary. He seems to have developed his own kind of language with his mother and although she works hard to discourage this by repeating words back to him, Daniel does not seem capable of conversing back with her. When discussing methods to encourage Daniel’s speech and language, it was important to keep Daniels parents involved as they are his primary care givers. This was also another method to keep the care given to Daniel as person centred as possible.
Children suffering from alalia can also suffer from psychosocial issues whereby their delay is associated with their surroundings and experiences with care. Their alalia can also be associated with self behaviors such as maturity during development and aggression. There is evidence to suggest that prolonged use of dummies can lead to alalia. A study in the Journal of the American Dental Association found that children who use a dummy increase the risk of dentition problems such as protruding front teeth and an improper bite, all of which can affect speech and language. Therefore, the use of dummies is discouraged from 6 months of age. Daniel does still drink out of a bottle and uses a dummy throughout the day. Although this does not fully explain Daniels lack of speech, it may have implications on his speech further on in his development as well as delaying any improvements in his speech and language.
There are many causes for alalia from mechanical impairment of the mouth to oral-motor issues. They tend to be characterised into speech mechanism, cognitive-linguistic aspect and psychosocial issues. Speech mechanism is associated with hearing and the mechanical methods through which speech is formed. Mechanical issues can include a deformed frenulum, lips or perhaps a palate issue. Any of these mechanical issues may inhibit the child’s ability to form words and appropriate sounds by shaping the lips and mouth. Dysarthria is a condition where speech and language is affected by weakness in the muscles that help with speech and eating. Dysarthria often causes sufferers to speak softly or in a whisper, something that Daniel is prone to doing with his restricted vocabulary. A person with dysarthria may also drool more than normal and have problems chewing foods or swallowing. Daniels parents had mentioned to us that he was a fussy eater and didn’t like eating foods he had to chew. Dysarthria can also cause a restrictive movement of the tongue, cheeks and jaw, making speech and language very difficult as well as eating. Daniel, over his evaluations was seen to drool excessively, this could be explained through his use of a dummy but dysarthria is also a possibility.
Cognitive-linguistic or oral-motor dysfunction refers to a lack or a delay in Broca’s area – a region in the brain at the frontal lobe of the dominant hemisphere, which is linked to speech production and language understanding. Deficits in speech and language developing from impairments to Broca’s area is known as Broca’s aphasia or expressive aphasia. The diagnostic requirements for aphasia there must be impairment in one or more of the four communication modalities after either a brain injury or a significant decline over a short period of time. The four modalities are auditory, verbal expression, literacy and functional communication. Whilst there is no obvious signs or incidents that would suggest that Daniel suffers from aphasia it is possible due to his poor communication on many levels.
Other medical conditions that can cause alalia include autism, childhood apraxia, cognitive impairment and hearing loss. Daniels behaviour and his adversity toward prolonged eye contact with people has led to him being investigated toward being on the autistic spectrum. Daniel also only has toys which have a transport theme and when his mother was asked about this she said that transport vehicles were the only thing that allowed Daniel to come out of his shell and communicate. His preference toward hard toys and his lack of imagination during play also led to his parents being concerned about autism.
Daniel was very shy to begin with and was known to disengage wit healthcare professionals. When Daniels mother’s attention was not focused solely on him, his behaviour become destructive and possessive towards her. Climbing on her back and pulling her hair, it became obvious that Daniel did not want a conversation about him to take place. His mother then states that Daniel engaged in lots of negative and harming behaviour, she believed, out of frustration.
The most interactive Daniel was seen to be throughout the assessments done was in the presence of his younger sister. Whilst playing with his younger sister, Daniel was heard repeating his limited vocabulary more. He also was more verbal in terms of laughing and was more emotive. This re-enforced the belief that Daniel would benefit most from being around his peers and that this would help improve his speech and language. However, Daniels behaviour became a lot more destructive around the presence of his younger sibling. He quickly became possessive of his toys and deliberately antagonised his younger sister. From his family’s explanation, this is often the behaviour that Daniel presents when in the company of his peers.
One program put in place by health visiting team to combat Daniels destructive behaviour is the Positive Parenting Programme, otherwise known as Triple P. Triple P is an initiative first brought out in the University of Queensland in Australia which has since been brought into Greater Glasgow and Clyde by participating health visiting teams. Triple P was created to assist parents to “raise healthy, well-adjusted children in a loving, predictable environment”. It teaches parents some of the typical parenting traps that can influence negative behaviour and developmental delay and tries to change behaviours using positive techniques. It can be used for families such as Daniels where the child has behavioural issues, or can be used for everyday parenting issues such as fussy eating, toilet training and temper tantrums.
Triple P was explained to Daniels parents in regards to his behaviour, to try not to pacify him when he is being violent and instead to make him realise the consequences of his behaviour. An incidence of this is when Daniel began hitting his father. His mother, having the better relationship with Daniel of the two, took Daniel to one side, told him he wasn’t able to do that and then quickly began playing with him. It was explained to Daniels mother that by so quickly forgetting his violent behaviour, she wasn’t teaching him the consequences of his actions. She was making him believe that it was a game and therefore he would continue to partake in the behaviour in order to continue getting attention from his parents.
One of the other interventions put in place for Daniel and his family was the referral to speech and language therapy. Initially Daniels hearing will be tested to ensure that this is not the cause for Daniels alalia. However, from observing him, he seems to have good hearing and understanding of languages, and is able to achieve tasks when asked including getting things and putting things away, showing his understanding. The speech and language therapy that Daniel will receive will be tailored to his specific needs, as therapies alter in severity, length and degree depending on the patient’s needs. Speech and language therapists often suggest reading regularly to a child with alalia to teach them a wider vocabulary and understanding of languages. Daniels parents already read to his every evening, forming part of his every day routine. Another suggestion is the use of questions and simple, clear language. An example of this being done in Daniels family is when he holophrases – grunts and points. Daniels family members will then ask if he would like the item – naming it clearly for his understanding. Although he does not verbally respond, this is important to Daniels development as it gives him context.
Should a child’s speech delay be due to mechanical difficulties, it can be difficult for them to learn to speak and eat. Healthcare professionals suggest in these circumstances to begin strengthening the jaw muscles by giving different foods and different textures. This is to promote jaw movements and strength. The prolonged feeding of fully blended foods can lead to children struggling to chew and is also bad for dentition.
It was suggested by the health visiting team that Daniel should attend an educational establishment, like his siblings. Daniels parents attempted to get Daniel into an establishment but unfortunately there were no spaces in the local area. There were also some complications as Daniels parents had moved to a cross boundary section, out with the catchment area for Greater Glasgow and Clyde, and struggled with new paperwork and guidelines regarding nursery placement. The health visiting team suggested writing a letter of support to the different nursery establishments in the area to explain how Daniel being among his peers would greatly develop his speech and language. The letter of support was written by Daniels health visitor with comments included by the community nursery nurse and support staff. This is another example of patient centred care and mutuality. By working together with Daniels family, we were able to obtain a placement for Daniel in a local council nursery 4 mornings a week. This allowed Daniel to be in a routine, however his mother voiced concerns about his ability to communicate his needs when in a large group. She also voiced concerns about him being able go to the bathroom, as Daniel was not yet toilet trained. One of the main reasons for this developmental delay is Daniel is unable to communicate when he needs the bathroom. He is able to go without a nappy when alone in the house with his mother on a one to one basis. However, his parents voiced concerns about him getting the one on one attention required at a large scale nursery. It was suggested to Daniels family that local parent and toddler groups, although the children may be younger than Daniel, would be good for his language development.
Another form of therapy available to Daniel is music therapy. This can promote and facilitate speech and language development. Although it’s been seen to be effective in childhood cases of speech delay, it is important to remember that music therapy is still in its infancy and still needs to be studied and practised in order to prove its full efficiency. Therefore, this was not offered to Daniel as an official form of therapy but Daniel’s mother was told about local play groups that use music. Daniels mother was reluctant to try this as the children that attend are typically much younger than Daniel.
The health visiting team used play therapy in order to assess and try to promote Daniels speech and language. By playing with Daniel and his family, the hope was to improve his confidence and build his therapeutic relationship with the health visiting team, allowing for a true assessment of his abilities. This was difficult as Daniel was very shy to begin with and did not want to interact with healthcare professionals. Over the course of his visits Daniel slowly became more engaging with the health visiting team. His scope of interaction with the health visiting team improved over time and eventually he would engage using one-word sentences. Daniel would begin to make short-term eye contact with people and began to use facial expressions to communicate his mood.
Throughout Daniels assessments and the interventions put in place, all decisions were discussed and agreed with Daniel’s parents. As they are the ones who provide care for Daniel on a daily basis it was important to involve them in his future care. It was seen in home visits that Daniel’s essential needs were being met by his parents. Using the GIRFEC (Getting It Right for Every Child, 2008) assessment tool, the health visiting team were able to assess Daniel’s home and living situation. SHANARRI
From the Universal Wellbeing Tool, it was assessed and determined that although Daniels development was delayed his family had kept Daniel safe through keeping his home clean, the use of safety gates and plug covers, he was physically healthy and a good height and weight for his age. Asides from his alalia and toilet training delay, Daniel was achieving other milestones for his age including his gross and fine motor skills and his ability to play, despite his inability to verbally communicate. Daniels parents are very responsive to his needs and cues, his mother especially. This along with the extra effort Daniel’s family have put in, in order to make his life easier, is enough to determine that Daniel is nurtured in his family home. Although Daniel’s behaviour makes it difficult for him to attend nursery or other play groups with his peers, he has an active life with him mother. They have a wide range of activities they do together and when his younger sibling is at home he often plays with her. As mentioned before Daniels parents both respond well to his cues and consider his wellbeing in their decision making and therefore Daniel is respected in his family home. Daniel’s mother works very hard to keep Daniel
To conclude patient centred, compassionate and competent care can be difficultly delivered in the community. With cases of childhood alalia it becomes even more difficult as it is challenging to engage the patient and their family. Lots of conflicting advice and waiting for diagnoses can lead to frustration on the family’s part which can delay development further. In Daniels case it was evident that Daniel’s speech and language would not improve without the help of a speech and language therapist. Therefore, it was the role of the health visiting team to follow up on referrals and support Daniels parents through establishing routines with him and developing his language as much as possible at home. By using play therapy with Daniel we were able to promote the therapeutic relationship and gain a better understanding of the circumstances surrounding Daniels alalia. Triple P was used to try and improve Daniels behaviour to prevent him from becoming frustrated and biting his peers. Other interventions were put in place for Daniel and his family such as support letters for nursery establishments and introductions into play groups in the local area to try and improve his socialisation skills.
Dodd, Barbara (2013). Differential Diagnosis and Treatment of Children with Speech Disorder. John Wiley & Sons.
Law J, Garrett Z, Nye C; Speech and language therapy interventions for children with primary speech and language delay or disorder. Cochrane Database Syst Rev. 2003;(3):CD004110.
McLaughlin MR; Speech and language delay in children. Am Fam Physician. 2011 May 15;83(10):1183-8.
University of Michigan. “Speech and Language Delay and Disorder”
Keep Kids Healthy “Speech Delay”
Grob, Wibke; Ulrike Linden; Thomas Ostermann, 2010 “Effects of music therapy in the treatment of children with delayed speech development – results of a pilot study”
http://www.gov.scot/Topics/People/Young-People/gettingitright/national-practice-modelhttp://www.gov.scot/Topics/People/Young-People/gettingitright/national-practice-modeln place, all decisions were discussed and agreed with Daniel’s parents. As they are the ones who provide care for Daniel on a daily basis it was important to involve them in his future care. It was seen in home visits that Daniel’s essential needs were being met by his parents. Using the GIRFEC (Getting It Right for Every Child, 2008) assessment tool, the health visiting team were able to assess Daniel’s home and living situation. SHANARRI
From the Universal Wellbeing Tool, it was assessed and determined that although Daniels developme