Today I want to talk treatment. That thing that we need to plan for as we are doing our assessments. But are we starting our treatments the right way? The answer may surprise you. I often see SLPs phrasing questions regarding treatment the following way: “I have a student diagnosed with ____ (insert disorder here). What is everyone using (program/app/materials) during therapy sessions to address ___ diagnosis?”
Of course, the answer is never that simple. Just because a child has a diagnosis of a social communication disorder, word-finding deficits, or a reading disability does not automatically indicate to the treating clinician, which ‘cookie cutter’ materials and programs are best suited for the child in question. Only a profile of strengths and needs based on a comprehensive language and literacy testing can address this in an adequate and targeted manner.
To illustrate, reading intervention is a much debated and controversial topic nowadays. Everywhere you turn there’s a barrage of advice for clinicians and parents regarding which program/approach to use. Barton, Wilson, OG… the well-intentioned advice just keeps on coming. The problem is that without knowing the child’s specific deficit areas, the application of the above approaches is quite frankly … pointless.
There could be endless variations of how deficits manifest in poor readers. Is it aspects of phonological awareness, phonics, morphology, etc. What combination of deficits is preventing the child from becoming a good reader?
Let’s a take a look at an example, below. It’s the CTOPP-2 results of a 7-6-year-old female with a documented history of extensive reading difficulties and a significant family history of reading disabilities in the family.
Results of the Comprehensive Test of Phonological Processing-2 (CTOPP-2)
| Subtests | Scaled Scores | Percentile Ranks | Description |
| Elision (EL) | 7 | 16 | Below Average |
| Blending Words (BW) | 13 | 84 | Above Average |
| Phoneme Isolation (PI) | 6 | 9 | Below Average |
| Memory for Digits (MD) | 8 | 25 | Average |
| Nonword Repetition (NR) | 8 | 25 | Average |
| Rapid Digit Naming (RD) | 10 | 50 | Average |
| Rapid Letter Naming (RL) | 11 | 63 | Average |
| Blending Nonwords (BN) | 8 | 25 | Average |
| Segmenting Nonwords (SN) | 8 | 25 | Average |
However, the results of her CTOPP-2 testing clearly indicate that phonological awareness, despite two areas of mild weaknesses, is not really a significant problem for this child. So let’s look at the student’s reading fluency results.
Reading Fluency: “LG’s reading fluency during this task was judged to be significantly affected by excessive speed, inappropriate pausing, word misreadings, choppy prosody, as well as inefficient word attack skills. While she was able to limitedly utilize the phonetic spelling of unfamiliar words (e.g., __) provided to her in parenthesis next to the word (which she initially misread as ‘__’), she exhibited limited use of metalinguistic strategies (e.g., pre-scanning sentences to aid text comprehension, self-correcting to ensure that the read words made sense in the context of the sentence, etc.), when reading the provided passage. To illustrate, during the reading of the text, LG was observed to frequently (at least 3 times) lose her place and skip entire lines of text without any attempts at self-correction. At times she was observed to read the same word a number of different ways (e.g., read ‘soup’ as ‘soup’ then as ‘soap’, ‘roots’ as ‘roofs’ then as ‘roots’, etc.) without attempting to self-correct. LG’s oral reading rate was also observed to be impaired for her age/grade levels. Her prosody was significantly adversely affected due to lack of adequate pausing for punctuation marks (e.g., periods, commas, etc.). Instead, she paused during text reading only when he could not decode select words in the text. Though, LG was able to read 70 words per minute, which was judged to be grossly commensurate with grade-level, out of these 70 words she skipped 2 entire lines of text, invented an entire line of text, as well as made 4 decoding errors and 6 inappropriate pauses.”
So now we know that despite quite decent phonological awareness abilities, this student presents with quite poor sound-letter correspondence skills and will definitely benefit from explicit phonics instruction addressing the above deficit areas. But that is only the beginning! By looking at the analysis of specific misreadings we next need to determine what other literacy areas need to be addressed. For the sake of brevity, I can specify that further analysis of this child reading abilities revealed that reading comprehension, orthographic knowledge, as well as morphological awareness were definitely areas that also required targeted remediation. The assessment also revealed that the child presented with poor spelling and writing abilities, which also needed to be addressed in the context of therapy.
Now, what if I also told you that this child had already been receiving private, Orton-Gillingham reading instruction for a period of 2 years, 1x per week, at the time the above assessment took place? Would you change your mind about the program in question?
Well, the answer is again not so simple! OG is a fine program, but as you can see from the above example it has definite limitations and is not an exclusive fit for this child, or for any child for that matter. Furthermore, a solidly-trained in literacy clinician DOES NOT need to rely on just one program to address literacy deficits. They simply need solid knowledge of typical and atypical language and literacy development/milestones and know how to create a targeted treatment hierarchy in order to deliver effective intervention services. But for that, they need to first, thoughtfully, construct assessment-based treatment goals by carefully taking into the consideration the child’s strengths and needs.
So let’s stop asking which approach/program we should use and start asking about the child’s profile of strengths and needs in order to create accurate language and literacy goals based on solid evidence and scientifically-guided treatment practices.
Helpful Resources Pertaining to Reading:
- Earle, G. A., Sayeski, K. L (2017) Systematic Instruction in Phoneme-Grapheme Correspondence for Students With Reading Disabilities. Intervention in School and Clinic. Vol. 52(5) 262–269
- The Florida Center for Reading Research (FCRR)
- Hasbrouck, J. & Tindal, G. A. (2006). Oral reading fluency norms: A valuable assessment tool for reading teachers. The Reading Teacher. 59(7), 636-644.
- O’Connor, R (2017) Reading Fluency and Students With Reading Disabilities: How Fast Is Fast Enough to Promote Reading Comprehension? Journal of Learning Disabilities
- Tolman, C (2005) Working Smarter, Not Harder: What Teachers of Reading Need to Know and Be Able to Teach IDA Perspectives pp. 15-23.
- Toste et al (2016) Reading Big Words: Instructional Practices to Promote Multisyllabic Word Reading Fluency Intervention in School and Clinic pp. 1–9
- Zipoli, R (2017) Unraveling-Difficult-Sentences: Strategies to Support Reading Comprehension. Intervention in School and Clinic, Vol. 52(4) 218–227. Intervention in School and Clinic, Vol. 52(4) 218–227
September is practically here and many speech language pathologists (SLPs) are looking to efficiently prepare for assessing and treating a variety of clients on their caseloads.
Today I am writing my last installment in the five-part early intervention assessment series. My 
Spoon Stripping and Mouth Closure: During the yogurt presentation, AK’s spoon stripping abilities and mouth closure were deemed good (adequate) when fed by a caregiver and fair when AK fed self (incomplete food stripping from the spoon was observed due to only partial mouth closure). According to parental report, AK’s spoon stripping abilities have improved in recent months. Ms. K was observed to present spoon upwardly in AK’s mouth and hold it still until AK placed her lips firmly around the spoon and initiated spoon stripping. Since this strategy is working adequately for all parties in question no further recommendations regarding spoon feeding are necessary at this time. Skill monitoring is recommended on an ongoing basis for further refinement. 
Cup and Straw Drinking: AK was also observed to drink 40 mls of water from a cup given parental assistance. Minor anterior spillage was intermittently noted during liquid intake. It is recommended that the parents modify cup presentation by providing AK with a plastic cup with two handles on each side, which would improve her ability to grasp and maintain hold on cup while drinking.
In the past several years, due to an influx of adolescent students with language and learning difficulties on my caseload, I have begun to research in depth aspects of adolescent 
For this purpose, I often use the books from the Continental Press series entitled: 
Text Vocabulary Comprehension:
Impressions: Clinical below grade-level reading comprehension assessment reading revealed that TS presents with a number of reading related difficulties. TS’s reading fluency was marked by monotone vocal quality, awkward word stress, imprecise articulatory contacts, false-starts, self–revisions, awkward mid-sentential pauses, limited pausing for punctuation, as well as misreadings and word substitutions, all of which resulted in an impaired reading prosody. TS’s understanding as well as his verbal summary of the presented text was immature for his age and was characterized by impaired gestalt processing of information resulting in an ineffective and confusing summarization. While TS’s text-based vocabulary knowledge was deemed to be grossly adequate for his age, his reading comprehension abilities were judged to be impaired for his age. Therapeutic intervention is strongly recommended to improve TS’s reading abilities. (See Impressions and Recommendations sections for further details).
As SLPs we routinely administer a variety of testing batteries in order to assess our students’ speech-language abilities. Grammar, syntax, vocabulary, and sentence formulation get frequent and thorough attention. But how about narrative production? Does it get its fair share of attention when the clinicians are looking to determine the extent of the child’s language deficits? I was so curious about what the clinicians across the country were doing that in 2013, I created a survey and posted a link to it in several SLP-related FB groups. I wanted to find out how many SLPs were performing narrative assessments, in which settings, and with which populations. From those who were performing these assessments, I wanted to know what type of assessments were they using and how they were recording and documenting their findings. Since the purpose of this survey was non-research based (I wasn’t planning on submitting a research manuscript with my findings), I only analyzed the first 100 responses (the rest were very similar in nature) which came my way, in order to get the general flavor of current trends among clinicians, when it came to narrative assessments. Here’s a brief overview of my [limited] findings. 
To date, I have written 3 posts on speech and language assessments of children under 3 years of age. My first post offered suggestions on what information to include in 
If I happen to know that a child is highly verbal, I may actually include a 
To illustrate, below is a narrative sample from a typically developing 2-year-old child based on the Mercer Mayer’s classic wordless picture book: “Frog Where Are You?”
Of course, a play assessment for this age group is a must. Since, in my first post, 
For toddlers 18+months of age, I like using the Language Use Inventory (LUI) 
In addition to the LUI, I recently discovered the 
In this post, I am continuing my series of articles on speech and language assessments of children under 3 years of age. My first installment in this series offered suggestions regarding what information to include in 
As mentioned in my previous post on 
Developmental Milestones expected of a 16-18 months old toddler: 
Play Skills/Routines:
Materials to use with the child to promote language and play: 
Core vocabulary categories for listening and speaking:
Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.
TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender. Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.
I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.
*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the 
Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of 
Today, I’d like to talk about speech and language assessments of children under three years of age. Namely, the quality of these assessments. Let me be frank, I am not happy with what I am seeing. Often times, when I receive a speech-language report on a child under three years of age, I am struck by how little functional information it contains about the child’s linguistic strengths and weaknesses. Indeed, conversations with parents often reveal that at best the examiner spent no more than half an hour or so playing with the child and performed very limited functional testing of their actual abilities. Instead, they interviewed the parent and based their report on parental feedback alone. Consequently, parents often end up with a report of very limited value, which does not contain any helpful information on how delayed is the child as compared to peers their age.
Why 30 months, you may ask? Well, there isn’t really any hard science to it. It’s just that I noticed that a significant percentage of parents who were already worried about their children’s speech-language abilities when they were younger, begin to act upon those worries as the child is nearing 3 years of age and their abilities are not improving or are not commensurate with other peers their age.
At this point, I am ready to move on to the language portion of the assessment. Here it is important to note that a number of assessments for toddlers under 3 years of age contain numerous limitations. Some such as REEL-3 or Rosetti (a criterion-referenced vs. normed-referenced instrument) are observational or limitedly interactive in nature, while others such as PLS-5, have a tendency to 
Now I know that many of you will tell me, that this is a ‘perfect world’ evaluation conducted by a private therapist with an unlimited amount of time on her hands. And to some extent, many of you will be right! Yes, such an evaluation was a result of more than 30 minutes spent face-to-face with the child. All in all, it took probably closer to 90 minutes of face to face time to complete it and a few hours to write. And yes, this is a luxury only a few possess and many therapists in the early intervention system lack. But in the long run, such evaluations pay dividends not only, obviously, to your clients but to SLPs who perform them. They enhance and grow your reputation as an evaluating therapist. They even make sense from a business perspective. If you are well-known and highly sought after due to your evaluating expertise, you can expect to be compensated for your time, accordingly. This means that if you decide that your time and expertise are worth private pay only (due to poor insurance reimbursement or low EI rates), you can be sure that parents will learn to appreciate your thoroughness and will choose you over other providers.