Category: Assessment

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Early Intervention Evaluations PART IV:Assessing Social Pragmatic Abilities of Children Under 3

Image result for toddlersTo 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 general speech-language assessments for this age group, my second post specifically discussed assessments of toddlers with suspected motor speech disorders and my third post described what information I tend to include in reports for children ~16-18 months of age.

Today, I’d like to offer some suggestions on the assessment of social emotional functioning and pragmatics of children, ages 3 and under.

For starters, below is the information I found compiled by a number of researchers on select social pragmatic milestones for the 0-3 age group:

  1. Peters, Kimberly (2013) Hierarchy of Social/Pragmatic Skills as Related to the Development of Executive Function 
  2. Hutchins & Prelock, (2016) Select Social Cognitive Milestones from the Theory of Mind Atlas 

3. Development of Theory of Mind (Westby, 2014)

In my social pragmatic assessments of the 0-3 population, in addition, to the child’s adaptive behavior during the assessment, I also describe the child’s joint attention,  social emotional reciprocity, as well as social referencing abilities.

Joint attention is the shared focus of two individuals on an object. Responding to joint attention refers to the child’s ability to follow the direction of the gaze and gestures of others in order to share a common point of reference. Initiating joint attention involves child’s use of gestures and eye contact to direct others’ attention to objects, to events, and to themselves. The function of initiating joint attention is to show or spontaneously seek to share interests or pleasurable experience with others. (Mundy, et al, 2007)

Social emotional reciprocity involves being aware of the emotional and interpersonal cues of others, appropriately interpreting those cues, responding appropriately to what is interpreted as well as being motivated to engage in social interactions with others (LaRocque and Leach,2009).

Social referencing refers to a child’s ability to look at a caregiver’s cues such as facial expressions, body language and tone of voice in an ambiguous situation in order to obtain clarifying information.   (Walden & Ogan, 1988)

Here’s a brief excerpt from an evaluation of a child ~18 months of age:

“RA’s joint attention skills, social emotional reciprocity as well as social referencing were judged to be appropriate for his age.  For example, when Ms. N let in the family dog from the deck into the assessment room, RA immediately noted that the dog wanted to exit the room and go into the hallway.  However, the door leading to the hallway was closed.  RA came up to the closed door and attempted to reach the doorknob.  When RA realized that he cannot reach to the doorknob to let the dog out, he excitedly vocalized to get Ms. N’s attention, and then indicated to her in gestures that the dog wanted to leave the room.”

If I happen to know that a child is highly verbal, I may actually include a narrative assessment, when evaluating toddlers in the 2-3 age group. Now, of course, true narratives do not develop in children until they are bit older. However, it is possible to limitedly assess the narrative abilities of verbal children in this age group. According to Hedberg & Westby (1993) typically developing 2-year-old children are at the Heaps Stage of narrative development characterized by

  • Storytelling in the form of a collection of unrelated ideas  which consist of labeling and describing events
  • Frequent switch of topic is evident with lack of central theme and cohesive  devices
  • The sentences are usually simple declarations which contain repetitive syntax and use of present or present progressive tenses
  • In this stage, children possess limited understanding that the character on the next page is still same as on the previous page

In contrast, though typically developing children between 2-3 years of age in the Sequences Stage of narrative development still arbitrarily link story elements together without transitions, they can:

  • Label and describe events about a central theme with stories that may contain a central character, topic, or setting

Image result for frog where are youTo 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?”

  • He put a froggy in there
  • He’s sleeping
  • Froggy came out
  • Where did did froggy go?
  • Now the dog fell out
  • Then he got him
  • You are a silly dog
  • And then
  • where did froggy go?
  • In in there
  • Up up into the tree
  • Up there  an owl
  • Froggy 
  • A reindeer caught him
  • Then he dropped him
  • Then he went into snow
  • And then he cleaned up that
  • Then stopped right there and see what wha wha wha what he found
  • He found two froggies
  • They lived happily ever after

Image result for play assessment kidsOf course, a play assessment for this age group is a must. Since, in my first post, I offered a play skills excerpt from one of my early intervention assessments and in my third blog post, I included a link to the Revised Westby Play Scale (Westby, 2000), I will now move on to the description of a few formal instruments I find very useful for this age group.

While some criterion-referenced instruments such as the Rossetti, contain sections on Interaction-Attachment and Pragmatics, there are other assessments which I prefer for evaluating social cognition and pragmatic abilities of toddlers.

Image result for language use inventoryFor toddlers 18+months of age, I like using the Language Use Inventory (LUI) (O’Neill, 2009) which is administered in the form of a parental questionnaire that can be completed in approximately 20 minutes.  Aimed at identifying children with delay/impairment in pragmatic language development it contains 180 questions and divided into 3 parts and 14 subscales including:

  1. Communication w/t gestures
  2. Communication w/t words
  3. Longer sentences

Therapists can utilize the Automated Score Calculator, which accompanies the LUI in order to generate several pages write up or summarize the main points of the LUI’s findings in their evaluation reports.

Below is an example of a summary I wrote for one of my past clients, 35 months of age.

AN’s ability to use language was assessed via the administration of the Language Use Inventory (LUI). The LUI is a standardized parental questionnaire for children ages 18-47 months aimed at identifying children with delay/impairment in pragmatic language development. Composed of 3 parts and 14 subscales it focuses on how the child communicates with gestures, words and longer sentences.

On the LUI, AN obtained a raw score of 53 and a percentile rank of <1, indicating profoundly impaired performance in the area of language use. While AN scored in the average range in the area of varied word use, deficits were noted with requesting help, word usage for notice, lack of questions and comments regarding self and others, lack of reciprocal word usage in activities with others, humor relatedness, adapting to conversations to others, as well as difficulties with building longer sentences and stories.

Based on above results AN presents with significant social pragmatic language weaknesses characterized by impaired ability to use language for a variety of language functions (initiate, comment, request, etc), lack of reciprocal word usage in activities with others, humor relatedness, lack of conversational abilities, as well as difficulty with spontaneous sentence and story formulation as is appropriate for a child his age. Therapeutic intervention is strongly recommended to improve AN’s social pragmatic abilities.

Downloadable DocumentsIn addition to the LUI, I recently discovered the Theory of Mind Inventory-2. The ToMI-2 was developed on a normative sample of children ages 2 – 13 years. For children between 2-3 years of age, it offers a 14 question Toddler Screen (shared here with author’s permission). While due to the recency of my discovery, I have yet to use it on an actual client, I did have fun creating a report with it on a fake client.

First, I filled out the online version of the 14 question Toddler Screen (paper version embedded in the link above for illustration purposes). Typically the parents are asked to place slashes on the form in relevant areas, however, the online version requested that I use numerals to rate skill acquisition, which is what I had done. After I had entered the data, the system generated a relevant report for my imaginary client.  In addition to the demographic section, the report generated the following information (below):

  1. A bar graph of the client’s skills breakdown in the developed, undecided and undeveloped ranges of the early ToM development scale.
  2. Percentile scores of how the client did in the each of the 14 early ToM measures
  3. Median percentiles of scores
  4. Table for treatment planning broken down into strengths and challenges

I find the information provided to me by the Toddler Screen highly useful for assessment and treatment planning purposes and definitely have plans on using this portion of the TOM-2 Inventory as part of my future toddler evaluations.

Of course, the above instruments are only two of many, aimed at assessing social pragmatic abilities of children under 3 years of age, so I’d like to hear from you! What formal and informal instruments are you using to assess social pragmatic abilities of children under 3 years of age? Do you have a favorite one, and if so, why do you like it?

References:

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Early Intervention Evaluations PART III: Assessing Children Under 2 Years of Age

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 general speech-language assessments for this age group, while my second post specifically discussed assessments of toddlers with suspected motor speech disorders.

Today, I’d like to describe what information I tend to include in reports for children ~16-18 months of age.  As I mentioned in my previous posts, the bulk of children I assess under the age of 3, are typically aged 30 months or older. However, a relatively small number of children are brought in for an assessment around an 18-month mark, which is the age group that I would like to discuss today.

Typically,  these children are brought in due to a lack of or minimal speech-language production. Interestingly enough, based on the feedback of colleagues, this group is surprisingly hard to report on. While all SLPs will readily state that 18-month-old children are expected to have a verbal vocabulary of at least 50 words and begin to combine them into two-word utterances (e.g., ‘daddy eat’). When prompted: “Well, what else should my child be capable of?” many SLPs draw a blank regarding what else to say to parents on the spot.

Image result for assessmentAs mentioned in my previous post on assessment of children under 3, the following sections should be an integral part of every early intervention speech-language assessment:

  • Background History
  • Language Development and Use  (Free Questionnaires)
  • Adaptive Behavior
  • Play Assessment (Westby, 2000) (Westby Play Scale-Revised Link)
  • Auditory Function
  • Oral Motor Exam
  • Feeding and Swallowing
  • Vocal Parameters
  • Fluency and Resonance
  • Articulation and Phonology
  • Receptive Language
  • Expressive Language
  • Social Emotional Development
  • Pragmatic Language
  • Impressions
  • Recommendations
  • Suggested Therapy Goals
  • References (if pertinent to a particular report)

In my two previous posts, I’ve also offered examples of select section write-ups (e.g., receptive, expressive phonology, etc.). Below a would like to offer a few more for this age group. Below is an example of a write-up on an 18-month-old bilingual child with a very limited verbal output.

RECEPTIVE LANGUAGE:

L’s receptive language skills were solid at 8 months of age (as per clinical observations and REEL-3 findings) which is significantly below age-expectancy for a child her age (18 months). During the assessment L received credit for appropriately reacting to prohibitive verbalizations (e.g., “No”, “Stop”), attending to speaker when her name was spoken, performing a routine activity upon request (when combined with gestures), looking at familiar object when named, finding the aforementioned familiar object when not in sight, as well as pointing to select body parts on Mrs. L and self (though identification on self was limited).  L is also reported to be able to respond to yes/no questions by head nods and shakes.

However, during the assessment L was unable to consistently follow 1 and 2 step directions without gestural cues, understand and perform simple actions per clinician’s request, select objects from a group of 3-5 items given a verbal command, select familiar puzzle pieces from a visual field of 2 choices, understand simple ‘wh questions (e.g., “what?”, “where?”), point to objects or pictures when named, identify simple pictures of objects in book, or display the knowledge and understanding of age appropriate content, function and early concept words (in either Russian or English) as is appropriate for a child her age.   

EXPRESSIVE LANGUAGE and ARTICULATION

L’s expressive language skills were judged to be solid at 7 months of age (as per clinical observations and REEL-3 findings), which is significantly below age-expectancy for a child her age (18 months). L was observed to spontaneously use proto-imperative gestures (eye gaze, reaching, and leading [by hand]), vocalizations, as well waving for the following language functions: requesting, rejecting, regulating own environment as well as providing closure (waving goodbye).

L’s spontaneous vocalizations consisted primarily of reduplicated babbling (with a limited range of phonemes) which is significantly below age-expectancy for a child her age (see below for developmental norms).  During the assessment, L was observed to frequently vocalize “da-da-da”. However, it was unclear whether she was vocalizing to request objects (in Russian “dai” means “give”) due to the fact that she was not observed to consistently vocalize the above solely when requesting items.  Additionally, L was not observed to engage in reciprocal babbling or syllable/word imitation during today’s assessment, which is a concern for a child her age.  When the examiner attempted to engage L in structured imitation tasks by offering and subsequently denying a toy of interest until L attempted to imitate the desired sound, L became easily frustrated and initiated tantrum behavior. During the assessment, L was not observed to imitate any new sounds trialed with her by the examiner.

During today’s assessment, L’s primary means of communication consisted of eye gaze, reaching, crying, gestures, as well as sound and syllable vocalizations.  L’s phonetic inventory consisted of the following consonant sounds: plosives (/p/, /b/ as reported by Mrs. L), alveolars (/t/, /d/ as reported and observed), fricative (/v/ as observed), velar (/g/ as observed), as well as nasal (/n/, and /m/ as observed).   L was also observed to produce two vowels /a/ and a pharyngeal /u/.  L’s phonotactic repertoire was primarily restricted to reported CV(C-consonant; V-vowel) and VCV syllable shapes, which is significantly reduced for a child her age.

According to developmental norms, a child of L’s age (18 months) is expected to produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000). During this time the child’s vocabulary size increases to 50+ words at which point children begin to combine these words to produce simple phrases and sentences (as per Russian and English developmental norms).  Additionally, an, 18 months old child is expected to begin monitoring and repairing own utterances, adjusting speech to different listeners, as well as practicing sounds, words, and early sentences. (Clark, adapted by Owens, 2015)

Based on the above guidelines L’s receptive and expressive language, as well as articulation abilities, are judged to be significantly below age expectancy at this time. Speech and language therapy is strongly recommended in order to improve L’s speech and language skills.

Typically when the assessed young children exhibit very limited comprehension and expression, I tend to provide their caregivers with a list of developmental expectations for that specific age group (given the range of a few months) along with recommendations of communication facilitation. Below is an example of such a list, pulled a variety of resources.

Image result for milestonesDevelopmental Milestones expected of a 16-18 months old toddler:

 Attention/Gaze:

  • Make frequent spontaneous eye contact with adults during interactions
  • Turn head to look towards the new voice, when another person begins to talk
  • Make 3-point gaze shifts by 1. looking at a toy in hand, 2. then at an adult, 3. then back to the toy
  • Make 4-point gaze shifts if more than one person is in the room – by looking from a toy in hand to one person, then the other person, then back to the toy,
  • Spontaneously attend to book, activity for 2-3+ minutes without redirection

Reaching and Gestures:

  • Show objects in hand to an adult (without actually giving them)
  • Push away items that aren’t wanted
  • Engage in give and take games when holding objects with an adult
  • Imitate simple gestures such as clapping hands or waving bye-bye
  • Hand an object to an adult to ask for help with it
  • Shake head “no?”

Image result for playPlay Skills/Routines:

  • Attempt to actively explore toys (e.g., push or spin parts of toys, turn toys over, roll them back and forth)
  • Repeat interesting actions with toys (e.g., make a toy produce an unusual noise, then attempt to make the noise again)
  • Imitate simple play activities (adult bangs two blocks together, then child imitates)
  • Use objects on daily basis (e.g., when given a spoon or cup the child attempts to feed himself. When putting on clothes the child begins to lift his arms in anticipation of a shirt going on.)

 Receptive (Listening Skills):

  • Consistently follow 1 and 2 step directions without gestural cues
  • Understand and perform simple actions per request (“sit down” or “come here”) without gestures
  • Select objects from a group of 3 items given a verbal command
  • Select familiar puzzle pieces from a visual field of 2 choices
  • Understand simple ‘wh questions (e.g., “what?”, “where?”)
  • Point to objects or pictures when named
  • Spontaneously and consistently identify simple pictures of objects in book
  • Stop momentarily what he is doing if an adult says “no” in a firm voice
  • Identify 2-3 common everyday objects or body parts when asked

 Expressive (Speaking Skills): 

  • Produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000).
  • Have a vocabulary size nearing 50 words (e.g., 35-40)
  • Imitate adult words or vocalizations
  • Attempt to practice sounds and words (Clark, adapted by Owens, 2015)
  • Appropriately label familiar objects (foods, toys, animals)

Related imageMaterials to use with the child to promote language and play:

  • Bubbles
  • Cause and effect toys
  • Toys with a variety of textures (soft toys, plastic toys, cardboard blocks, ridged balls)
  • Toys with multiple actions
  • Toys with special effects: lights, sounds, movement (push and go vehicles)
  • Building and linking toys
  • Toys with multiple parts
  • Balls, cars and trucks, animals, dolls
  • Puzzles
  • Pop-up picture books
  • Toys the child demonstrates an interest in (parents should advise)

Strategies:

  • Reduce distractions (noise, clutter etc)
  • Provide one on one interaction in a structured space (e.g., sitting at the play table or sitting on parent’s lap) to improve attention
  • Offer favorite activities and toys of interest initially before branching out to new materials
  • Offer favorite foods/toys as reinforcers to continue working
  • Offer choices of two toys, then remove one toy and focus interaction with one toy of interest
  • Try to prolong attention to toy for several minutes at a time
  • Change activities frequently, HOWEVER, repeat same activities in cycles over and over again during home practice in order to solidify skills
  • Label objects and actions in the child’s immediate environment
  • Use brief but loud utterances (2-3 words not more) to gain attention and understanding
  • Frequently repeat words in order to ensure understanding of what is said/expected of child
  • Use combination of gestures, signs, words, and pictures to teach new concepts
  • Do not force child to speak if he doesn’t want to rather attempt to facilitate production of gestures/sounds (e.g., use “hand over hand” to show child the desired gesture such as pointing/waving/motioning in order to reduce his/her frustration
  • Use play activities as much as possible to improve child’s ability to follow directions and comprehend language
    • Doll House (with Little People)
    • Garage
    • Farm, etc

Related imageCore vocabulary categories for listening and speaking:

  • Favorite and familiar toys and objects
  • Names of people in the child’s life as well as his own name
  • Pets
  • Favorite or familiar foods
  • Clothing
  • Body parts
  • Names of daily activities and actions (go, fall, drink, eat, walk, wash, open)
  • Recurrence (more)
  • Names of places (bed, outside)
  • Safety words (hot, no, stop, dangerous, hurt, don’t touch, yuck, wait)
  • Condition words (boo-boo, sick/hurt, mad, happy)
  • Early pronouns (me, mine)
  • Social words (hi, bye, please, sorry)
  • Early concepts: in, off, on, out, big, hot, one, up, down, yucky, wet, all done)
  • Yes/no

 Select References:

  • Owens, R. E. (2015). Language development: An introduction (9th ed.). Boston, MA: Allyn & Bacon.
  • Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587–599.
  • Rescorla, L., Hadicke-Wiley, M., & Escarce, E. (1993). Epidemiological investigation of expressive language delay
    at age two. First Language, 13, 5–22.
  • Robb, M. P., & Bleile, K. M. (1994). Consonant inventories of young children from 8 to 25 months. Clinical Linguistics and Phonetics, 8, 295-320.
  • Selby, J. C., Robb, M. P., & Gilbert, H. R. (2000). Normal vowel articulations between 15 and 36 months of age. Clinical Linguistics and Phonetics, 14, 255-266.

Click HERE for the Early Intervention Evaluations PART IV: Assessing Pragmatic Abilities of Children Under 3

Stay Tuned for the next installment in this series:

  • Early Intervention Evaluations PART V: Assessing Feeding and Swallowing in Children Under Two

 

 

 

 

 

 

 

 

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Early Intervention Evaluations PART II: Assessing Suspected Motor Speech Disorders in Children Under 3

In my previous post on this topic, I brought up concerns regarding the paucity of useful information in EI SLP reports for children under 3 years of age and made some constructive suggestions of how that could be rectified. In 2013, I had written about another significant concern, which involved neurodevelopmental pediatricians (rather than SLPs), diagnosing Childhood Apraxia of Speech (CAS), without the adequate level of training and knowledge regarding motor speech disorders. Today, I wanted to combine both topics and delve deeper into another area of EI SLP evaluations, namely, assessments of toddlers with suspected motor speech disorders.

Firstly, it is important to note that CAS is disturbingly overdiagnosed. A cursory review of both parent and professional social media forums quickly reveals that this diagnosis is doled out like candy by both SLPs and medical professionals alike, often without much training and knowledge regarding the disorder in question.   The child is under 3, has a limited verbal output coupled with a number of phonological processes,  and the next thing you know,  s/he is labeled as having Childhood Apraxia of Speech (CAS).  But is this diagnosis truly that straightforward?

Let us begin with the fact that all reputable organizations involved in the dissemination of information on the topic of CAS (e.g., ASHA, CASANA, etc.), strongly discourage the diagnosis of CAS in children under three years of age with limited verbal output,  and limited time spent in EBP therapy specifically targeting the remediation of motor speech disorders.

Assessment of motor speech disorders in young children requires solid knowledge and expertise. That is because CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc). Furthermore, symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of  “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis. Finally, the diagnosis of CAS is also problematic due to the fact that there are still to this day no valid or reliable standardized assessments sensitive to CAS detection (McCauley & Strand, 2008).

In March 2017, Dr. Edythe Strand wrote an excellent article for the ASHA Leader entitled: “Appraising Apraxia“, in which she used a case study of a 3-year-old boy to describe how a differential diagnosis for CAS can be performed. She reviewed CAS characteristics, informal assessment protocols, aspects of diagnosis and treatment, and even included ‘Examples of Diagnostic Statements for CAS’ (which illustrate how clinicians can formulate their impressions regarding the child’s strengths and needs without explicitly labeling the child’s diagnosis as CAS).

Today, I’d like to share what information I tend to include in speech-language reports geared towards the assessing motor speech disorders in children under 3 years of age. I have a specific former client in mind for whom a differential diagnosis was particularly needed. Here’s why.

This particular 30-month client, TQ, (I did mention that I get quite a few clients for assessment around that age), was brought in due to parental concerns over her significantly reduced speech and expressive language abilities characterized by unintelligible “babbling-like” utterances and lack of expressive language.  All of TQ’s developmental milestones with the exception of speech and language had been achieved grossly at age expectancy. She began limitedly producing word approximations at ~16 months of age but at 30 months of age, her verbal output was still very restricted. She mainly communicated via gestures, pointing, word approximations, and a handful of signs.

Interestingly, as an infant, she had a restricted lingual frenulum.  However, since it did not affect her ability to feed, no surgical intervention was needed. Indeed, TQ presented with an adequate lingual movement for both feeding and speech sound production, so her ankyloglossia (or anterior tongue tie) was definitely not the culprit which caused her to have limited speech production.

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.

Assessment of TQ’s social-emotional functioning, play skills, and receptive language  (via a combination of Revised Westby Play Scale (Westby, 2000), REEL-3, & PLS-5) quickly revealed that she was a very bright little girl who was developing on target in all of the tested areas. Assessment of TQ’s expressive language (via REEL-3, PLS-5 & LUI*), revealed profoundly impaired, expressive language abilities.  But due to which cause?

Despite lacking verbal speech, TQ’s communicative frequency (how often she attempted to spontaneously and appropriately initiate interactions with others), as well as her communicative intent (e.g., gaining attention, making requests, indicating protests, etc), were judged to be appropriate for her age. She was highly receptive to language stimulation given tangible reinforcements and as the assessment progressed she was observed to significantly increase the number and variety of vocalizations and word approximations including delayed imitation of words and sounds containing bilabial and alveolar nasal phonemes.  

For the purpose of TQ’s speech assessment, I was interested in gaining knowledge regarding the following:

  • Automatic vs. volitional control
  • Simple vs. complex speech production
  • Consistency of productions on repetitions of the same words/word approximations
  • Vowel Productions
  • Imitation abilities
  • Prosody
  • Phonetic inventory
  • Phonotactic Constraints
  • Stimulability

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.

  1. Phonetic inventory of all the sounds TQ produced during the assessment is as follows:
    • Consonants:  plosive nasals (/m/) and alveolars (/t/, /d/, n), as well as a glide (/w/)
    • Vowels: (/a/, /e/, /i/, /o/)
  2. TQ’s phonotactic repertoire was primarily comprised of word approximations restricted to specific sounds and consisted of CV (e.g., ne), VCV (e.g., ada), CVC (e.g., nyam), CVCV (e.g., nada), VCVC (e.g., adat), CVCVCV (nadadi), VCVCV(e.g., adada) syllable shapes
  3. TQ’s speech intelligibility in known and unknown contexts was profoundly reduced to unfamiliar listeners. However, her word approximations were consistent across all productions.
  4. Due to the above I could not perform an in-depth phonological processes analysis

However, by this time I had already formulated a working hypothesis regarding TQ’s speech production difficulties. Based on her speech sound assessment TQ presented with severe phonological disorder characterized by restricted sound inventory, simplification of sound sequences, as well as patterns of sound use errors (e.g., predominance of alveolar /d/ and nasal /n/ sounds when attempting to produce most word approximations) in speech (Stoel-Gammon, 1987).

TQ’s difficulties were not consistent with the diagnosis Childhood Apraxia of Speech (CAS) at that time due to the following:

  • Adequate and varied production of vowels
  • Lack of restricted use of syllables during verbalizations (TQ was observed to make verbalizations up to 3 syllables in length)
  • Lack of disruptions in rate, rhythm, and stress of speech
  • Frequent and spontaneous use of consistently produced verbalizations
  • Lack of verbal groping behaviors when producing word-approximations
  • Good control of pitch, loudness and vocal quality during vocalizations

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.

I still, however, wanted to be cautious as there were a few red flags I had noted which may have potentially indicative of a non-CAS motor speech involvement, due to which I wanted to include some recommendations pertaining to motor speech remediation.

Now it is possible that after 6 months of intensive application of EBP phonological and motor speech approaches TQ would have turned 3 and still presented with highly restricted speech sound inventory and profoundly impaired speech production, making her eligible for the diagnosis of CAS in earnest.  However,  at the time of my assessment,  making such diagnosis in view of all the available evidence would have been both clinically inappropriate and unethical.

So what were my recommendations you may ask? Well, I provisionally diagnosed TQ with a severe phonological disorder and recommended that among a variety of phonologically-based approaches to trial, an EBP approach to the treatment of motor speech disorders be also used with her for a period of 6 months to determine if it would expedite speech gains.

*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the Rapid Syllable Transition Treatment (ReST). ReST is a free EBP treatment developed by the SLPs at the University of Sydney, which uses nonsense words, designed to help children coordinate movements across syllables in long words and phrases as well as helps them learn new speech movements. It is, however, important to note for young children with highly restricted sound inventories, characterized by a lack of syllable production, ReST will not be applicable. For them, the Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC) approaches do have some limited empirical support.

I also made sure to make a note in my report regarding the inappropriate use of non-speech oral motor exercises (NSOMEs) in therapy, indicating that there is NO research to support the use of NSOMEs to stimulate speech production (Lof, 2010).

In addition to the trialing of phonological and motor based approaches I also emphasized the need to establish consistent lexicon via development of functional words needed in daily communication and listed a number of examples across several categories. I made recommendations regarding select approaches and treatment techniques to trial in therapy,  as well as suggestions for expansion of sounds and structures. Finally, I made suggestions for long and short term therapy goals for a period of 6 months to trial with TQ in therapy and provided relevant references to support the claims I’ve made in my report.

You may be interested in knowing that nowadays TQ is doing quite well, and at this juncture, she is still, ineligible for the diagnosis CAS (although she needs careful ongoing monitoring with respect to the development of reading difficulties when she is older).

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 questionable and even downright harmful bunk treatments for their children,  the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.

That is why the correct diagnosis is so important for young children under 3 years of age. But before it can be made, extensive (reputable and evidence supported) training and education are needed by evaluating SLPs on the assessment and treatment of motor speech disorders in young children.

References:

  1. Davis, B & Velleman, S (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. 10 (3): 177 – 192.
  2. Lof, G., & Watson, M. (2010). Five reasons why nonspeech oral-motor exercises do not work. Perspectives on School-Based Issues, 11.109-117.
  3. McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
  4. McCauley R.J., Strand E., Lof, G.L., Schooling T. & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech, American Journal of Speech-Language Pathology, 18, 343-360.
  5. Murray, E., McCabe, P. & Ballard, K.J. (2015). A Randomized Control Trial of Treatments for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research 58 (3) 669-686.
  6. Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
  7. Strand, E (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, L & Campbell, T (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.
  8. Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.
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Early Intervention Evaluations PART I: Assessing 2.5 year olds

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.

So today I like to talk about what information should such speech-language reports should contain.   For the purpose of this particular post,  I will choose a particular developmental age at which children at risk of language delay are often assessed by speech-language pathologists. Below you will find what information I typically like to include in these reports as well as developmental milestones for children 30 months or 2.5 years of 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.

So here is the information I include in such reports (after I’ve gathered pertinent background information in the form of relevant intakes and questionnaires, of course).  Naturally, detailed BACKGROUND HISTORY section is a must! Prenatal, perinatal, and postnatal development should be prominently featured there.   All pertinent medical history needs to get documented as well as all of the child’s developmental milestones in the areas of cognition,  emotional development, fine and gross motor function, and of course speech and language.  Here,  I also include a family history of red flags: international or domestic adoption of the child (if relevant) as well as familial speech and language difficulties, intellectual impairment, psychiatric disorders, special education placements, or documented deficits in the areas of literacy (e.g., reading, writing, and spelling). After all, if any of the above issues are present in isolation or in combination, the risk for language and literacy deficits increases exponentially, and services are strongly merited for the child in question.

For bilingual children,  the next section will cover LANGUAGE BACKGROUND AND USE.  Here, I describe how many and which languages are spoken in the home and how well does the child understand and speak any or all of these languages (as per parental report based on questionnaires).

After that,  I  move on to describe the child’s ADAPTIVE BEHAVIOR during the assessment.  In this section, I cover emotional relatedness, joint attention, social referencing,  attention skills, communicative frequency, communicative intent,  communicative functions, as well as any and all unusual behaviors noted during the therapy session (e.g., refusal, tantrums, perseverations, echolalia, etc.) Then I move on to PLAY SKILLS. For the purpose of play assessment, I use the Revised Westby Play Scale (Westby, 2000). In this section,  I describe where the child is presently with respect to play skills,  and where they actually need to be developmentally (excerpt below).

“During today’s assessment, LS’s play skills were judged to be significantly reduced for his age. A child of LS’s age (30 months) is expected to engage in a number of isolated pretend play activities with realistic props to represent daily experiences (playing house) as well as less frequently experienced events (e.g., reenacting a doctor’s visit, etc.) (corresponds to Stage VI on the Westby Play Scale, Revised Westby Play Scale (Westby, 2000)). Contrastingly, LS presented with limited repertoire routines, which were characterized primarily by exploration of toys, such as operating simple cause and effect toys (given modeling) or taking out and then putting back in playhouse toys.  LS’s parents confirmed that the above play schemas were representative of play interactions at home as well. Today’s LS’s play skills were judged to be approximately at Stage II (13 – 17 months) on the Westby Play Scale, (Revised Westby Play Scale (Westby, 2000)) which is significantly reduced for a child of  LS’s age, since it is almost approximately ±15 months behind his peers. Thus, based on today’s play assessment, LS’s play skills require therapeutic intervention. “

Sections on AUDITORY FUNCTION, PERIPHERAL ORAL MOTOR EXAM, VOCAL PARAMETERS, FLUENCY AND RESONANCE (and if pertinent FEEDING and SWALLOWING follow) (more on that in another post).

Now, it’s finally time to get to the ‘meat and potatoes’ of the report ARTICULATION AND PHONOLOGY as well as RECEPTIVE and EXPRESSIVE LANGUAGE (more on PRAGMATIC ASSESSMENT in another post).

First, here’s what I include in the ARTICULATION AND PHONOLOGY section of the report.

  1. Phonetic inventory: all the sounds the child is currently producing including (short excerpt below):
    • Consonants:  plosive (/p/, /b/, /m/), alveolar (/t/, /d/), velar (/k/, /g/), glide (/w/), nasal (/n/, /m/) glottal (/h/)
    • Vowels and diphthongs: ( /a/, /e/, /i/, /o/, /u/, /ou/, /ai/)
  2. Phonotactic repertoire: What type of words comprised of how many syllables and which consonant-vowel variations the child is producing (excerpt below)
    • LS primarily produced one syllable words consisting of CV (e.g., ke, di), CVC (e.g., boom), VCV (e.g., apo) syllable shapes, which is reduced for a child his age. 
  3. Speech intelligibility in known and unknown contexts
  4. Phonological processes analysis

Now that I have described what the child is capable of speech-wise,  I discuss where the child needs to be developmentally:

“A child of LS’s age (30 months) is expected to produce additional consonants in initial word position (k, l, s, h), some consonants (t, d, m, n, s, z) in final word position (Watson & Scukanec, 1997b), several consonant clusters (pw, bw, -nd, -ts) (Stoel-Gammon, 1987) as well as evidence a more sophisticated syllable shape structure (e.g., CVCVC)   Furthermore, a 30 month old child is expected to begin monitoring and repairing own utterances, adjusting speech to different listeners, as well as practicing sounds, words, and early sentences (Clark, adapted by Owens, 1996, p. 386) all of which LS is not performing at this time.  Based on above developmental norms, LS’s phonological abilities are judged to be significantly below age-expectancy at this time. Therapy is recommended in order to improve LS’s phonological skills.”

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 over inflate scores,  resulting in a significant number of children not qualifying for rightfully deserved speech-language therapy services.  This is exactly why it’s so important that SLPs have a firm knowledge of developmental milestones!  After all,  after they finish describing what the child is capable of,  they then need to describe what the developmental expectations are for a child this age (excerpts below).

RECEPTIVE LANGUAGE

“LS’s receptive language abilities were judged to be scattered between 11-17 months of age (as per clinical observations as well as informal PLS-5 and REEL-3 findings), which is also consistent with his play skills abilities (see above).  During the assessment LS was able to appropriately understand prohibitive verbalizations (e.g., “No”, “Stop”), follow simple 1 part directions (when repeated and combined with gestures), selectively attend to speaker when his name was spoken (behavioral), perform a routine activity upon request (when combined with gestures), retrieve familiar objects from nearby (when provided with gestures), identify several major body parts (with prompting) on a doll only, select a familiar object when named given repeated prompting, point to pictures of familiar objects in books when named by adult, as well as respond to yes/no questions by using head shakes and head nods. This is significantly below age-expectancy.

A typically developing child 30 months of age is expected to spontaneously follow (without gestures, cues or prompts) 2+ step directives, follow select commands that require getting objects out of sight, answer simple “wh” questions (what, where, who), understand select spatial concepts, (in, off, out of, etc), understand select pronouns (e.g., me, my, your), identify action words in pictures, understand concept sizes (‘big’, ‘little’), identify simple objects according to their function, identify select clothing items such as shoes, shirt, pants, hat (on self or caregiver) as well as understand names of farm animals, everyday foods, and toys. Therapeutic intervention is recommended in order to increase LS’s receptive language abilities.

EXPRESSIVE LANGUAGE:

“During today’s assessment, LS’s expressive language skills were judged to be scattered between 10-15 months of age (as per clinical observations as well as informal PLS-5 and REEL-3 findings). LS was observed to communicate primarily via proto-imperative gestures (requesting and object via eye gaze, reaching) as well as proto-declarative gestures (showing an object via eye gaze, reaching, and pointing). Additionally, LS communicated via vocalizations, head nods, and head shakes.  According to parental report, at this time LS’s speaking vocabulary consists of approximately 15-20 words (see word lists below).  During the assessment LS was observed to spontaneously produce a number of these words when looking at a picture book, playing with toys, and participating in action based play activities with Mrs. S and clinician.  LS was also observed to produce a number of animal sounds when looking at select picture books and puzzles.  For therapy planning purposes, it is important to note that LS was observed to imitate more sounds and words, when they were supported by action based play activities (when words and sounds were accompanied by a movement initiated by clinician and then imitated by LS). Today LS was observed to primarily communicate via a very limited number of imitated and spontaneous one word utterances that labeled basic objects and pictures in his environment, which is significantly reduced for his age.

A typically developing child of LS’s chronological age (30 months) is expected to possess a minimum vocabulary of 200+ words (Rescorla, 1989), produce 2-4 word utterance combinations (e.g., noun + verb, verb + noun + location, verb + noun + adjective, etc), in addition to asking 2-3 word questions as well as maintaining a topic for 2+ conversational turns. Therapeutic intervention is recommended in order to increase LS’s expressive language abilities.”

Here you have a few speech-language evaluation excerpts which describe not just what the child is capable of but where the child needs to be developmentally.   Now it’s just a matter of summarizing my IMPRESSIONS (child’s strengths and needs), RECOMMENDATIONS as well as SUGGESTED (long and short term) THERAPY GOALS.  Now the parents have some understanding regarding their child’s  strengths and needs.   From here,  they can also track their child’s progress in therapy as they now have some idea to what it can be compared 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.

So, how about it? Can you give it a try? Trust me, it’s worth it!

Selected References:

  • Owens, R. E. (1996). Language development: An introduction (4th ed.). Boston, MA: Allyn & Bacon.
  • Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587–599.
  • Selby, J. C., Robb, M. P., & Gilbert, H. R. (2000). Normal vowel articulations between 15 and 36 months of age. Clinical Linguistics and Phonetics, 14, 255-266.
  • Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
  • Watson, M. M., & Scukanec, G. P. (1997b). Profiling the phonological abilities of 2-year-olds: A longitudinal investigation. Child Language Teaching and Therapy, 13, 3-14.

For more information on EI Assessments click on any of the below posts:

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Is it a Difference or a Disorder? Free Resources for SLPs Working with Bilingual and Multicultural Children

Image result for bilingualFor bilingual and monolingual SLPs working with bilingual and multicultural children, the question of: “Is it a difference or a disorder?” arises on a daily basis as they attempt to navigate the myriad of difficulties they encounter in their attempts at appropriate diagnosis of speech, language, and literacy disorders.

For that purpose, I’ve recently created a Checklist for Identification of Speech-Language Disorders in Bilingual and Multicultural Children. Its aim is to assist Speech Language Pathologists (SLPs) and Teachers in the decision-making process of how to appropriately identify bilingual/multicultural children who present with speech-language delay/deficits (vs. a language difference), for the purpose of initiating a formal speech-language-literacy evaluation. The goal is to ensure that educational professionals are appropriately identifying bilingual children for assessment and service provision due to legitimate speech language deficits/concerns, and are not over-identifying students because they speak multiple languages or because they come from low socioeconomic backgrounds. It is very important to understand that true language impairment in bilingual children will be evident in both languages from early childhood onwards, and thus will adversely affect the learning of both languages.

However, today the aim of today’s post is not on the above product but rather on the FREE free bilingual and multicultural resources available to SLPs online in their quest of differentiating between a language difference from a language disorder in bilingual and multicultural children.

Let’s start with an excellent free infographic entitled from the Hola Blog “Myth vs. Fact: Bilingual Language Development” which was created by Kelly Ibanez, MS CCC-SLP to help dispel bilingual myths and encourage practices that promote multilingualism.  Clinicians can download it and refer to it themselves, share it with other health and/or educational professionals as well as show it to parents of their clients.

Let us now move on to the typical phonological development of English speaking children. After all, in order to compare other languages to English, SLPs need to be well versed in the acquisition of speech sounds in the English language. Children’s speech acquisition, developed by Sharynne McLeod, Ph.D., of Charles Sturt University, is one such resource. It contains a compilation of data on typical speech development for English speaking children, which is organized according to children’s ages to reflect a typical developmental sequence.

Next up, is a great archive which contains phonetic inventories of the various language spoken around the world for contrastive analysis purposes. The same website also contains a speech accent archive. Native and non-native speakers of English were recorded reading the same English paragraph for teaching and research purposes. It is meant to be used by professionals who are interested in comparing the accents of different English speakers.

Image result for charles sturt universityNow let’s talk about one of my favorite websites, MULTILINGUAL CHILDREN’S SPEECH, also developed by Dr. Mcleod of Charles Stuart University. It contains an AMAZING plethora of resources on bilingual speech development and assessment. To illustrate, its Speech Acquisition Data includes A list of over 200 speech acquisition studies. It also contains a HUGE archive on Speech Assessments in NUMEROUS LANGUAGES as well as select assessment reviews. Finally, the website also lists in detail how aspects of speech (e.g., consonants, vowels, syllables, tones) differ between languages.

The Leader’s Project Website is another highly informative source of FREE information on bilingual assessments, intervention, and FREE CEUS.

Now, I’d like to list some resources regarding language transfer errors.

This chart from Cengage Learning contains a nice, concise Language Guide to Transfer Errors. While it is aimed at multilingual/ESL writers, the information contained on the site is highly applicable to multilingual speakers as well.

You can also find a bonus transfer chart HERE. It contains information on specific structures such as articles, nouns, verbs, pronouns, adverbs, adjectives, word order, questions, commands, and negatives on pages 1-6 and phonemes on pages 7-8.

A final bonus chart entitled: Teacher’s Resource Guide of Language Transfer Issues for English Language Learners containing information on grammar and phonics for 10 different languages can be found HERE.  

Similarly, this 16-page handout: Language Transfers: The Interaction Between English and Students’ Primary Languages also contains information on phonics and grammar transfers for Spanish, Cantonese, Vietnamese, Hmong Korean, and Khmer languages.

Image result for russian languageFor SLPs working with Russian-speaking children the following links pertinent to assessment, intervention and language transference may be helpful:

  1. Working with Russian-speaking clients: implications for speech-language assessment 
  2. Strategies in the acquisition of segments and syllables in Russian-speaking children
  3. Language Development of Bilingual Russian/ English Speaking Children Living in the United States: A Review of the Literature
  4. The acquisition of syllable structure by Russian-speaking children with SLI

To determine information about the children’s language development and language environment, in both their first and second language, visit the CHESL Centre website for  The Alberta Language Development Questionnaire and The Alberta Language Environment Questionnaire

There you have it! FREE bilingual/multicultural SLP resources compiled for you conveniently in one place. And since there are much more FREE GEMS online, I’d love it if you guys contributed to and expanded this modest list by posting links and title descriptions in the comments section below for others to benefit from!

Together we can deliver the most up to date evidence-based assessment and intervention to bilingual and multicultural students that we serve! Click HERE to check out the FREE Resources in the  SLPs for Evidence-Based Practice Group

Helpful Bilingual Smart Speech Therapy Resources:

  1. Checklist for Identification of Speech-Language Disorders in Bilingual and Multicultural Children
  2. Multicultural Assessment Bundle
  3. Best Practices in Bilingual Literacy Assessments and Interventions
  4. Dynamic Assessment of Bilingual and Multicultural Learners in Speech-Language Pathology
  5. Practical Strategies for Monolingual SLPs Assessing and Treating Bilingual Children
  6. Language Difference vs. Language Disorder: Assessment & Intervention Strategies for SLPs Working with Bilingual Children
  7. Impact of Cultural and Linguistic Variables On Speech-Language Services
  8. Assessment of sound and syllable imitation in Russian-speaking infants and toddlers
  9. Russian Articulation Screener 
  10. Creating Translanguaging Classrooms and Therapy Rooms

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What do Narratives and Pediatric Psychiatric Impairments Have in Common?

High comorbidity between language and psychiatric disorders has been well documented (Beitchman, Cohen, Konstantaras, & Tannock, 1996; Cohen, Barwick, Horodezky, Vallence, & Im, 1998; Toppelberg & Shapiro, 2000). However, a lesser known fact is that there’s also a significant under-diagnosis of language impairments in children with psychiatric disorders.  Continue reading What do Narratives and Pediatric Psychiatric Impairments Have in Common?

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Dear SLPs, Here’s What You Need to Know About Internationally Adopted Children

In the past several years there has been a sharp decline in international adoptions. Whereas in 2004, Americans adopted a record high of 22,989 children from overseas, in 2015, only 5,647 children  (a record low in 30 years) were adopted from abroad by American citizens.

Primary Data Source: Data Source: U.S. State Department Intercountry Adoption Statistics  

Secondary Data Source: Why Did International Adoption Suddenly End?

Despite a sharp decline in adoptions many SLPs still frequently continue to receive internationally adopted (IA) children for assessment as well as treatment – immediately post adoption as well as a number of years post-institutionalization.

In the age of social media, it may be very easy to pose questions and receive instantaneous responses on platforms such as Facebook and Twitter with respect to assessment and treatment recommendations. However, it is very important to understand that many SLPs, who lack direct clinical experience in international adoptions may chime in with inappropriate recommendations with respect to the assessment or treatment of these children.

Consequently, it is important to identify reputable sources of information when it comes to speech-language assessment of internationally adopted children.

There are a number of researchers in both US and abroad who specialize in speech-language abilities of Internationally Adopted children. This list includes (but is by far not limited to) the following authors:

The works of these researchers can be readily accessed in the ASHA Journals or via ResearchGate.

Meanwhile, here are some basic facts regarding internationally adopted children that all SLPs and parents need to know.

Demographics:

  • —A greater number of older, preschool and school-aged children and fewer number of infants and toddlers are placed for adoption (Selman, 2012).
  • —Significant increase in special needs adoptions from Eastern European countries (e.g., Ukraine, Kazhakstan, etc.) as well as China.  The vast majority of Internationally Adopted children arrive to the United States with significant physical, linguistic, and cognitive disabilities as well as mental health problems. Consequently, it is important for schools to immediately provide the children with a host of services including speech-language therapy, immediately post-arrival.
  • It is also important to know that in the vast majority of cases the child’s linguistic, cognitive, or mental health deficits may not be documented in the adoption records due to poor record keeping, lack of access to adequate healthcare or often to ensure their “adoptability”. As such, parental interviews and anecdotal evidence become the primary source of information regarding these children’s social and academic functioning in their respective birth countries.

The question of bilingualism: 

  • Internationally Adopted children are NOT bilingual children! In fact, the vast majority of internationally adopted children will very rapidly lose their birth language, in a period of 2-3 months post arrival (Gindis, 2005), since they are most often adopted by parents who do not speak the child’s birth language and as such are unable/unwilling to maintain it.
  • IA children do not need to be placed in ESL classes since they are not bilingual children. Not only are IA children not bilingual, they are also not ‘truly’ monolingual since their first language is lost rather rapidly, while their second language has been gained minimally at the time of loss.
  • IA children need to acquire  Cognitive Language Mastery (CLM) which is language needed for formal academic learning. This includes listening, speaking, reading, and writing about subject area content material including analyzing, synthesizing, judging and evaluating presented information. This level of language learning is essential for a child to succeed in school. CLM takes years and years to master, especially because, IA children did not have the same foundation of knowledge and stimulation as bilingual children in their birth countries.

Image result for assessmentAssessment Parameters: 

  • —IA children’s language abilities should be retested and monitored at regular intervals during the first several years post arrival.  —
  • Glennen (2007) recommends 3 evaluations during the first year post arrival, with annual reevaluations thereafter.  —
  • Hough & Kaczmarek (2011) recommend a reevaluation schedule of 3-4 times a year for a period of two years, post arrival because some IA children continue to present with language-based deficits many years (5+) post-adoption.
  • —If an SLP speaking the child’s first language is available the window of opportunity to assess in the first language is very limited (~2-3 months at most).
  • Similarly, an assessment with an interpreter is recommended immediately post arrival from the birth country for a period of approximately the same time.
  • —If an SLP speaking the child’s first language is not available English-speaking SLP should consider assessing the child in English between 3-6 months post arrival (depending on the child and the situational constraints) in order to determine the speed with which s/he are acquiring English language abilities
    • —Children should be demonstrating rapid language gains in the areas of receptive language, vocabulary as well as articulation (Glennen 2007, 2009)
    • Dynamic assessment is highly recommended
  • It is important to remember that language and literacy deficits are not always very apparent and can manifest during any given period post arrival

To treat or NOT to Treat?

  • “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)
  • —IA children with medical diagnoses, which impact their speech language abilities should be assessed and considered for S-L therapy services as well (Ladage, 2009).

Helpful Links:

  1. Elleseff, T (2013) Changing Trends in International Adoption: Implications for Speech-Language Pathologists. Perspectives on Global Issues in Communication Sciences and Related Disorders, 3: 45-53
  2. Assessing Behaviorally Impaired Students: Why Background History Matters!
  3. Dear School Professionals Please Be Aware of This
  4. What parents need to know about speech-language assessment of older internationally adopted children
  5. Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted (IA) children
  6. Understanding the extent of speech and language delays in older internationally adopted children

References:

  • Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315.
  • Glennen, S (2009) Speech and language guidelines for children adopted from abroad at older ages.  Topics in language Disorders 29, 50-64.
  • —Ladage, J. S. (2009). Medical Issues in International Adoption and Their Influence on Language Development. Topics in Language Disorders , 29 (1), 6-17.
  • Selman P. (2012) Global trends in Intercountry Adoption 2000-2010. New York: National Council for Adoption, 2012.
  • Selman P. The global decline of intercountry adoption: What lies ahead?. Social Policy and Society 2012, 11(3), 381-397.

Additional Helpful References:

  • Abrines, N., Barcons, N., Brun, C., Marre, D., Sartini, C., & Fumadó, V. (2012). Comparing ADHD symptom levels in children adopted from Eastern Europe and from other regions: discussing possible factors involved. Children and Youth Services Review, 34 (9) 1903-1908.
  • Balachova, T et al (2010). Changing physicians’ knowledge, skills and attitudes to prevent FASD in Russia: 800. Alcoholism: Clinical & Experimental Research. 34(6) Sup 2:210A.
  • Barcons-Castel, N, Fornieles-Deu,A, & Costas-Moragas, C (2011). International adoption: assessment of adaptive and maladaptive behavior of adopted minors in Spain. The Spanish Journal of Psychology, 14 (1): 123-132.
  • Beverly, B., McGuinness, T., & Blanton, D. (2008). Communication challenges for children adopted from the former Soviet Union. Language, Speech, and Hearing Services in Schools, 39, 1-11.
  • Cohen, N. & Barwick, M. (1996). Comorbidity of language and social-emotional disorders: comparison of psychiatric outpatients and their siblings. Journal of Clinical Child Psychology, 25(2), 192-200.
  • Croft, C et al, (2007). Early adolescent outcomes of institutionally-deprived and nondeprived adoptees: II. Language as a protective factor and a vulnerable outcome. The Journal of Child Psychology and Psychiatry, 48, 31–44.
  • Dalen, M. (2001). School performances among internationally adopted children in Norway. Adoption Quarterly, 5(2), 39-57.
  • Dalen, M. (1995). Learning difficulties among inter-country adopted children. Nordisk pedagogikk, 15 (No. 4), 195-208
  • Davies, J., & Bledsoe, J. (2005). Prenatal alcohol and drug exposures in adoption. Pediatric Clinics of North America, 52, 1369–1393.
  • Desmarais, C., Roeber, B. J., Smith, M. E., & Pollak, S. D. (2012). Sentence comprehension in post-institutionalized school-age children. Journal of Speech, Language, and Hearing Research, 55, 45-54
  • Eigsti, I. M., Weitzman, C., Schuh, J. M., de Marchena, A., & Casey, B. J. (2011). Language and cognitive outcomes in internationally adopted children. Development and Psychopathology, 23, 629-646.
  • Geren, J., Snedeker, J., & Ax, L. (2005). Starting over:  a preliminary study of early lexical and syntactic development in internationally-adopted preschoolers. Seminars in Speech & Language, 26:44-54.
  • Gindis (2008) Abrupt native language loss in international adoptees.  Advance for Speech/Language Pathologists and Audiologists.  18(51): 5.
  • Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315. Gindis, B. (1999) Language-related issues for international adoptees and adoptive families. In: T. Tepper, L. Hannon, D. Sandstrom, Eds. “International Adoption: Challenges and Opportunities.” PNPIC, Meadow Lands , PA. , pp. 98-108
  • Glennen, S (2009) Speech and language guidelines for children adopted from abroad at older ages.  Topics in language Disorders 29, 50-64.
  • Glennen, S. (2007) Speech and language in children adopted internationally at older ages. Perspectives on Communication Disorders in Culturally and Linguistically Diverse Populations, 14, 17–20.
  • Glennen, S., & Bright, B. J.  (2005).  Five years later: language in school-age internally adopted children.  Seminars in Speech and Language, 26, 86-101.
  • Glennen, S. & Masters, G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe. American Journal of Speech-Language Pathology, 44, 417-433
  • Gordina, A (2009) Parent Handout: The Dream Referral, Unpublished Manuscript.
  • Hough, S., & Kaczmarek, L. (2011). Language and reading outcomes in young children adopted from Eastern European orphanages. Journal of Early Intervention, 33, 51-57.
  • Hwa-Froelich, D (2012) Childhood maltreatment and communication development. Perspectives on School-Based Issues,  13: 43-53;
  • Jacobs, E., Miller, L. C., & Tirella, G. (2010).  Developmental and behavioral performance of internationally adopted preschoolers: a pilot study.  Child Psychiatry and Human Development, 41, 15–29.
  • Jenista, J., & Chapman, D. (1987). Medical problems of foreign-born adopted children. American Journal of Diseases of Children, 141, 298–302.
  • Johnson, D. (2000). Long-term medical issues in international adoptees. Pediatric Annals, 29, 234–241.
  • Judge, S. (2003). Developmental recovery and deficit in children adopted from Eastern European orphanages. Child Psychiatry and Human Development, 34, 49–62.
  • Krakow, R. A., & Roberts, J. (2003). Acquisitions of English vocabulary by young Chinese adoptees. Journal of Multilingual Communication Disorders, 1, 169-176
  • Ladage, J. S. (2009). Medical issues in international adoption and their influence on language development. Topics in Language Disorders , 29 (1), 6-17.
  • Loman, M. M., Wiik, K. L., Frenn, K. A., Pollak, S. D., & Gunnar, M. R. (2009). Post-institutionalized children’s development: growth, cognitive, and language outcomes. Journal of Developmental Behavioral Pediatrics, 30, 426–434.
  • McLaughlin, B., Gesi Blanchard, A., & Osanai, Y.  (1995). Assessing language development in bilingual preschool children.  Washington, D.C.: National Clearinghouse for Bilingual Education.
  • Miller, L., Chan, W., Litvinova, A., Rubin, A., Tirella, L., & Cermak, S. (2007). Medical diagnoses and growth of children residing in Russian orphanages. Acta Paediatrica, 96, 1765–1769.
  • Miller, L., Chan, W., Litvinova, A., Rubin, A., Comfort, K., Tirella, L., et al. (2006). Fetal alcohol spectrum disorders in children residing in Russian orphanages: A phenotypic survey. Alcoholism: Clinical and Experimental Research, 30, 531–538.
  • Miller, L. (2005). Preadoption counseling and evaluation of the referral. In L. Miller (Ed.), The Handbook of International Adoption Medicine (pp. 67-86). NewYork: Oxford.
  • Pollock, K. E.  (2005) Early language growth in children adopted from China: preliminary normative data.  Seminars in Speech and Language, 26, 22-32.
  • Roberts, J., Pollock, K., Krakow, R., Price, J., Fulmer, K., & Wang, P. (2005). Language development in preschool-aged children adopted from China. Journal of Speech, Language, and Hearing Research, 48, 93–107.
  • Scott, K.A., Roberts, J.A., & Glennen, S. (2011).  How well children who are internationally do adopted acquire language? A meta-analysis. Journal of Speech, Language and Hearing Research, 54. 1153-69.
  • Scott, K.A., & Roberts, J. (2011). Making evidence-based decisions for children who are internationally adopted. Evidence-Based Practice Briefs. 6(3), 1-16.
  • Scott, K.A., & Roberts, J. (2007) language development of internationally adopted children: the school-age years.  Perspectives on Communication Disorders in Culturally and Linguistically Diverse Populations, 14: 12-17. 
  • Selman P. (2012a) Global trends in intercountry adoption 2000-2010. New York: National Council for Adoption.
  • Selman P (2012b). The rise and fall of intercountry adoption in the 21st century. In: Gibbons, J.L., Rotabi, K.S, ed. Intercountry Adoption: Policies, Practices and Outcomes. London: Ashgate Press.
  • Selman, P. (2010) “Intercountry adoption in Europe 1998–2009: patterns, trends and issues,” Adoption & Fostering, 34 (1): 4-19.
  • Silliman, E. R., & Scott, C. M. (2009). Research-based oral language intervention routes to the academic language of literacy: Finding the right road. In S. A. Rosenfield & V. Wise Berninger (Eds.), Implementing evidence-based academic interventions in school (pp. 107–145). New York: Oxford University Press.
  • Tarullo, A. R., Bruce, J., & Gunnar, M. (2007). False belief and emotion understanding in post-institutionalized children. Social Development, 16, 57-78
  • Tarullo, A. & Gunnar, M. R. (2005). Institutional rearing and deficits in social relatedness: Possible mechanisms and processes. Cognitie, Creier, Comportament [Cognition, Brain, Behavior], 9, 329-342.
  • Varavikova, E. A. & Balachova, T. N. (2010). Strategies to implement physician training in FAS prevention as a part of preventive care in primary health settings: P120.Alcoholism: Clinical & Experimental Research. 34(8) Sup 3:119A.
  • Welsh, J. A., & Viana, A. G. (2012). Developmental outcomes of children adopted internationally. Adoption Quarterly, 15, 241-264.
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Review of the Test of Integrated Language and Literacy (TILLS)

The Test of Integrated Language & Literacy Skills (TILLS) is an assessment of oral and written language abilities in students 6–18 years of age. Published in the Fall 2015, it is  unique in the way that it is aimed to thoroughly assess skills  such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school age children.   As I have been using this test since the time it was published,  I wanted to take an opportunity today to share just a few of my impressions of this assessment.

               

First, a little background on why I chose to purchase this test  so shortly after I had purchased the Clinical Evaluation of Language Fundamentals – 5 (CELF-5).   Soon after I started using the CELF-5  I noticed that  it tended to considerably overinflate my students’ scores  on a variety of its subtests.  In fact,  I noticed that unless a student had a fairly severe degree of impairment,  the majority of his/her scores  came out either low/slightly below average (click for more info on why this was happening HERE, HERE, or HERE). Consequently,  I was excited to hear regarding TILLS development, almost simultaneously through ASHA as well as SPELL-Links ListServe.   I was particularly happy  because I knew some of this test’s developers (e.g., Dr. Elena Plante, Dr. Nickola Nelson) have published solid research in the areas of  psychometrics and literacy respectively.

According to the TILLS developers it has been standardized for 3 purposes:

  • to identify language and literacy disorders
  • to document patterns of relative strengths and weaknesses
  • to track changes in language and literacy skills over time

The testing subtests can be administered in isolation (with the exception of a few) or in its entirety.  The administration of all the 15 subtests may take approximately an hour and a half, while the administration of the core subtests typically takes ~45 mins).

Please note that there are 5 subtests that should not be administered to students 6;0-6;5 years of age because many typically developing students are still mastering the required skills.

  • Subtest 5 – Nonword Spelling
  • Subtest 7 – Reading Comprehension
  • Subtest 10 – Nonword Reading
  • Subtest 11 – Reading Fluency
  • Subtest 12 – Written Expression

However,  if needed, there are several tests of early reading and writing abilities which are available for assessment of children under 6:5 years of age with suspected literacy deficits (e.g., TERA-3: Test of Early Reading Ability–Third Edition; Test of Early Written Language, Third Edition-TEWL-3, etc.).

Let’s move on to take a deeper look at its subtests. Please note that for the purposes of this review all images came directly from and are the property of Brookes Publishing Co (clicking on each of the below images will take you directly to their source).

TILLS-subtest-1-vocabulary-awareness1. Vocabulary Awareness (VA) (description above) requires students to display considerable linguistic and cognitive flexibility in order to earn an average score.    It works great in teasing out students with weak vocabulary knowledge and use,   as well as students who are unable to  quickly and effectively analyze  words  for deeper meaning and come up with effective definitions of all possible word associations. Be mindful of the fact that  even though the words are presented to the students in written format in the stimulus book, the examiner is still expected to read  all the words to the students. Consequently,  students with good vocabulary knowledge  and strong oral language abilities  can still pass this subtest  despite the presence of significant reading weaknesses. Recommendation:  I suggest informally  checking the student’s  word reading abilities  by asking them to read of all the words, before reading all the word choices to them.   This way  you can informally document any word misreadings  made by the student even in the presence of an average subtest score.

TIILLS-subtest-2-phonemic-awareness

2. The Phonemic Awareness (PA) subtest (description above) requires students to  isolate and delete initial sounds in words of increasing complexity.  While this subtest does not require sound isolation and deletion in various word positions, similar to tests such as the CTOPP-2: Comprehensive Test of Phonological Processing–Second Edition  or the The Phonological Awareness Test 2 (PAT 2),   it is still a highly useful and reliable measure of  phonemic awareness (as one of many precursors to reading fluency success).  This is especially because after the initial directions are given, the student is expected to remember to isolate the initial sounds in words without any prompting from the examiner.  Thus,  this task also  indirectly tests the students’ executive function abilities in addition to their phonemic awareness skills.

TILLS-subtest-3-story-retelling

3. The Story Retelling (SR) subtest (description above) requires students to do just that retell a story. Be mindful of the fact that the presented stories have reduced complexity. Thus, unless the students possess  significant retelling deficits, the above subtest  may not capture their true retelling abilities. Recommendation:  Consider supplementing this subtest  with informal narrative measures. For younger children (kindergarten and first grade) I recommend using wordless picture books to perform a dynamic assessment of their retelling abilities following a clinician’s narrative model (e.g., HERE).  For early elementary aged children (grades 2 and up), I recommend using picture books, which are first read to and then retold by the students with the benefit of pictorial but not written support. Finally, for upper elementary aged children (grades 4 and up), it may be helpful for the students to retell a book or a movie seen recently (or liked significantly) by them without the benefit of visual support all together (e.g., HERE).

TILLS-subtest-4-nonword-repetition

4. The Nonword Repetition (NR) subtest (description above) requires students to repeat nonsense words of increasing length and complexity. Weaknesses in the area of nonword repetition have consistently been associated with language impairments and learning disabilities due to the task’s heavy reliance on phonological segmentation as well as phonological and lexical knowledge (Leclercq, Maillart, Majerus, 2013). Thus, both monolingual and simultaneously bilingual children with language and literacy impairments will be observed to present with patterns of segment substitutions (subtle substitutions of sounds and syllables in presented nonsense words) as well as segment deletions of nonword sequences more than 2-3 or 3-4 syllables in length (depending on the child’s age).

TILLS-subtest-5-nonword-spelling

5. The Nonword Spelling (NS) subtest (description above) requires the students to spell nonwords from the Nonword Repetition (NR) subtest. Consequently, the Nonword Repetition (NR) subtest needs to be administered prior to the administration of this subtest in the same assessment session.  In contrast to the real-word spelling tasks,  students cannot memorize the spelling  of the presented words,  which are still bound by  orthographic and phonotactic constraints of the English language.   While this is a highly useful subtest,  is important to note that simultaneously bilingual children may present with decreased scores due to vowel errors.   Consequently,  it is important to analyze subtest results in order to determine whether dialectal differences rather than a presence of an actual disorder is responsible for the error patterns.

TILLS-subtest-6-listening-comprehension

6. The  Listening Comprehension (LC) subtest (description above) requires the students to listen to short stories  and then definitively answer story questions via available answer choices, which include: “Yes”, “No’, and “Maybe”. This subtest also indirectly measures the students’ metalinguistic awareness skills as they are needed to detect when the text does not provide sufficient information to answer a particular question definitively (e.g., “Maybe” response may be called for).  Be mindful of the fact that because the students are not expected to provide sentential responses  to questions it may be important to supplement subtest administration with another listening comprehension assessment. Tests such as the Listening Comprehension Test-2 (LCT-2), the Listening Comprehension Test-Adolescent (LCT-A),  or the Executive Function Test-Elementary (EFT-E)  may be useful  if  language processing and listening comprehension deficits are suspected or reported by parents or teachers. This is particularly important  to do with students who may be ‘good guessers’ but who are also reported to present with word-finding difficulties at sentence and discourse levels. 

TILLS-subtest-7-reading-comprehension

7. The Reading Comprehension (RC) subtest (description above) requires the students to  read short story and answer story questions in “Yes”, “No’, and “Maybe”  format.   This subtest is not stand alone and must be administered immediately following the administration the Listening Comprehension subtest. The student is asked to read the first story out loud in order to determine whether s/he can proceed with taking this subtest or discontinue due to being an emergent reader. The criterion for administration of the subtest is making 7 errors during the reading of the first story and its accompanying questions. Unfortunately,  in my clinical experience this subtest  is not always accurate at identifying children with reading-based deficits.

While I find it terrific for students with severe-profound reading deficits and/or below average IQ, a number of my students with average IQ and moderately impaired reading skills managed to pass it via a combination of guessing and luck despite being observed to misread aloud between 40-60% of the presented words. Be mindful of the fact that typically  such students may have up to 5-6  errors during the reading of the first story. Thus, according to administration guidelines these students will be allowed to proceed and take this subtest.  They will then continue to make text misreadings  during each story presentation (you will know that by asking them to read each story aloud vs. silently).   However,  because the response mode is in definitive (“Yes”, “No’, and “Maybe”) vs. open ended question format,  a number of these students  will earn average scores by being successful guessers. Recommendation:  I highly recommend supplementing the administration of this subtest with grade level (or below grade level) texts (see HERE and/or HERE),  to assess the student’s reading comprehension informally.

I present a full  one page text to the students and ask them to read it to me in its entirety.   I audio/video record  the student’s reading for further analysis (see Reading Fluency section below).   After the  completion of the story I ask  the student questions with a focus on main idea comprehension and vocabulary definitions.   I also ask questions pertaining to story details.   Depending on the student’s age  I may ask them  abstract/ factual text questions with and without text access.  Overall, I find that informal administration of grade level (or even below grade-level) texts coupled with the administration of standardized reading tests provides me with a significantly better understanding of the student’s reading comprehension abilities rather than administration of standardized reading tests alone.

TILLS-subtest-8-following-directions

8. The Following Directions (FD) subtest (description above) measures the student’s ability to execute directions of increasing length and complexity.  It measures the student’s short-term, immediate and working memory, as well as their language comprehension.  What is interesting about the administration of this subtest is that the graphic symbols (e.g., objects, shapes, letter and numbers etc.) the student is asked to modify remain covered as the instructions are given (to prevent visual rehearsal). After being presented with the oral instruction the students are expected to move the card covering the stimuli and then to executive the visual-spatial, directional, sequential, and logical if–then the instructions  by marking them on the response form.  The fact that the visual stimuli remains covered until the last moment increases the demands on the student’s memory and comprehension.  The subtest was created to simulate teacher’s use of procedural language (giving directions) in classroom setting (as per developers).

TILLS-subtest-9-delayed-story-retelling

9. The Delayed Story Retelling (DSR) subtest (description above) needs to be administered to the students during the same session as the Story Retelling (SR) subtest, approximately 20 minutes after the SR subtest administration.  Despite the relatively short passage of time between both subtests, it is considered to be a measure of long-term memory as related to narrative retelling of reduced complexity. Here, the examiner can compare student’s performance to determine whether the student did better or worse on either of these measures (e.g., recalled more information after a period of time passed vs. immediately after being read the story).  However, as mentioned previously, some students may recall this previously presented story fairly accurately and as a result may obtain an average score despite a history of teacher/parent reported  long-term memory limitations.  Consequently, it may be important for the examiner to supplement the administration of this subtest with a recall of a movie/book recently seen/read by the student (a few days ago) in order to compare both performances and note any weaknesses/limitations.

TILLS-subtest-10-nonword-reading

10. The Nonword Reading (NR) subtest (description above) requires students to decode nonsense words of increasing length and complexity. What I love about this subtest is that the students are unable to effectively guess words (as many tend to routinely do when presented with real words). Consequently, the presentation of this subtest will tease out which students have good letter/sound correspondence abilities as well as solid orthographic, morphological and phonological awareness skills and which ones only memorized sight words and are now having difficulty decoding unfamiliar words as a result.      TILLS-subtest-11-reading-fluency

11. The Reading Fluency (RF) subtest (description above) requires students to efficiently read facts which make up simple stories fluently and correctly.  Here are the key to attaining an average score is accuracy and automaticity.  In contrast to the previous subtest, the words are now presented in meaningful simple syntactic contexts.

It is important to note that the Reading Fluency subtest of the TILLS has a negatively skewed distribution. As per authors, “a large number of typically developing students do extremely well on this subtest and a much smaller number of students do quite poorly.”

Thus, “the mean is to the left of the mode” (see publisher’s image below). This is why a student could earn an average standard score (near the mean) and a low percentile rank when true percentiles are used rather than NCE percentiles (Normal Curve Equivalent). Tills Q&A – Negative Skew

Consequently under certain conditions (See HERE) the percentile rank (vs. the NCE percentile) will be a more accurate representation of the student’s ability on this subtest.

Indeed, due to the reduced complexity of the presented words some students (especially younger elementary aged) may obtain average scores and still present with serious reading fluency deficits.  

I frequently see that in students with average IQ and go to long-term memory, who by second and third grades have managed to memorize an admirable number of sight words due to which their deficits in the areas of reading appeared to be minimized.  Recommendation: If you suspect that your student belongs to the above category I highly recommend supplementing this subtest with an informal measure of reading fluency.  This can be done by presenting to the student a grade level text (I find science and social studies texts particularly useful for this purpose) and asking them to read several paragraphs from it (see HERE and/or HERE).

As the students are reading  I calculate their reading fluency by counting the number of words they read per minute.  I find it very useful as it allows me to better understand their reading profile (e.g, fast/inaccurate reader, slow/inaccurate reader, slow accurate reader, fast/accurate reader).   As the student is reading I note their pauses, misreadings, word-attack skills and the like. Then, I write a summary comparing the students reading fluency on both standardized and informal assessment measures in order to document students strengths and limitations.

TILLS-subtest-12-written-expression

12. The Written Expression (WE) subtest (description above) needs to be administered to the students immediately after the administration of the Reading Fluency (RF) subtest because the student is expected to integrate a series of facts presented in the RF subtest into their writing sample. There are 4 stories in total for the 4 different age groups.

The examiner needs to show the student a different story which integrates simple facts into a coherent narrative. After the examiner reads that simple story to the students s/he is expected to tell the students that the story is  okay, but “sounds kind of “choppy.” They then need to show the student an example of how they could put the facts together in a way that sounds more interesting and less choppy  by combining sentences (see below). Finally, the examiner will ask the students to rewrite the story presented to them in a similar manner (e.g, “less choppy and more interesting.”)

tills

After the student finishes his/her story, the examiner will analyze it and generate the following scores: a discourse score, a sentence score, and a word score. Detailed instructions as well as the Examiner’s Practice Workbook are provided to assist with scoring as it takes a bit of training as well as trial and error to complete it, especially if the examiners are not familiar with certain procedures (e.g., calculating T-units).

Full disclosure: Because the above subtest is still essentially sentence combining, I have only used this subtest a handful of times with my students. Typically when I’ve used it in the past, most of my students fell in two categories: those who failed it completely by either copying text word  for word, failing to generate any written output etc. or those who passed it with flying colors but still presented with notable written output deficits. Consequently, I’ve replaced Written Expression subtest administration with the administration of written standardized tests, which I supplement with an informal grade level expository, persuasive, or narrative writing samples.

Having said that many clinicians may not have the access to other standardized written assessments, or lack the time to administer entire standardized written measures (which may frequently take between 60 to 90 minutes of administration time). Consequently, in the absence of other standardized writing assessments, this subtest can be effectively used to gauge the student’s basic writing abilities, and if needed effectively supplemented by informal writing measures (mentioned above).

TILLS-subtest-13-social-communication

13. The Social Communication (SC) subtest (description above) assesses the students’ ability to understand vocabulary associated with communicative intentions in social situations. It requires students to comprehend how people with certain characteristics might respond in social situations by formulating responses which fit the social contexts of those situations. Essentially students become actors who need to act out particular scenes while viewing select words presented to them.

Full disclosure: Similar to my infrequent administration of the Written Expression subtest, I have also administered this subtest very infrequently to students.  Here is why.

I am an SLP who works full-time in a psychiatric hospital with children diagnosed with significant psychiatric impairments and concomitant language and literacy deficits.  As a result, a significant portion of my job involves comprehensive social communication assessments to catalog my students’ significant deficits in this area. Yet, past administration of this subtest showed me that number of my students can pass this subtest quite easily despite presenting with notable and easily evidenced social communication deficits. Consequently, I prefer the administration of comprehensive social communication testing when working with children in my hospital based program or in my private practice, where I perform independent comprehensive evaluations of language and literacy (IEEs).

Again, as I’ve previously mentioned many clinicians may not have the access to other standardized social communication assessments, or lack the time to administer entire standardized written measures. Consequently, in the absence of other social communication assessments, this subtest can be used to get a baseline of the student’s basic social communication abilities, and then be supplemented with informal social communication measures such as the Informal Social Thinking Dynamic Assessment Protocol (ISTDAP) or observational social pragmatic checklists. 

TILLS-subtest-14-digit-span-forward

14.  The Digit Span Forward (DSF) subtest (description above) is a relatively isolated  measure  of short term and verbal working memory ( it minimizes demands on other aspects of language such as syntax or vocabulary).

TILLS-subtest-15-digit-span-backward

15.  The Digit Span Backward (DSB) subtest (description above) assesses the student’s working memory and requires the student to mentally manipulate the presented stimuli in reverse order. It allows examiner to observe the strategies (e.g. verbal rehearsal, visual imagery, etc.) the students are using to aid themselves in the process.  Please note that the Digit Span Forward subtest must be administered immediately before the administration of this subtest.

SLPs who have used tests such as the Clinical Evaluation of Language Fundamentals – 5 (CELF-5) or the Test of Auditory Processing Skills – Third Edition (TAPS-3) should be highly familiar with both subtests as they are fairly standard measures of certain aspects of memory across the board.

To continue, in addition to the presence of subtests which assess the students literacy abilities, the TILLS also possesses a number of interesting features.

For starters, the TILLS Easy Score, which allows the examiners to use their scoring online. It is incredibly easy and effective. After clicking on the link and filling out the preliminary demographic information, all the examiner needs to do is to plug in this subtest raw scores, the system does the rest. After the raw scores are plugged in, the system will generate a PDF document with all the data which includes (but is not limited to) standard scores, percentile ranks, as well as a variety of composite and core scores. The examiner can then save the PDF on their device (laptop, PC, tablet etc.) for further analysis.

The there is the quadrant model. According to the TILLS sampler (HERE)  “it allows the examiners to assess and compare students’ language-literacy skills at the sound/word level and the sentence/ discourse level across the four oral and written modalities—listening, speaking, reading, and writing” and then create “meaningful profiles of oral and written language skills that will help you understand the strengths and needs of individual students and communicate about them in a meaningful way with teachers, parents, and students. (pg. 21)”

tills quadrant model

Then there is the Student Language Scale (SLS) which is a one page checklist parents,  teachers (and even students) can fill out to informally identify language and literacy based strengths and weaknesses. It  allows for meaningful input from multiple sources regarding the students performance (as per IDEA 2004) and can be used not just with TILLS but with other tests or in even isolation (as per developers).

Furthermore according to the developers, because the normative sample included several special needs populations, the TILLS can be used with students diagnosed with ASD,  deaf or hard of hearing (see caveat), as well as intellectual disabilities (as long as they are functioning age 6 and above developmentally).

According to the developers the TILLS is aligned with Common Core Standards and can be administered as frequently as two times a year for progress monitoring (min of 6 mos post 1st administration).

With respect to bilingualism examiners can use it with caution with simultaneous English learners but not with sequential English learners (see further explanations HERE).   Translations of TILLS are definitely not allowed as they will undermine test validity and reliability.

So there you have it these are just some of my very few impressions regarding this test.  Now to some of you may notice that I spend a significant amount of time pointing out some of the tests limitations. However, it is very important to note that we have research that indicates that there is no such thing as a “perfect standardized test” (see HERE for more information).   All standardized tests have their limitations. 

Having said that, I think that TILLS is a PHENOMENAL addition to the standardized testing market, as it TRULY appears to assess not just language but also literacy abilities of the students on our caseloads.

That’s all from me; however, before signing off I’d like to provide you with more resources and information, which can be reviewed in reference to TILLS.  For starters, take a look at Brookes Publishing TILLS resources.  These include (but are not limited to) TILLS FAQ, TILLS Easy-Score, TILLS Correction Document, as well as 3 FREE TILLS Webinars.   There’s also a Facebook Page dedicated exclusively to TILLS updates (HERE).

But that’s not all. Dr. Nelson and her colleagues have been tirelessly lecturing about the TILLS for a number of years, and many of their past lectures and presentations are available on the ASHA website as well as on the web (e.g., HERE, HERE, HERE, etc). Take a look at them as they contain far more in-depth information regarding the development and implementation of this groundbreaking assessment.

To access TILLS fully-editable template, click HERE

Disclaimer:  I did not receive a complimentary copy of this assessment for review nor have I received any encouragement or compensation from either Brookes Publishing  or any of the TILLS developers to write it.  All images of this test are direct property of Brookes Publishing (when clicked on all the images direct the user to the Brookes Publishing website) and were used in this post for illustrative purposes only.

References: 

Leclercq A, Maillart C, Majerus S. (2013) Nonword repetition problems in children with SLI: A deficit in accessing long-term linguistic representations? Topics in Language Disorders. 33 (3) 238-254.

Related Posts:

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If It’s NOT CAPD Then Where do SLPs Go From There?

Image result for processingIn July 2015 I wrote a blog post entitled: “Why (C) APD Diagnosis is NOT Valid!” citing the latest research literature to explain that the controversial diagnosis of (C)APD tends to

a) detract from understanding that the child presents with legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development

b) may result in the above deficits not getting adequately addressed due to the provision of controversial APD treatments

To CLARIFY, I was NOT trying to disprove that the processing deficits exhibited by the children diagnosed with “(C)APD” were not REAL. Rather I was trying to point out that these processing deficits are of neurolinguistic origin and as such need to be addressed from a linguistic rather than ‘auditory’ standpoint.

In other words, if one carefully analyzes the child’s so-called processing issues, one will quickly realize that those issues are not related to the processing of auditory input  (auditory domain) since the child is not processing tones, hoots, or clicks, etc. but rather has difficulty processing speech and language (linguistic domain). Continue reading If It’s NOT CAPD Then Where do SLPs Go From There?

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What Research Shows About the Functional Relevance of Standardized Language Tests

Image result for standardized language testsAs an SLP who routinely conducts speech and language assessments in several settings (e.g., school and private practice), I understand the utility of and the need for standardized speech, language, and literacy tests.  However, as an SLP who works with children with dramatically varying degree of cognition, abilities, and skill-sets, I also highly value supplementing these standardized tests with functional and dynamic assessments, interactions, and observations.

Since a significant value is placed on standardized testing by both schools and insurance companies for the purposes of service provision and reimbursement, I wanted to summarize in today’s post the findings of recent articles on this topic.  Since my primary interest lies in assessing and treating school-age children, for the purposes of today’s post all of the reviewed articles came directly from the Language Speech and Hearing Services in Schools  (LSHSS) journal.

We’ve all been there. We’ve all had situations in which students scored on the low end of normal, or had a few subtest scores in the below average range, which equaled  an average total score.  We’ve all poured over eligibility requirements trying to figure out whether the student should receive therapy services given the stringent standardized testing criteria in some states/districts.

Of course, as it turns out, the answer is never simple.  In 2006, Spaulding, Plante & Farinella set out to examine the assumption: “that children with language impairment will receive low scores on standardized tests, and therefore [those] low scores will accurately identify these children” (61).   So they analyzed the data from 43 commercially available child language tests to identify whether evidence exists to support their use in identifying language impairment in children.

Turns out it did not!  Turns out due to the variation in psychometric properties of various tests (see article for specific details), many children with language impairment are overlooked by standardized tests by receiving scores within the average range or not receiving low enough scores to qualify for services. Thus, “the clinical consequence is that a child who truly has a language impairment has a roughly equal chance of being correctly or incorrectly identified, depending on the test that he or she is given.” Furthermore, “even if a child is diagnosed accurately as language impaired at one point in time, future diagnoses may lead to the false perception that the child has recovered, depending on the test(s) that he or she has been given (69).”

Consequently, they created a decision tree (see below) with recommendations for clinicians using standardized testing. They recommend using alternate sources of data (sensitivity and specificity rates) to support accurate identification (available for a small subset of select tests).

The idea behind it is: “if sensitivity and specificity data are strong, and these data were derived from subjects who are comparable to the child tested, then the clinician can be relatively confident in relying on the test score data to aid his or her diagnostic decision. However, if the data are weak, then more caution is warranted and other sources of information on the child’s status might have primacy in making a diagnosis (70).”

Fast forward 6 years, and a number of newly revised tests later,  in 2012, Spaulding and colleagues set out to “identify various U.S. state education departments’ criteria for determining the severity of language impairment in children, with particular focus on the use of norm-referenced tests” as well as to “determine if norm-referenced tests of child language were developed for the purpose of identifying the severity of children’s language impairment”  (176).

They obtained published procedures for severity determinations from available U.S. state education departments, which specified the use of norm-referenced tests, and reviewed the manuals for 45 norm-referenced tests of child language to determine if each test was designed to identify the degree of a child’s language impairment.

What they found out was “the degree of use and cutoff-point criteria for severity determination varied across states. No cutoff-point criteria aligned with the severity cutoff points described within the test manuals. Furthermore, tests that included severity information lacked empirical data on how the severity categories were derived (176).”

Thus they urged SLPs to exercise caution in determining the severity of children’s language impairment via norm-referenced test performance “given the inconsistency in guidelines and lack of empirical data within test manuals to support this use (176)”.

Following the publication of this article, Ireland, Hall-Mills & Millikin issued a response to the  Spaulding and colleagues article. They pointed out that the “severity of language impairment is only one piece of information considered by a team for the determination of eligibility for special education and related services”.  They noted that  they left out a host of federal and state guideline requirements and “did not provide an analysis of the regulations governing special education evaluation and criteria for determining eligibility (320).” They pointed out that “IDEA prohibits the use of ‘any single measure or assessment as the sole criterion’ for determination of disability  and requires that IEP teams ‘draw upon information from a variety of sources.”

They listed a variety of examples from several different state departments of education (FL, NC, VA, etc.), which mandate the use of functional assessments, dynamic assessments criterion-referenced assessments, etc. for their determination of language therapy eligibility.

But are the SLPs from across the country appropriately using the federal and state guidelines in order to determine eligibility? While one should certainly hope so, it does not always seem to be the case.  To illustrate, in 2012, Betz & colleagues asked 364 SLPs to complete a survey “regarding how frequently they used specific standardized tests when diagnosing suspected specific language impairment (SLI) (133).”

Their purpose was to determine “whether the quality of standardized tests, as measured by the test’s psychometric properties, is related to how frequently the tests are used in clinical practice” (133).

What they found out was that the most frequently used tests were the comprehensive assessments including the Clinical Evaluation of Language Fundamentals and the Preschool Language Scale as well as one word vocabulary tests such as the Peabody Picture Vocabulary Test. Furthermore, the date of publication seemed to be the only factor which affected the frequency of test selection.

They also found out that frequently SLPs did not follow up the comprehensive standardized testing with domain specific assessments (critical thinking, social communication, etc.) but instead used the vocabulary testing as a second measure.  They were understandably puzzled by that finding. “The emphasis placed on vocabulary measures is intriguing because although vocabulary is often a weakness in children with SLI (e.g., Stothard et al., 1998), the research to date does not show vocabulary to be more impaired than other language domains in children with SLI (140).“

According to the authors, “perhaps the most discouraging finding of this study was the lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores (141).”

If since the time (2012) SLPs have not significantly change their practices, the above is certainly disheartening, as it implies that rather than being true diagnosticians, SLPs are using whatever is at hand that has been purchased by their department to indiscriminately assess students with suspected speech language disorders. If that is truly the case, it certainly places into question the Ireland, Hall-Mills & Millikin’s response to Spaulding and colleagues.  In other words, though SLPs are aware that they need to comply with state and federal regulations when it comes to unbiased and targeted assessments of children with suspected language disorders, they may not actually be using appropriate standardized testing much less supplementary informal assessments (e.g., dynamic, narrative, language sampling) in order to administer well-rounded assessments.  

So where do we go from here? Well, it’s quite simple really!   We already know what the problem is. Based on the above articles we know that:

  1. Standardized tests possess significant limitations
  2. They are not used with optimal effectiveness by many SLPs
  3.  They may not be frequently supplemented by relevant and targeted informal assessment measures in order to improve the accuracy of disorder determination and subsequent therapy eligibility

Now that we have identified a problem, we need to develop and consistently implement effective practices to ameliorate it.  These include researching psychometric properties of tests to review sample size, sensitivity and specificity, etc, use domain specific assessments to supplement administration of comprehensive testing, as well as supplement standardized testing with a plethora of functional assessments.

SLPs can review testing manuals and consult with colleagues when they feel that the standardized testing is underidentifying students with language impairments (e.g., HERE and HERE).  They can utilize referral checklists (e.g., HERE) in order to pinpoint the students’ most significant difficulties. Finally, they can develop and consistently implement informal assessment practices (e.g., HERE and HERE) during testing in order to gain a better grasp on their students’ TRUE linguistic functioning.

Stay tuned for the second portion of this post entitled: “What Research Shows About the Functional Relevance of Standardized Speech Tests?” to find out the best practices in the assessment of speech sound disorders in children.

References:

  1. Spaulding, Plante & Farinella (2006) Eligibility Criteria for Language Impairment: Is the Low End of Normal Always Appropriate?
  2. Spaulding, Szulga, & Figueria (2012) Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers
  3. Ireland, Hall-Mills & Millikin (2012) Appropriate Implementation of Severity Ratings, Regulations, and State Guidance: A Response to “Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers” by Spaulding, Szulga, & Figueria (2012)
  4. Betz et al. (2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment