A Collaborative Model of Team Assessment & Planning for Toddlers School Children with ASD

Transcription

1 A Collaborative Model of Team Assessment & Planning for Toddlers School Children with ASD Roula Choueiri, MD Neurodevelopmental Pediatrician Kathleen Reilly, SLP Speech Language Pathologist Center for Children with Special Needs 1 SC17 / ASHA / 2013

2 Learning Outcomes (1) Integrate 3 neurodevelopmental findings to the diagnostic process of understanding ASD in children (2) Select 2 appropriate test measures to evaluate language impairment in children with ASD. (3) Plan 3 pragmatic interventions to address social difficulties of children with ASD 2 SC17 / ASHA / 2013

3 Plan of Talk A. Introduction Center for Children with Special Needs (CCSN) Neurodevelopment of Autism Spectrum Disorders (ASD) Pragmatic Language Impairment (PLI) B. Team Assessment Model, with Autism Diagnostic Observation Schedule (ADOS) Case I (Low verbal Toddler) Case II (Verbal Preschooler) Case III (High functioning School Age) C. Treatment Planning Medical Testing Programmatic (IEP) 3 SC17 / ASHA / 2013

4 Pop Quiz True or False 1. A diagnosis of ASD means speech onset was delayed. 2. The critical symptoms for a diagnosis of ASD must be present within the first two years of life. 3. The mechanisms underlying the etiology of ASD appear to be environmental. 4. Asperger Syndrome is a type of ASD under DSM A diagnosis of ASD means a pragmatic language impairment (PLI) is present. 4 SC17 / ASHA / 2013

5 Introduction

6 Nothing to disclose; lots to reveal (Karen Miller, M.D.) 6 SC17 / ASHA / 2013

7 Who we are An interdisciplinary team, consisting of: Neurodevelopmental, and Developmental Behavioral Pediatrics Neuropsychology, Education Speech Language Pathology Social Work Trainees Autism Resource Specialist Research 7 SC17 / ASHA / 2013

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9 Neurodevelopment Overview of Autism Spectrum Disorders (ASD) DSM-IV and DSM-5

10 ASD What is it? Autism Spectrum Disorders are a Neurodevelopmental disorder affecting the functioning of the brain, and language development, social interactions and certain repetitive behaviors ASD is thought to start prenatally but can be clinically observed - in some cases - starting 6 months of age. 10 SC17 / ASHA / 2013

11 Epidemiology Leo Kanner, 1943 Prevalence 1 in 88 [CDC 2010] Found in all cultures Symptoms visible as early as 6-12 months Average age of initial diagnosis 4 years. Variation linked to SES and culture Thought to have genetic basis 11 SC17 / ASHA / 2013

12 ASD How Systems Interrelate Language / Communication Restricted Repetitive Behaviors Interpersonal Relations 12 SC17 / ASHA / 2013

13 DSM-IV-TR (2000) PDD (Pervasive Developmental Disorders) Autism PDD-NOS Asperger Syndrome Rett Syndrome Childhood Disintegrative Disorder Autism Spectrum Disorders (ASD) 13 SC17 / ASHA / 2013

14 DSM-IV Diagnostic Criteria of ASD - DSM-IV Multiple ASD categories, e.g., Asperger s, PDD-NOS Three core symptom domains: i. Qualitative abnormalities in Reciprocal Social Interaction ii. iii. Qualitative abnormalities in Communication Restricted, Repetitive and Stereotyped Patterns of Behavior (RRB) Plus, onset before 36 months of age 14 SC17 / ASHA / 2013

15 Diagnostic Criteria of ASD DSM-5 (May 2013) DSM-IV Multiple ASD categories, e.g., Asperger s, PDD-NOS Three core symptom domains: i. Qualitative abnormalities in Reciprocal Social Interaction ii. iii. Qualitative abnormalities in Communication Restricted, Repetitive and Stereotyped Patterns of Behavior (RRB) Plus, onset before 36 months of age DSM-5 Single category with levels of severity, i.e., ASD Two core symptom domains: i. Qualitative abnormalities in Social Communication, marked by deficits in social-emotional reciprocity, deficits in nonverbal communicative behaviors, & deficits in developing relationships. ii. RRBs, inclusive of repetitive speech, hyper/hypo-reactivity to sensory input Plus, symptoms limit & impair everyday functioning 15 SC17 / ASHA / 2013

16 DSM-5 ASD Criteria (I, II) I. Social Communication (must meet all) Deficits in socio-emotional reciprocity Deficits in nonverbal communication behaviors used for social interaction Deficits in developing and maintaining relationships appropriate to developmental level 16 SC17 / ASHA / 2013

17 DSM-5 Criteria (I, II) II. Restricted Repetitive Behaviors (RRB) (minimum 2 of 4) Stereotyped or repetitive speech, motor movements or use of objects Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior or excessive resistance to change Highly restricted, fixated interests that are abnormal in intensity or focus Hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment 17 SC17 / ASHA / 2013

18 Medical Associations Always consider if a medical issue is present when behaviors change suddenly or intensify Seizures Complex partial Language Regression : Landau-Kleffner Syndrome Variant Gastrointestinal Reflux, Constipation Allergies Sleep Sensory Feeding Hearing SC17 / ASHA / 2013

19 Specifiers and Moderators Examples: ASD associated with known medical or genetic condition (e.g., Fragile X, VCFS, TS) Verbal Abilities Cognitive Abilities ADHD Severity 19 SC17 / ASHA / 2013

20 DSM-5 Severity Levels Severity Level Social Communication RRBs I (mild) Inclusion support with peers; child shows age level speech Cues & reminders for transitions to manage reluctance, organization and planning II (moderate) Inclusion support/partial separate class depending on variability in behaviors; inability to engage with peers; immature and diminished talk, and talk topics limited to interests Step plans for transitions to manage inflexibility; distress around change, visible to casual observer III (severe) Restricted/Repet itive Interests and Behaviors 20 SC17 / ASHA / 2013 Separate class due to limited & minimal initiations, responses, little intelligible speech & shows responses limited to self needs Need to reduce demands due to limited coping, level of RRBs interfere with function, & frequent distress reactions with change

21 DSM-5 NEW DIAGNOSTIC CATEGORIES Social Communication Disorder (SCD) More about this A pragmatic language disorder Late Language Emergence (LLE) Fewer than 50 words at 2 years, and few word combinations at 2 ½ years, with delays in language comprehension, play & vocalizations 21 SC17 / ASHA / 2013

22 What is the Pediatrician s role (AAP)? Autism screen at 18 and 24 mo! Ongoing developmental surveillance & case management General observation and milestones Referral to Early Intervention, SLP or School Team for evaluation and services 22 SC17 / ASHA / 2013

23 Autism Screening M-CHAT is free, and translated in multiple languages 23 SC17 / ASHA / 2013

24 Autism Screening (stay tuned) Rapid Interactive Test for Autism in Toddlers RITA-T) Promising preliminary results: Correlates with M-CHAT Correlates with ADOS Differentiates Language Impairment / ASD Reliable, easy, 5-10 minutes 24 SC17 / ASHA / 2013

25 Social Missteps Diagnostic Quick Tricks Teasing Toy Play (Behne et al, 2005) Blocking Toy Play (Phillips et al, 1992) What does a child do during a play interaction in response to ambiguous signals from you? 25 SC17 / ASHA / 2013

26 Is Optimal Outcome possible in Autism? Loosing the diagnosis, its interpretation and frequency: controversial Optimal Outcomes in individuals with a history of Autism: 34 individuals with previous ASD no longer met criteria on social communication measures and clinically. Diagnosis made before age 5y and history of language delays Type of interventions? Being analyzed Fein et al: Optimal outcome in individuals with a history of autism. Journal of Child Psychology and Psychiatry 54:2 (2013), pp SC17 / ASHA / 2013

27 ASD Pragmatic Language Impairment (PLI)

28 DSM-5 NEW DIAGNOSTIC CATEGORIES Social Communication Disorder (SCD) Impairment of pragmatics Diagnosis based on difficulty in the social uses of verbal and nonverbal communication in naturalistic contexts Impairment in functional development of social relationships and discourse Disorder not otherwise explained by low abilities in language (vocabulary, grammar) nor by general cognitive ability SCD is NOT ASD SCD is communication impairment 29 SC17 / ASHA / 2013

29 What is each type of PLI? Neurodevelopmental disorder affecting language development, social interactions and repetitive behaviors. Thought to start prenatally but can be clinically observed starting 6 months of age. ASD Persistent difficulties in the acquisition and use of language across modalities (spoken, written, sign) due to deficits in comprehension/production. LI Persistent difficulties in the social use of verbal & nonverbal communication, i.e., conversation, storytelling, presuppositionality, ambiguity, nonliterality SCD

30 The spectrum of ASD to the practice of SLP Question: How do we tease apart ASD from non-spectrum language impairment? Diagnosis of ASD is tricky: No clinical average across parameters (e.g., IQ, social, communication) No uniform set of behaviors marked in each child Answer: A diagnosis of ASD involves both the absence of typical behaviors & the presence of non-typical behaviors, e.g., echoing versus echolalia 31 SC17 / ASHA / 2013

31 Video 21 month old: - when does Ben look? 32 SC17 / ASHA / 2013

32 Example Ben, at 21 months When does he look? 33 SC17 / ASHA / 2013

33 Social Interaction & Social Communication Autism Diagnostic Observation Scale (ADOS-2) Lord et al, 2012 Modules 1 4 Toddler Module A social world 34 SC17 / ASHA / 2013

34 ADOS the fit with SLP Choice of module determined by child s expressive language level Speech quality gets rated in normalcy (prosody, fluency, rate, articulation, volume) Play interactions are child centered yet unstructured Results capture behavioral data useful for goal setting, i.e., joint attention Examiner talking scripts utilize a least-to-most hierarchy 35 SC17 / ASHA / 2013

35 Play Assessment Symbolic Play Test (SPT-2) Lowe & Costello, months Talking not required A measure of functional play 36 SC17 / ASHA / 2013

36 Least to most hierarchy Rylee, 8;4 Birthday Party 37 SC17 / ASHA / 2013

37 PLI Components of Assessment Play Spontaneous Oral Language/Narrative echoic vs echolalic Gesture Standardized pragmatic tools 38 SC17 / ASHA / 2013

38 Functional vs. Imaginative Play Functional Play: Use of toys in the manner they are intended to be used: e.g., playing ball toss, stacking blocks, reading a book, talking on a toy phone. Imaginative play: Use of toys in a pretend manner with a focus on dolls/action figures as independent agents of action, e.g., doll reading book. Or the child directing pretend action to a doll, e.g., shampooing the doll s hair. The use of one object to represent another, i.e., yarn as spaghetti, is also imaginative. 39 SC17 / ASHA / 2013

39 Echoing versus Echolalia Echoing done by Typically developing children between months Echolalia is the continued parroting or scripting beyond expected ages (Heffner, 2000); 75-85% of ASD; in varied forms Echolalia is associated with interactive purpose (Prizant, 1983) Echolalia decreases with spontaneous language increase (Charlop, 1983) 41 SC17 / ASHA / 2013

40 Gestures - Assessment Definition Actions of the hands or body used to communicate a message to another person Which is this? Types Descriptive, e.g., flying, Others 42 SC17 / ASHA / 2013

41 Gestures to communicate You monkey you; you give me back my cap A shake of the finger A stomp of the foot Emphatic, emotional Instrumental, conventional 43 SC17 / ASHA / 2013 Caps For Sale (Slobodkina, 1940)

42 Screeners for Pragmatics 44 Wetherby & Prizant, 2001; 6 24 months SC17 / ASHA / 2013 Bishop, 2003; 4;0 16;11 years

43 Break

44 Team Assessment Model

45 Philosophy A Village 1. Child behavior and development are inseparable 2. More than one clinician is required to evaluate all of a child s needs 3. Treatment is informed by interdisciplinary perspectives Justification: No biological test for ASD Variability in behaviors across different children with ASD Variability in behaviors within the same child across contexts Symptom overlap between ASD and other developmental disorders, e.g., language impairment, learning disorder 47 SC17 / ASHA / 2013

46 Components of Team Assessment 1. Interview Parent : Detailed developmental, medical, social history 2. Gather input, i.e., pediatrician, school, agency, & clinic 3. Observe spontaneous behaviors, play, interaction with parents 4. Complete neurodevelopmental assessment Language Social - Emotional Motor Play Physical and neurological exam 5. Conference with team 6. Provide results and recommendations to family 48 SC17 / ASHA / 2013

47 Developmental Assessment Tools CAT/CLAMS; 0 36 months MSEL; 0 5;8 years 49 SC17 / ASHA / 2013

48 Case #1: Developmental Assessment Mullen Scales of Early Learning (MSEL), Mullen ;8 years Visual Reception Receptive Language Expressive Language Fine Motor (Gross Motor) 50 SC17 / ASHA / 2013

49 Clinical Case #1: Low verbal child: Jep Jep is 30 months old, a boy Team of 5 Referral from Pediatrician: Language delay Failed the M-CHAT Does he have ASD? 51 SC17 / ASHA / 2013

50 Clinical Case #1: Low verbal child: Jep Developmental History Developmental delays in speech and self-care skills No history of regression Medical History Jep is an ex- premature born at 36 weeks Family History Lives with parents & twin sister also referred for evaluation Family home is bilingual (Creole, English) Current Services EI since age 18 months: ST,OT, Playgroup 52 SC17 / ASHA / 2013

51 Clinical Case #1: Low verbal child: Jep Ball toss play 53 SC17 / ASHA / 2013

52 Clinical Case #1: Low verbal child: Jep Jep, at 33 months (MSEL): Visual Reception, Language 54 SC17 / ASHA / 2013

53 Clinical Case #1: Low verbal child: Jep Results: ADOS Module Toddler Range of Concern Moderate to Severe Mullen Scales (MSEL) Visual Reception Receptive Language Expressive Language T Score Percentile Age Score in months SC17 / ASHA / 2013

54 Break

55 Clinical Case #2: Verbal Preschooler: Gabe Gabe is 4 years 2 months old, a boy Team of 2, tandem appointments Referral from Pediatrician Early Speech Delay Reduced self regulation skills: Impulsive, tantrums, sensory issues, immature 57 SC17 / ASHA / 2013

56 Clinical Case #2: Verbal Preschooler: Gabe Developmental History Speech delay, difficulty with transitions, hypersensitivity to sounds, parallel play, talkative; runs into people No regression Medical History Born full term; no medical issues except infant colic Family History Lives with biological parents, sibling, monolingual Services Current: private OT and ST 58 SC17 / ASHA / 2013

57 Clinical Case #2: Verbal Preschooler: Gabe Observation Inconsistent eye contact Talkative but decreased conversations Decreased facial expressions Decreased gestures Assessment Plan ADOS-2, Module 2. Kaufman Brief IntelligenceTest-2 (KBIT-2, a cognitive screener) S/L testing battery 59 SC17 / ASHA / 2013

58 Clinical Case #2: Verbal Preschooler: Gabe ADOS-2: Module Results Range of Concern for ASD 2 Moderate-to-Severe KBIT-2: Component Standard Score Percentile Category Verbal 93 32% Average Nonverbal 98 45% Average IQ Composite 95 37% Average 60 SC17 / ASHA / 2013

59 Clinical Case #2: Verbal Preschooler: Gabe Findings and Diagnoses ASD (then PDD-NOS) Mixed receptive/expressive language disorder Sensory Processing Delays 61 SC17 / ASHA / 2013

60 Clinical Case #2: Verbal Preschooler: Gabe / S-L Speech Language In Play How does G use language? How does reduced eye contact impact on communication? 62 SC17 / ASHA / 2013

61 Clinical Case #2: Verbal Preschooler: Gabe / S-L Speech Language Assessment Plan Visit 1 (2011) Visit 2 (2012) Visit 3 (2013) 4;2 years 5;4 years 6;2 years GFTA-2 Soap Story TACL-3 EOWPVT-4 GFTA-2 Soap Story CCC-2 TACL-3 BSRA GFTA-2 Soap Story CCC-2 SPELT-2 63 SC17 / ASHA / 2013

62 Clinical Case #2: Verbal Preschooler: Gabe / S-L Changes in Narratives (GFTA-2 Soap Story) 2013: He s pwayin wif his drums (p) he pways wif his ball, he pways wif his wagon, he plays wif his ball, he makes too much noise. 2012: Pwayin drums, the ball, and using the wagon 64 SC17 / ASHA / 2013

63 Clinical Case #2: Verbal Preschooler: Gabe / S-L Changes in Pragmatics GCC Percentile SIDI Type 76 (66) 5 (5) - 13 (-4) ASD ( * ) Component 2012 / (2011) speech 9 (8) syntax 10(3) semantics 7 (8) coherence 4 (3) imitation 3 (3) scripted language 6 (50) context 4 (3) nonverbal communication 6 (4) social relations 2 (4) interest 9 (5) 65 SC17 / ASHA / 2013

64 Clinical Case #3: School-age: Damian Damian is 10 years 1 month, a 5 th grade boy Initially diagnosed with ASD at 2 years; nonverbal Team of 2 / 3 Referral from parent / pediatrician: School reduction in academics: literacy Frustrations with Math Anxiety 66 SC17 / ASHA / 2013

65 Clinical Case #3: School-age: Damian Developmental History Communication increased (eye contact, pointing, language) Continued perseverations Medical History Question of substance abuse during pregnancy No other early medical issues ADHD diagnosis at 7y, on metadate Anxiety: new settings, questions about bio mother Family History Lives with father and stepmother, very involved Contact from bio mother, erratic 67 SC17 / ASHA / 2013

66 Clinical Case #3: School-age: Damian Educational History At 4:10 years, Psychological (WPPSI-III): profile of Language Based Learning Disability: VIQ = 78; PIQ = 101 At 5:4 years, Core language (CELF-P): profile of language deficiencies in concepts, vocabulary, & grammar. Grades 1-4 Inclusion class with pull out services in ST; In 4 th grade ST discontinued Grade 5 (current): Regular classroom with classroom support 68 SC17 / ASHA / 2013

67 Clinical Case #3: School-age: Damian Observation Emotional distress Difficulty with verbal communication Difficulty with nonverbal communication 69 SC17 / ASHA / 2013 Assessment Plan EINSTEIN academic screener (5 th grade) General Physical and Neurological Exam, including medication evaluation ADOS-2, Module 3 Pragmatic Language battery

68 Clinical Case #3: School-age: Damian Results Medication: Stable vital signs Anxiety and Sadness: Realization that bio mother absent Voices concerns about his runaway cat EINSTEIN: Results & Clinical Observations Comes up just early grade level but: 1:1 structured setting Directions needed to be repeated Difficulty with auditory memory: especially with sentences (better with numbers) Extreme difficulty completing math equations, and showing frustration 70 SC17 / ASHA / 2013

69 Clinical Case #3: School-age: Damian Findings and Diagnoses ASD Primarily expressive language disorder, with higher level pragmatic language impairment Referral for Educational Testing (Math) 71 SC17 / ASHA / 2013

70 Clinical Case #3: School-age: Damian / S-L Speech Language Pragmatic Assessment Plan Test of Narrative Language (TNL) Children s Communication Checklist-2 (CCC-2) ADOS-2, Module 3 Update collateral information: School 72 SC17 / ASHA / 2013

71 Clinical Case #3: School-age Damian / S-L; Narrative Aliens Story 73 SC17 / ASHA / 2013

72 Clinical Case #3: School-age: Damian / S-L; Narratives TNL SS Percentile Age/Category Comprehension ;3 years Narration 5 3 6;7 years Quotient Below Average 74 SC17 / ASHA / 2013

73 Clinical Case #3: School-age: Damian / S-L Pragmatics GCC Percentile SIDI Type 48 < 1 9 Inconclusive Component 2013 speech 2 syntax 2 semantics 1 coherence 1 imitation 3 scripted language 3 context 2 nonverbal communication 2 social relations 3 interest 7 75 SC17 / ASHA / 2013

74 Clinical Case #3: School-age: Damian / S-L What are your friends names? What do you like to do with your friends? 76 SC17 / ASHA / 2013

75 Clinical Case #3: School-age: Damian / S-L Do you think you ve ever annoyed anyone at school? 77 SC17 / ASHA / 2013

76 Clinical Case #3: School-age: Damian Speech Language Pragmatic Assessment Data ADOS-2 Module Classification 3 Testing Underway 78 SC17 / ASHA / 2013

77 79 SC17 / ASHA / 2013 Break

78 Treatment Planning Medical Testing Programmatic (IFSP, IEP)

79 What is the goal of treatment in ASD? To maximize the child s ultimate functional independence, including communication and quality of life by: -minimizing the core autism spectrum disorder features -facilitating growth and learning -promoting socialization -reducing maladaptive behaviors -educating and supporting families 81 SC17 / ASHA / 2013

80 Medical Interventions Always consider if a medical issue is present when behaviors change suddenly or intensify Seizures Complex partial Language Regression : Landau-Kleffner Syndrome Variant Gastrointestinal Reflux, Constipation Allergies Sleep Sensory Feeding Hearing SC17 / ASHA / 2013

81 Interventions, Behavioral ABA is core treatment for ASD to address the foundation skills to communication and others - social skills, daily-living skills, play and leisure skills, academic achievement, and maladaptive behaviors. Established treatment 83 SC17 / ASHA / 2013

82 Social Skills Interventions Core ASD deficit Review of published studies using the EBP criteria: Group based social skills training for school aged children with ASD effective in improving peer relationships(reichow 2010) In younger children: focus on Joint attention (JA), imitation, scripted and unscripted vocalizations, eye contact, peer relationships. Need for generalization 84 SC17 / ASHA / 2013

83 Anxiety, Emotional Regulation, Aggression Most distressing symptoms and behaviors to parents Common co-morbid symptoms Anxiety Cognitive Behavioral Therapy (CBT) most effective treatment for anxiety in children with ASD (several studies; recent: Storch, 2013) Decreases in anxiety could result in changes in social symptoms core to ASD CBT with social skills intervention most effective in treatment in children with high functioning ASD(Lang 2010) 85 SC17 / ASHA / 2013

84 Speech Language Therapy Consider: Joint Attention Play Conversation Storytelling Literacy Breakouts to plan treatment for each case: (1) Nonspeaking toddler (2) Verbal Preschooler (3) High functioning School age All have ASD with language impairment! 86 SC17 / ASHA / 2013

85 87 SC17 / ASHA / 2013 Share group planning

86 Case #1: Our Recommendation Plan A- Medical: Genetics: Routine for ASD diagnoses checking for microarray & Fragile X, adds to data base Hearing Test B- Services: Continued E.I. with ST, OT therapies & toddler playgroup Addition of Behavior therapy, ABA (15-20 hours/week) Follow up in 3-4 months 88 SC17 / ASHA / 2013

87 Case #2: Our Recommendation Plan A- Medical: -Follow up on hearing Test B-Services: Addition of home ABA parent training Continued ST and sensory based OT Social Skills group add services at school Full day kindergarten program 89 SC17 / ASHA / 2013

88 Case #3: Our Recommendation Plan A- Medical: Continued follow up for medication as per AAP guidelines Monitor Anxiety and consider counseling if increased signs B- Services: School reevaluation Social Skills Group Speech Therapy Monitor academics closely: at risk for Language based learning disorder. 90 SC17 / ASHA / 2013

89 Is Optimal Outcome possible in Autism? Loosing the diagnosis, its interpretation and frequency: controversial Optimal Outcomes in individuals with a history of Autism: 34 individuals with previous ASD no longer met criteria on social communication measures and clinically. Diagnosis made before age 5y and history of language delays Type of interventions? Being analyzed Fein et al: Optimal outcome in individuals with a history of autism. Journal of Child Psychology and Psychiatry 54:2 (2013), pp SC17 / ASHA / 2013

90 Pop Quiz True or False 1. F A diagnosis of ASD means speech onset was delayed. 2. F The critical symptoms for a diagnosis of ASD must be present within the first two years of life. 3. F The mechanisms underlying the etiology of ASD appear to be environmental. 4. F Asperger Syndrome is a type of ASD under DSM T A diagnosis of ASD means a pragmatic language impairment (PLI) is present. 92 SC17 / ASHA / 2013

91 Summary Assessment & Treatment Planning is strengthened by interdisciplinary diagnostics Changes in definitions & diagnostic criteria affect the practice of SLP, i.e., SCD Standard language batteries do not capture the pragmatic deficits of ASD; SLPs need to modify test practice to diagnose PLI Higher oral language, including echolalia, is associated with higher outcomes for children with ASD 93 SC17 / ASHA / 2013

92 Remember Advocate! Each one of us can make a difference in the life of one child 94 SC17 / ASHA / 2013

93 More DSM-5 & SLP (1) Power point: (2) ASHA Leader er/2013/130801/dsm-5-chart.pdf (3) Free download of the Infant-Toddler Checklist (CSBS- ITC) 95 SC17 / ASHA / 2013

94 Questions? 96 SC17 / ASHA / 2013