Category: Assessment

Posted on by — Leave a comment

The Limitations of Using Total/Core Scores When Determining Speech-Language Eligibility

In both of the settings where I work, psychiatric outpatient school as well as private practice, I spend a fair amount of time reviewing speech language evaluation reports.  As I’m looking at these reports I am seeing that many examiners choose to base their decision making with respect to speech language services eligibility on the students’ core, index, or total scores, which are composite scores. For those who are not familiar with this term, composite scores are standard scores based on the sum of various test scaled scores.

When the student displays average abilities on all of the presented subtests, use of composite scores clearly indicates that the child does not present with deficits and thereby is not eligible for therapy services.

The same goes for the reverse, when the child is displaying a pattern of deficits which places their total score well below the average range of functioning. Again, it indicates that the child is performing poorly and requires therapy services.

However, there’s also a the third scenario, which presents a cause for concern namely, when the students display a pattern of strengths and weaknesses on a variety of subtests, but end up with an average/low average total scores, making them ineligible for services. 

Results of the Test of Problem Solving -2 Elementary (TOPS-3)

Subtests Raw Score Standard Score Percentile Rank Description
Making Inferences 19 83 12 Below Average
Sequencing 22 86 17 Low Average
Negative Questions 21 95 38 Average
Problem Solving 21 90 26 Average
Predicting 18 92 29 Average
Determining Causes 13 82 11 Below Average
Total Test 114 86 18 Low Average

Results of the Test of Reading Comprehension-Fourth Edition (TORC-4)

Subtests Raw Score Standard Score Percentile Rank Description
Relational Vocabulary 24 9 37 Average
Sentence Completion 25 9 37 Average
Paragraph Construction 41 12 75 Average
Text Comprehension 21 7 16 Below Average
Contextual Fluency 86 6 9 Below Average
Reading Comprehension Index 90 Average

The above tables, taken from different evaluations, perfectly illustrate such a scenario. While we see that their total/index scores are within average range, the first student has displayed a pattern of strengths and weaknesses across various subtests of the TOPS-3, while the second one displayed a similar performance pattern on the TORC-4.

Typically in such cases, clinical judgment dictates a number of options:

  1. Administration of another standardized test further probing into related areas of difficulty (e.g., in such situations the administration of a social pragmatic standardized test may reveal a significant pattern of weaknesses which would confirm student’s eligibility for language therapy services).                                                                                                        
  2. Administration of informal/dynamic assessments/procedures further probing into the student’s critical thinking/verbal reasoning skills.

Image result for follow upHere is the problem though: I only see the above follow-up steps in a small percentage of cases. In the vast majority of cases in which score discrepancies occur, I see the examiners ignoring the weaknesses without follow up. This of course results in the child not qualifying for services.

So why do such practices frequently take place? Is it because SLPs want to deny children services?  And the answer is NOT at all! The vast majority of SLPs, I have had the pleasure interacting with, are deeply caring and concerned individuals, who only want what’s best for the student in question. Oftentimes, I believe the problem lies with the misinterpretation of/rigid adherence to the state educational code.

For example, most NJ SLPs know that the New Jersey State Education Code dictates that initial eligibility must be determined via use of two standardized tests on which the student must perform 1.5 standard deviations below the mean (or below the 10th percentile).  Based on such phrasing it is reasonable to assume that any child who receives the total scores on two standardized tests above the 10th percentile will not qualify for services. Yet this is completely incorrect!

Let’s take a closer look at the clarification memo issued on October 6, 2015, by the New Jersey Department of Education, in response to NJ Edu Code misinterpretation. Here is what it actually states.

“In accordance with this regulation, when assessing for a language disorder for purposes of determining whether a student meets the criteria for communication impaired, the problem must be demonstrated through functional assessment of language in other than a testing situation and performance below 1.5 standard deviations, or the 10th percentile on at least two standardized language tests, where such tests are appropriate, one of which shall be a comprehensive test of both receptive and expressive language.”

“When implementing the requirement with respect to “standardized language tests,” test selection for evaluation or reevaluation of an individual student is based on various factors, including the student’s ability to participate in the tests, the areas of suspected language difficulties/deficits (e.g., morphology, syntax, semantics, pragmatics/social language) and weaknesses identified during the assessment process which require further testing, etc. With respect to test interpretation and decision-making regarding eligibility for special education and related services and eligibility for speech-language services, the criteria in the above provision do not limit the types of scores that can be considered (e.g., index, subtest, standard score, etc.).”

Firstly, it emphasizes functional assessments. It doesn’t mean that assessments should be exclusively standardized rather it emphasizes the best appropriate procedures for the student in question be they standardized and nonstandardized.

Secondly, it does not limit standardized assessment to 2 tests only. Rather it uses though phrase “at least” to emphasize the minimum of tests needed.

It explicitly makes a reference to following up on any weaknesses displayed by the students during standardized testing in order to get to the root of a problem.

It specifies that SLPs must assess all displayed areas of difficulty (e.g., social communication) rather than assessing general language abilities only.

Finally, it explicitly points out that SLPs cannot limit their testing interpretation to the total scores but must to look at the testing results holistically, taking into consideration the student’s entire assessment performance.

The problem is that if SLPs only look at total/core scores then numerous children with linguistically-based deficits will fall through the cracks.  We are talking about children with social communication deficits, children with reading disabilities, children with general language weaknesses, etc.  These students may be displaying average total scores but they may also be displaying significant subtest weaknesses. The problem is that unless these weaknesses are accounted for and remediated as they are not going to magically disappear or resolve on their own. In fact both research and clinical judgment dictates that these weaknesses will exacerbate over time and will continue to adversely impact both social communication and academics.

So the next time you see a pattern of strengths and weaknesses and testing, even if it amounts to a total average score, I urge you to dig deeper. I urge you to investigate why this pattern is displayed in the first place. The same goes for you – parents! If you are looking at average total scores  but seeing unexplained weaknesses in select testing areas, start asking questions! Ask the professional to explain why those deficits are occuring and tell them to dig deeper if you are not satisfied with what you are hearing. All students deserve access to FAPE (Free and Appropriate Public Education). This includes access to appropriate therapies, they may need in order to optimally function in the classroom.

I urge my fellow SLP’s to carefully study their respective state codes as well as know who they are state educational representatives are. These are the professionals SLPs can contact with questions regarding educational code clarification.  For example, the SEACDC Consultant for the state of New Jersey is currently Fran Liebner (phone: 609-984-4955; Fax: 609-292-5558; e-mail: fran.leibner@doe.state.nj.us).

However, the Department of Education is not the only place SLPs can contact in their state.  Numerous state associations worked diligently on behalf of SLPs by liaising with the departments of education in order to have access to up to date information pertaining to school services.  ASHA also helpfully provides contact information by state HERE.

When it comes to score interpretation, there are a variety of options available to SLPs in addition to the detailed reading of the test manual. We can use them to ensure that the students we serve experience optimal success in both social and academic settings.

Helpful Smart Speech Therapy Resources:

Posted on by — 9 Comments

Why Are My Child’s Test Scores Dropping?

“I just don’t understand,” says a parent bewilderingly, “she’s receiving so many different therapies and tutoring every week, but her scores on educational, speech-language, and psychological testing just keep dropping!”

I hear a variation of this comment far too frequently in both my private practice as well as outpatient school in hospital setting, from parents looking for an explanation regarding the decline of their children’s standardized test scores in both cognitive (IQ) and linguistic domains. That is why today I wanted to take a moment to write this blog post to explain a few reasons behind this phenomenon.

Children with language impairments represent a highly diverse group, which exists along a continuum.   Some children’s deficits may be mild while others far more severe. Some children may receive very little intervention  services and thrive academically, while others can receive inordinate amount of interventions and still very limitedly benefit from them.  To put it in very simplistic terms, the above is due to two significant influences – the interaction between the child’s (1) genetic makeup and (2) environmental factors.

There is a reason why language disorders are considered developmental.   Firstly, these difficulties are apparent from a young age when the child’s language just begins to develop.  Secondly, the trajectory of the child’s language deficits also develops along with the child and can progress/lag based on the child’s genetic predisposition, resiliency, parental input, as well as schooling and academically based interventions.

Let us discuss some of the reasons why standardized testing results may decline for select students who are receiving a variety of support services and interventions.

Ineffective Interventions due to Misdiagnosis 

Sometimes, lack of appropriate/relevant intervention provision may be responsible for it.  Let’s take an example of a misdiagnosis of alcohol related deficits as Autism, which I have frequently encountered in my private practice, when performing second opinion testing and consultations. Unfortunately, the above is not uncommon.  Many children with alcohol-related impairments may present with significant social emotional dysregulation coupled with significant externalizing behavior manifestations.  As a result, without a thorough differential diagnosis they may be frequently diagnosed with ASD and then provided with ABA therapy services for years with little to no benefit.

Ineffective Interventions due to Lack of Comprehensive Testing 

Let us examine another example of a student with average intelligence but poor reading performance.  The student may do well in school up to certain grade but then may begin to flounder academically.  Because only the student’s reading abilities ‘seem’ to be adversely impacted, no comprehensive language and literacy evaluations are performed.   The student may receive undifferentiated extra reading support in school while his scores may continue to drop.

Once the situation ‘gets bad enough’, the student’s language and literacy abilities may be comprehensively assessed.  In a vast majority of situations these type of assessments yield the following results:

  1. The student’s oral language expression as well as higher order language abilities are adversely affected and require targeted language intervention
  2. The undifferentiated reading intervention provided to the student was NOT targeting actual areas of weaknesses

As can be seen from above examples, targeted intervention is hugely important and, in a number of cases, may be responsible  for the student’s declining performance. However, that is not always the case.

What if it was definitively confirmed that the student was indeed diagnosed appropriately and was receiving quality services but still continued to decline academically. What then?

Well, we know that many children with genetic disorders (Down Syndrome, Fragile X, etc.) as well as intellectual disabilities (ID) can make incredibly impressive gains in a variety of developmental areas (e.g., gross/fine motor skills, speech/language, socio-emotional, ADL, etc.)  but their gains will not be on par with peers without these diagnoses.

The situation becomes much more complicated when children without ID (or with mild intellectual deficits) and varying degrees of language impairment, receive effective therapies, work very hard in therapy, yet continue  to be perpetually behind their peers when it comes to making academic gains.  This occurs because of a phenomenon known as Cumulative Cognitive Deficit (CCD).

The Effect of Cumulative Cognitive Deficit (CCD) on Academic Performance 

According to Gindis (2005) CCD “refers to a downward trend in the measured intelligence and/or scholastic achievement of culturally/socially disadvantaged children relative to age-appropriate societal norms and expectations” (p. 304). Gindis further elucidates by quoting Satler (1992): “The theory behind cumulative deficit is that children who are deprived of enriching cognitive experiences during their early years are less able to profit from environmental situations because of a mismatch between their cognitive schemata and the requirements of the new (or advanced) learning situation”  (pp. 575-576).

So who are the children potentially at risk for CCD?

One such group are internationally (and domestically) adopted as well as foster care children.  A number of studies show that due to the early life hardships associated with prenatal trauma (e.g., maternal substance abuse, lack of adequate prenatal care, etc.) as well as postnatal stress (e.g., adverse effect of institutionalization), many of these children have much poorer social and academic outcomes despite being adopted by well-to-do, educated parents who continue to provide them with exceptional care in all aspects of their academic and social development.

Another group, are children with diagnosed/suspected psychiatric impairments and concomitant overt/hidden language deficits. Depending on the degree and persistence of the psychiatric impairment, in addition to having intermittent access to classroom academics and therapy interventions, the quality of their therapy may be affected by the course of their illness. Combined with sporadic nature of interventions this may result in them falling further and further behind their peers with respect to social and academic outcomes.

A third group (as mentioned previously) are children with genetic syndromes, neurodevelopmental disorders (e.g., Autism) and intellectual disabilities. Here, it is very important to explicitly state that children with diagnosed or suspected alcohol related deficits (FASD) are particularly at risk due to the lack of consensus/training  regarding FAS detection/diagnosis. Consequently, these children may evidence a steady ‘decline’ on standardized testing despite exhibiting steady functional gains in therapy.

Brief Standardized Testing Score Tutorial:

When we look at norm-referenced testing results, score interpretation can be quite daunting. For the sake of simplicity,  I’d like to restrict this discussion to two types of scores: raw scores and standard scores.

The raw score is the number of items the child answered correctly on a test or a subtest. However, raw scores need to be interpreted to be meaningful.  For example, a 9 year old student can attain a raw score of 12 on a subtest of a particular test (e.g., Listening Comprehension Test-2 or LCT-2).  Without more information, the raw score has no meaning. If the test consisted of 15 questions, a raw score of 12 would be an average score. Alternatively, if the subtest had 36 questions, a raw score of 12 would be significantly below-average (e.g., Test of Problem Solving-3 or TOPS-3).

Consequently, the raw score needs to be converted to a standard score. Standard scores compare the student’s performance on a test to the performance of other students his/her age.  Many standardized language assessments have a mean of 100 and a standard deviation of 15. Thus, scores between 85 and 115 are considered to be in the average range of functioning.

Now lets discuss testing performance variation across time. Let’s say an 8.6 year old student took the above mentioned LCT-2 and attained poor standard scores on all subtests.   That student qualifies for services and receives them for a period of one year. At that time the LCT-2 is re-administered once again and much to the parents surprise the student’s standard scores appear to be even lower than when he had taken the test as an eight year old (illustration below).

Results of The Listening Comprehension Test -2 (LCT-2): Age: 8:4

Subtests Raw Score Standard Score Percentile Rank Description
Main Idea 5 67 2 Severely Impaired
Details 2 63 1 Severely Impaired
Reasoning 2 69 2 Severely Impaired
Vocabulary 0 Below Norms Below Norms Profoundly Impaired
Understanding Messages 0 <61 <1 Profoundly Impaired
Total Test Score 9 <63 1 Profoundly Impaired

(Mean = 100, Standard Deviation = +/-15)

Results of The Listening Comprehension Test -2 (LCT-2):  Age: 9.6

Subtests Raw Score Standard Score Percentile Rank Description
Main Idea 6 60 0 Severely Impaired
Details 5 66 1 Severely Impaired
Reasoning 3 62 1 Severely Impaired
Vocabulary 4 74 4 Moderately Impaired
Understanding Messages 2 54 0 Profoundly Impaired
Total Test Score 20 <64 1 Profoundly Impaired

(Mean = 100, Standard Deviation = +/-15)

However, if one looks at the raw score column on the far left, one can see that the student as a 9 year old actually answered more questions than as an 8 year old and his total raw test score went up by 11 points.

The above is a perfect illustration of CCD in action. The student was able to answer more questions on the test but because academic, linguistic, and cognitive demands continue to steadily increase with age, this quantitative improvement in performance (increase in total number of questions answered) did not result in qualitative  improvement in performance (increase in standard scores).

In the first part of this series I have introduced the concept of Cumulative Cognitive Deficit and its effect on academic performance. Stay tuned for part II of this series which describes what parents and professionals can do to improve functional performance of students with Cumulative Cognitive Deficit.

References:

  • Bowers, L., Huisingh, R., & LoGiudice, C. (2006). The Listening Comprehension Test-2 (LCT-2). East Moline, IL: LinguiSystems, Inc.
  • Bowers, L., Huisingh, R., & LoGiudice, C. (2005). The Test of Problem Solving 3-Elementary (TOPS-3). East Moline, IL: LinguiSystems.
  • Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315.
  • Sattler, J. M. (1992). Assessment of Children. Revised and updated 3rd edition. San Diego: Jerome M. Sattler.
Posted on by — 5 Comments

Test Review: Test of Written Language-4 (TOWL-4)

Today due to popular demand I am reviewing The Test of Written Language-4 or TOWL-4. TOWL-4 assesses the basic writing readiness skills of students 9:00-17:11 years of age. The tests consist of two forms – A and B, (which contain different subtest content).

According to the manual, the entire test takes approximately  60-90 minutes to administer and examines 7 skill areas. Only the “Story Composition” subtest is officially timed (the student is given 15 minutes to write it and 5 minutes previous to that, to draft it). However, in my experience, each subtest administration, even with students presenting with mild-moderately impaired writing abilities, takes approximately 10 minutes to complete with average results (can you see where I am going with this yet?) 

For detailed information regarding the TOWL-4 development and standardization, validity and reliability, please see HERE. However, please note that the psychometric properties of this test are weak.

Below are my impressions (to date) of using this assessment with students between 11-14 years of age with (known) mild-moderate writing impairments.

Subtests:

1. Vocabulary – The student is asked to write a sentence that incorporates a stimulus word.  The student is not allowed to change the word in any way, such as write ‘running’ instead of run’. If this occurs, an automatic loss of points takes place. The ceiling is reached when the student makes 3 errors in a row.  While some of the subtest vocabulary words are perfectly appropriate for younger children (~9), the majority are too simplistic to assess the written vocabulary of middle and high schoolers. These words may work well to test the knowledge of younger children but they do not take into the account the challenging academic standards set forth for older students. As a result, students 11+ years of age may pass this subtest with flying colors but still present with a fair amount of difficulty using sophisticated vocabulary words in written compositions.

2/3.   Spelling and Punctuation (subtests 2 and 3). These two subtests are administered jointly but scored separately. Here, the student is asked to write sentences dictated by the examiner using appropriate rules for spelling and punctuation and capitalization. Ceiling for each subtest is reached separately. It  occurs when the student makes 3 errors in a row in each of the subtests.   In other words, if a student uses correct punctuation but incorrect spelling, his/her ceiling on the ‘Spelling’ subtest will be reached sooner then on the ‘Punctuation’ subtest and vise versa. Similar to the ‘Vocabulary‘ subtest I feel that the sentences the students are asked to write are far too simplistic to showcase their “true” grade level abilities.

The requirements of these subtests are also not too stringent.  The spelling words are simple and the punctuation requirements are very basic: a question mark here, an exclamation mark there, with a few commas in between. But I was particularly disappointed with the ‘Spelling‘ subtest.  Here’s why. I have a 6th-grade client on my caseload with significant well-documented spelling difficulties. When this subtest was administered to him he scored within the average range (Scaled Score of 8 and Percentile Rank of 25).  However, an administration of Spelling Performance Evaluation for Language and Literacy – SPELL-2, yielded 3 assessment pages of spelling errors, as well as 7 pages of recommendations on how to remediate those errors.  Had he received this assessment as part of an independent evaluation from a different examiner, nothing more would have been done regarding his spelling difficulties since the TOWL-4 revealed an average spelling performance due to its focus on overly simplistic vocabulary.

4. Logical Sentences – The student is asked to edit an illogical sentence so that it makes better sense. Ceiling is reached when the student makes 3 errors in a row. Again I’m not too thrilled with this subtest. Rather than truly attempting to ascertain the student’s grammatical and syntactic knowledge at sentence level a large portion of this subtest deals with easily recognizable semantic incongruities.

5. Sentence Combining – The student integrates the meaning of several short sentences into one grammatically correct written sentence. Ceiling is reached when the student makes 3 errors in a row.  The first few items contain only two sentences which can be combined by adding the conjunction “and”. The remaining items are a bit more difficult due to the a. addition of more sentences and b. increase in the complexity of language needed to efficiently combine them. This is a nice subtest to administer to students who present with difficulty effectively and efficiently expressing their written thoughts on paper. It is particularly useful with students who write down  a lot of extraneous information in their compositions/essays and frequently overuse run-on sentences. 

6. Contextual Conventions – The student is asked to write a story in response to a stimulus picture. S/he earn points for satisfying specific requirements relative to combined orthographic (E.g.: punctuation, spelling) and grammatical conventions (E.g.: sentence construction, noun-verb agreement).  The student’s written composition needs to contain more than 40 words in order for the effective analysis to take place.

The scoring criteria ranges from no credit or a score of 0 ( based on 3 or more mistakes), to partial credit, a score of 1 (based on 1-2 mistakes) to full a credit – a score of 3 (no mistakes). There are 21 scoring parameters which are highly useful for younger elementary-aged students who may exhibit significant difficulties in the domain of writing. However,  older middle school and high-school aged students as well as elementary aged students with moderate writing difficulties may attain average scoring on this subtest but still present with significant difficulties in this area as compared to typically developing grade level peers. As a result, in addition to this assessment, it is recommended that a functional assessment of grade-level writing also be performed in order to accurately identify the student’s writing needs.

7. Story Composition – The student’s story is evaluated relative to the quality of its composition (E.g.: vocabulary, plot, development of characters, etc.). The examiner first provides the student with an example of a good story by reading one written by another student.  Then, the examiner provides the student with an appropriate picture card and tell them that they need to take time to plan their story and make an outline on the (also provided) scratch paper.  The student has 5 minutes to plan before writing the actual story.  After the 5 minutes, elapses they 15 minutes to write the story.  It is important to note that story composition is the very first subtest administered to the student. Once they complete it they are ready to move on to the Vocabulary subtest. There are 11 scoring parameters that are significantly more useful for me to use with younger students as well as significantly impaired students vs. older students or students with mild-moderate writing difficulties. Again if your aim is to get an accurate picture of the older students writing abilities I definitely recommend the usage of clinical writing assessment rubrics based on the student’s grade level in order to have an accurate picture of their abilities.

OVERALL IMPRESSIONS:

Strengths:

  • A thorough assessment of basic writing areas for very severely impaired students with writing deficits
  • Flexible subtest administration (can be done on multiple occasions with students who fatigue easily)

Limitations:

  • Untimed testing administration (with the exception of story composition subtests) is NOT functional with students who present with significant processing difficulties. One 12-year-old student actually took ~40 minutes to complete each subtest.
  • Primarily  useful for students with severe deficits in the area of written expression
  • Not appropriate for students with mild-moderate needs (requires suplementation)
  • Lack of remediation suggestions based on subtest deficits
  • Weak psychometric properties

Overall, TOWL-4 can be a useful testing measure for ruling out weaknesses in the student’s basic writing abilities, with respect to simple vocabulary, sentence construction, writing mechanics, punctuation, etc.  If I identify previously unidentified gaps in basic writing skills I can then readily intervene, where needed, if needed. However, it is important to understand that the TOWL-4 is only a starting point for most of our students with complex literacy needs whose writing abilities are above severe level of functioning. Most students with mild-moderate writing difficulties will pass this test with flying colors but still present with significant writing needs. As a result I highly recommend a functional grade-level writing assessment as a supplement to the above-standardized testing.

References: 

Hammill, D. D., & Larson, S. C. (2009). Test of Written Language—Fourth Edition. (TOWL-4). Austin, TX: PRO-ED.

Disclaimer: The views expressed in this post are the personal impressions of the author. This author is not affiliated with PRO-ED in any way and was NOT provided by them with any complimentary products or compensation for the review of this product. 

Posted on by — 1 Comment

Assessing Behaviorally Impaired Students: Why Background History Matters!

As a speech language pathologist (SLP) who works in an outpatient psychiatric school-based setting, I frequently review incoming students previous speech language evaluation reports.  There are a number of trends I see in these reports which I have written about in the past as well as planned on writing about in the future.

For example, in the past I wrote about my concern regarding the lack of adequate or even cursory social communication assessments for students with documented psychiatric impairments and emotional behavioral deficits.

This leads many professionals to do the following: 

a. Miss vital assessment elements which denies students appropriate school based services and

b. Assume that the displayed behavioral challenges are mere results of misbehaving. 

Today however I wanted express my thoughts regarding another disturbing trend I see in numerous incoming speech-language reports in both outpatient school/hospital setting as well as in private practice  – and that is lack of background information in the students assessment reports.

Despite its key role in assessment, this section is frequently left bare. Most of the time it contains only the information regarding the students age and grade levels as well as the reasons for the referral (e.g., initial evaluation, triennial evaluation).  Some of the better reports will include cursory mention of the student’s developmental milestones but most of the time information will be sorely lacking.

Clearly this problem is not just prevalent in my incoming assessment reports. I frequently see manifestations of it in a variety of speech pathology related social media forums such as Facebook. Someone will pose a question regarding how to distinguish a _____ from ____ (e.g., language difference vs. language disorder, behavioral noncompliance vs. social communication deficits, etc.) yet when they’re questioned further many SLPs will admit that they are lacking any/most information regarding the students background history.

When questioned regarding the lack of this information, many SLPs get defensive. They cite a variety of reasons such as lack of parental involvement (“I can’t reach the parents”), lack of access to records (“it’s a privacy issue”), division of labor (e.g., “it’s the social worker’s responsibility and not mine to obtain this information”) as well as other justifications why this information is lacking.

Now, I don’t know about you, but one of my earliest memories of the ‘diagnostics’ class in graduate school involved collecting data and writing comprehensive ‘Background Information’ section of the report. I still remember multiple professors imparting upon me the vital importance is this section plays in the student’s evaluation report.

Indeed, many years later, I clearly see its vital role in assessment. Unearthing the student’s family history, developmental milestones, medical/surgical history, as well as history of past therapies is frequently the key to a successful diagnosis and appropriate provision of therapy services.  This is the information that frequently plays a vital role in subsequent referrals of “mystery” cases to relevant health professionals as well as often leads to resolution of particularly complicated diagnostic puzzles.

Of course I understand that frequently there are legitimate barriers to obtaining this information.  However, I also know that if one digs deep enough one will frequently find the information they’re seeking despite the barriers. To illustrate, at the psychiatric hospital level where I work,  I frequently encounter a number of barriers to accessing the student’s background information during the assessment process. This may include parental language/education barrier, parental absence, Division of Child Protective Services involvement,  etc.  Yet I always try to ensure that my reports contain all the background information that I’m able to unearth because I know how vitally important it is for the student in question.

In the past I have been able to use the student’s background information to make important discoveries, which were otherwise missed by other health professionals. This included undocumented history of traumatic brain injuries, history of language and literacy disabilities in the family, history of genetic disorders and/or intellectual disabilities in the family, history of maternal alcohol abuse during pregnancy, and much much more.

So what do I consider to be an adequate Background History section of the assessment report?

For starters, the basics, of course.

I begin by stating the child’s age and grade levels, who referred the child (and for what reason), as well as whether the child previously received any form of speech language assessment/therapy services in the past.

If I am preforming a reassessment (especially if it happens shortly after the last assessment took place) I provide a clear justification why the present reassessment is taking place. Here is an actual excerpt from one of my reevaluation reports. “Despite receiving average language scores on his _______ speech language testing which resulted in the  recommendation for speech therapy only, upon his admission to ______, student was referred for a language reassessment in _____, by the classroom staff who expressed significant concerns regarding validity and reliability of past speech and language testing on the ground of the student’s persistent “obvious” listening comprehension and verbal expression deficits.”

For those of you in need of further justification I’ve created a brief list of reasons why a reassessment, closely following recent testing may be needed.

  1. SLP/Parent feels additional testing is needed to create comprehensive goals for child.
  2. Previous testing was inadequate. Here it’s very important to provide comprehensive rationale  and list the reasons for it.
  3. A reevaluation was requested due to third party  concerns (e.g., psychiatrist, psychologist, etc.)

Secondly, it is important to document all relevant medical history, which includes: prenatal, perinatal, and early childhood diseases, surgical interventions and incidents. It is important to note that if a child has a long standing history of documented psychiatric difficulties, you may want to separate these sections and describe psychiatric history/diagnoses following the section that details the onset of the child’s emotional and behavioral deficits.

Let us now move on to the child’s developmental history, which should include, gross/fine motor, speech/ language milestones, and well as cognitive and socioemotional functioning.  This is a section where I typically add information regarding any early intervention services which may have been provided to the child prior to the age of three.

In my next section I discuss the child’s academic functioning to date. Here I mention whether the student qualified for a preschool disabled eligibility category and received services from the age of 3+.  I also discuss their educational classification (if one exists), briefly mention the results of previous most recent cognitive and educational testing (if available) as well as mention any academic struggles (if applicable).

After that I move on to the child’s psychiatric history. I briefly document when did the emotional behavioral problems first arose, and what had been done about them to date (out of district placements, variety of psychiatric services, etc.)  Here I also document  the student’s most recent psychiatric diagnoses (if available) and mention any medication they may be currently on (applicable due to the effect of psychiatric medications on language and memory skills).

The following section is perhaps the most important one in the  report. It is the family’s history of genetic disorders, psychiatric impairments, special education placements, as well as language, learning, and literacy deficits.  This section plays a vital importance in my determination of the contributions to the student’s language difficulties as well as guides my assessment recommendations in the presence of borderline assessment results.

I finish this section by briefly discussing the student’s Family Composition as well as Language Knowledge and Use.

I discuss family composition due to several factors.  For example, lack of consistent caregivers, prolonged absence of parental figures, as well as presence of a variety of people in the home can serve as significant stressor for children with psychiatric impairments and learning difficulties.  As a result of this information is pertinent to the report especially when it comes to figuring out the antecedents for the child’s behavior fluctuation on daily basis.

Language knowledge and use  is particularly relevant to culturally and linguistically diverse children. It is very important to understand what languages does the child understand and use at home and at school as well as what do the parents think about the child’s language abilities in both languages. These factors will guide my decision making process regarding what type of assessments would be most relevant for this child.

So there you have it.  This is the information I include in the background history section of every single one of my reports.  I believe that this information contributes to the making of the appropriate and accurate diagnosis of the child’s difficulties.

Please don’t get me wrong. This information is hugely relevant for all students that we SLPs are assessing.

However, the above is especially relevant for such vulnerable populations as children with emotional and behavioral disturbances, whose struggle with social communication is frequently misinterpreted as “it’s just behavior“. As a result, they are frequently denied social communication therapy services, which ultimately leads to denial of Free Appropriate Public Education (FAPE) that they are entitled to.

Let us ensure that this does not happen by doing all that we can to endure that the student receives a fair assessment, correct diagnosis, and can have access to the best classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.  And the first step of that process begins with obtaining a detailed background history!

Helpful Resources: 

 

 

 

Posted on by — 1 Comment

Parent Consultation Services

Today I’d like to officially introduce a new parent consultation service which I had originally initiated  with a few out-of-state clients through my practice a few years ago.

The idea for this service came after numerous parents contacted me and initiated dialogue via email and phone calls regarding the services/assessments needed for their monolingual/bilingual internationally/domestically adopted or biological children with complex communication needs. Here are some details about it.

Parent consultations is a service provided to clients who live outside Smart Speech Therapy LLC geographical area (e.g., non-new Jersey residents) who are interested in comprehensive specialized in-depth consultations and recommendations regarding what type of follow up speech language services they should be seeking/obtaining in their own geographical area for their children as well as what type of carryover activities they should be doing with their children at home.

Consultations are provided with the focus on the following specialization areas with a focus on comprehensive assessment and intervention recommendations:

  • Language and Literacy 
  • Children with Social Communication (Pragmatic) Disorders
  • Bilingual and Multicultural Children
  • Post-institutionalized Internationally Adopted Children
  • Children with Psychiatric and Emotional Disturbances
  • Children with Fetal Alcohol Spectrum Disorders

The initial consultation length of this service is  1 hour. Clients are asked to forward their child’s records prior to the consultation for review, fill out several relevant intakes and questionnaires, as well as record a short video (3-5 minutes). The instructions regarding video content will be provided to them following session payment.

Upon purchasing a consultation the client will be immediately emailed the necessary paperwork to fill out as well as potential dates and times for the consultation to take place.   Afternoon, Evening and Weekend hours are available for the client’s convenience. In cases of emergencies consultations may be rescheduled at the client’s/Smart Speech Therapy’s mutual convenience.

Refunds are available during a 3 day grace period if a mutually convenient time could not be selected for the consultation. Please note that fees will not be refundable from the time the scheduled consultation begins.

Following the consultation the client has the option of requesting a written detailed consultation report at an additional cost, which is determined based on the therapist’s hourly rate. For further information click HERE. You can also call 917-916-7487 or email tatyana.elleseff@smartspeechtherapy.com if you wanted to find out whether this service is right for you.

Below is a past parent consultation testimonial.

International Adoption Consultation Parent Testimonial (11/11/13)

I found Tatyana and Smart Speech Therapy online while searching for information about internationally adopted kids and speech evaluations. We’d already taken our three year old son to a local SLP but were very unsatisfied with her opinion, and we just didn’t know where to turn. Upon finding the articles and blogs written by Tatyana, I felt like I’d finally found someone who understood the language learning process unique to adopted kids, and whose writings could also help me in my meetings with the local school system as I sought special education services for my son.

I could have never predicted then just how much Tatyana and Smart Speech Therapy would help us. I used the online contact form on her website to see if Tatyana could offer us any services or recommendations, even though we are in Virginia and far outside her typical service area. She offered us an in-depth phone consultation that was probably one of the most informative, supportive and helpful phone calls I’ve had in the eight months since adopting my son. Through a series of videos, questionnaires, and emails, she was better able to understand my son’s speech difficulties and background than any of the other sources I’d sought help from. She was able to explain to me, a lay person, exactly what was going on with our son’s speech, comprehension, and learning difficulties in a way that a) added urgency to our situation without causing us to panic, b) provided me with a ton of research-orientated information for our local school system to review, and c) validated all my concerns and gut instincts that had previously been brushed aside by other physicians and professionals who kept telling us to “wait and see”.

After our phone call, we contracted Tatyana to provide us with an in-depth consultation report that we are now using with our local school and child rehab center to get our son the help he needs. Without that report, I don’t think we would have had the access to these services or the backing we needed to get people to seriously listen to us. It’s a terrible place to be in when you think something might be wrong, but you’re not sure and no one around you is listening. Tatyana listened to us, but more importantly, she looked at our son as a specific kid with a specific past and specific needs. We were more than just a number or file to her – and we’ve never even actually met in person! The best move we’ve could’ve made was sending her that email that day. We are so appreciative.

Kristen, P. Charlottesville, VA

Posted on by — Leave a comment

Professional Consultation Services for Speech Language Pathologists

Today I’d like to officially introduce a new professional consultation service for  speech language pathologists (SLPs), which I initiated  with select few clinicians through my practice some time ago.

The idea for this service came after numerous SLPs contacted me and initiated dialogue via email and phone calls regarding cases they were working on or asked for advice on how to initiate assessment or therapy services to new clients with complex communication issues. Here are some details about it.

Professional consultation is a service provided to Speech Language Pathologists (SLPs) seeking specialized in-depth assessment and/or treatment recommendations regarding specific client cases or who are looking to further their professional education in the following specialization areas:

  • Performing Independent Evaluations (IEEs) in Special Education Disputes
  • Comprehensive Early Intervention Assessments of Monolingual and Bilingual Children
  • Speech Language Assessment and Treatment of post-institutionalized Internationally Adopted Children
  • Speech Language Assessment and Treatment of Children with Psychiatric and Emotional Disturbances
  • Speech and Language Assessment and Treatment of Children with Fetal Alcohol Spectrum Disorders
  • Assessment and Management of Social Pragmatic Language Disorders
  • Speech Language Assessment and Treatment of Bilingual and Multicultural Children
  • Speech Language Assessment and Treatment of Severely Cognitively Impaired Clients
  • Speech Language Assessment and Treatment of Children with Genetic Disorders

These professional consultation sessions are conducted via GoTo Meeting and includes video conferencing as well as screen sharing.

The goal of this service is to facilitate the SLPs learning process in the desired specialization area. The initial consultation includes extensive literature, material and resource website recommendations, with the exception of Smart Speech Therapy LLC products, which are available separately for purchase through the online store.

The initial consultation length is 1 hour. SLPs are encouraged to forward de-identified client records prior to the consultation for review. In select cases (and with appropriate permissions) forwarding a short video/audio recording (~7 minutes)  of the client in question is recommended.

Upon purchasing a consultation the client will be immediately emailed potential dates and times for the consultation to take place.   Afternoon, Evening and Weekend hours are available for the client’s convenience. In cases of emergencies consultations may be rescheduled at the client’s/Smart Speech Therapy’s mutual convenience.

While refunds are not available for this type of service, in an unlikely event that the consultation lasts less than 1 hour, leftover time can be banked for future calls without any expiration limits.  Call sessions can be requested as needed and conveyed in advance via email.  For further information click HERE. You can also call 917-916-7487 or email tatyana.elleseff@smartspeechtherapy.com if you wanted to find out whether this service is right for you. 

Below is the recent professional consultation testimonial.

Professional Independent Evaluation Consultation Testimonial (8/20/15)

Tatyana,

I just wanted to thank you from the bottom of my heart for the mentorship consultation with you yesterday. I learned a great deal, and appreciated your straight forward approach, and most of all, your scholarly input. You are a thorough professional. This new service that you offer is invaluable for many reasons, one of which is that it buffers the clinical isolation of solo private practice.  I look forward to our next session, about which I will email you in the next week or so. If stars are given, I give you the maximum number of stars possible!    The consultations are pure wonderful!
With gratitude,
Aletta Sinoff Ph.D., CCC-SLP, BCBA-D
Licensed Speech-Language Pathologist
Board Certified Behavior Analyst
Beachwood  OH 44122
Posted on by — 8 Comments

What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?

I frequently see a variation of the following question on a variety of speech language forums: “My student scored within the average range on all the tested subtests with the exception of working memory and sentence recall. What other testing do you recommend to determine whether these difficulties are impacting their academics?”

First, lets provide a definition of working memory (WM). WM is the memory used for temporarily storing and manipulating information so we can perform a particular task. It’s one of the executive functions (EFs) and contains two important subcomponents: a phonological loop that stores verbal information and a visuo-spatial ‘sketchpad’ which stores visual and spatial information (Baddeley & Hitch, 2007). Together they are responsible for acquisition of sound-letter correspondence, phonemic awareness and ultimately reading comprehension since WM influences the duration the information stays in memory as well as its eventual transfer (or lack of thereof) to long-term memory.

In other words, students with adequate working memory will have enough capacity to appropriately decode, fluently read and adequately comprehend text while students with poor working memory will expend all their capacity on basic tasks such as decoding, which leaves them with very little capacity to devote to comprehension of read material.

Outside of testing, WM deficits typically become glaringly apparent as students move up grade levels and are given challenging subject-specific abstract texts, requiring in-depth analysis.  This is when parents and professionals start to see that in addition to experiencing difficulty comprehending the read texts, students with poor WM also tire easily when presented with lengthy texts, and tend to evidence increased frustration and decreased self-efficacy during reading tasks.

Now let’s get back to our original question: “What other testing do you recommend to determine whether these [memory] difficulties are impacting their academics?”

Typically when asked that question I always tend to recommend that a trained SLP  performs a series of tests aimed to determine whether the student presents with reading and writing deficits.

In my clinical experience (which is of course substantiated by research) in 99% of cases, reading disabilities are the hidden culprit behind seemingly average oral language skills and working memory deficits.   For more information on what testing is recommended to tease out the presence of reading disorders, see my series posts on Comprehensive Dyslexia Testing (HERE) as well as on the validity of (C)APD diagnosis (HERE).

keep calm and don't ignore the signs

So the next time you encounter this perplexing pattern of strengths and weaknesses don’t just ignore it as inconsequential and not recommend or dismiss the student from language services.  Delve into it further! You will often find that it is representative of reading difficulties, the cumulative impact of which may significantly affect the student’s academic performance and ultimately school outcomes, unless appropriate therapeutic interventions are provided.

References:

  • Baddeley, A. D., & Hitch, G. J. (2007). Working memory: Past, present…and future? In N.Osaka, R. Logie & M. D’Esposito (Eds), Working Memory – Behavioural & Neural Correlates. Oxford University Press.

Useful Resources:

  1. Help, Student Tested Average on ALL Standardized Tests but is Still Struggling
  2. Is “Dyslexia” a Useful Label for Diagnostic and Treatment Purposes?
  3. Quality Assessments for Students with Suspected/Confirmed “APD”

Posted on by — 2 Comments

Have you Worked on Morphological Awareness Lately?

Last year an esteemed colleague, Dr. Roseberry-McKibbin posed this question in our Bilingual SLPs Facebook Group:  “Is anyone working on morphological awareness in therapy with ELLs (English Language Learners) with language disorders?”

Her question got me thinking: “How much time do I spend on treating morphological awareness in therapy with monolingual and bilingual language disordered clients?” The answer did not make me happy!

So what is morphological awareness and why is it important to address when treating monolingual and bilingual  language impaired students?

Morphemes are the smallest units of language that carry meaning. They can be free (stand alone words such as ‘fair’, ‘toy’, or ‘pretty’) or bound (containing prefixes and suffixes that change word meanings – ‘unfair’ or ‘prettier’).

Morphological awareness refers to a ‘‘conscious awareness of the morphemic structure of words and the ability to reflect on and manipulate that structure’’ (Carlisle, 1995, p. 194). Also referred to as “the study of word structure” (Carlisle, 2004), it is an ability to recognize, understand, and use affixes or word parts (prefixes, suffixes, etc) that “carry significance” when speaking as well as during reading tasks. It is a hugely important skill for building vocabulary, reading fluency and comprehension as well as spelling (Apel & Lawrence, 2011; Carlisle, 2000; Binder & Borecki, 2007; Green, 2009). 

So why is teaching morphological awareness important? Let’s take a look at some research.

Goodwin and Ahn (2010) found morphological awareness instruction to be particularly effective for children with speech, language, and/or literacy deficits. After reviewing 22 studies Bowers et al. (2010) found the most lasting effect of morphological instruction was on readers in early elementary school who struggled with literacy.

Morphological awareness instruction mediates and facilitates vocabulary acquisition leading to improved reading comprehension abilities (Bowers & Kirby, 2010; Carlisle, 2003, 2010; Guo, Roehrig, & Williams, 2011; Tong, Deacon, Kirby, Cain, & Parilla, 2011).

Unfortunately as important morphological instruction is for vocabulary building, reading fluency, reading comprehension, and spelling, it is often overlooked during the school years until it’s way too late. For example, traditionally morphological instruction only beings in late middle school or high school but research actually found that in order to be effective one should actually begin teaching it as early as first grade (Apel & Lawrence, 2011).

So now that we know that we need to target morphological instruction very early in children with language deficits, let’s talk a little bit regarding how morphological awareness can be assessed in language impaired learners.

When it comes to standardized testing, both the Test of Language Development: Intermediate – Fourth Edition (TOLD-I:4) and the Test of Adolescent and Adult Language–Fourth Edition (TOAL-4) have subtests which assess morphology as well as word derivations. However if you do not own either of these tests you can easily create non-standardized tasks to assess  morphological awareness.

Apel, Diehm, & Apel (2013) recommend multiple measures which include:  phonological awareness tasks, word level reading tasks, as well as reading comprehension tasks.

Below are direct examples of tasks from their study:

MATs

One can test morphological awareness via production or decomposition tasks. In a production task a student is asked to supply a missing word, given the root morpheme (e.g., ‘‘Sing. He is a great _____.’’ Correct response: singer).  A decomposition task asks the student to identify the correct root of a given derivation or inflection. (e.g., ‘‘Walker. How slow can she _____?’’ Correct response: walk).

Another way to test morphological awareness is through completing analogy tasks since it involves both  decomposition and production components (provide a missing word based on the presented pattern—crawl: crawled:: fly: ______ (flew).

Still another way to test morphological awareness with older students is through deconstruction tasks: Tell me what ____ word means? How do you know? (The student must explain the meaning of individual morphemes).

Finding the affix: Does the word ______ have smaller parts?

So what are the components of effective morphological instruction you might ask?

Below is an example of a ‘Morphological Awareness Intervention With Kindergarteners and First and Second Grade Students From Low SES Homes’ performed by Apel & Diehm, 2013:

Apel and Diem 2011

Here are more ways in which this can be accomplished with older children:

  • Find the root word in a longer word
  • Fix the affix (an additional element placed at the beginning or end of a root, stem, or word, or in the body of a word, to modify its meaning)
    • Affixes at the beginning of words are called “prefixes”
    • Affixes at the end of words are called “suffixes
  • Word sorts to recognize word families based on morphology or orthography
  • Explicit instruction of syllable types to recognize orthographical patterns
  • Word manipulation through blending and segmenting morphemes to further solidify patterns

Now that you know about the importance of morphological awareness, will you be incorporating it into your speech language sessions? I’d love to know!

Until then, Happy Speeching!

References:

  • Apel, K., & Diehm, E. (2013). Morphological awareness intervention with kindergarteners and first and second grade students from low SES homes: A small efficacy study. Journal of Learning Disabilities.
  • Apel, K., & Lawrence, J. (2011). Contributions of morphological awareness skills to word-level reading and spelling in first-grade children with and without speech sound disorder. Journal of Speech, Language & Hearing Research, 54, 1312–1327.
  • Apel, K., Brimo, D., Diehm, E., & Apel, L. (2013). Morphological awareness intervention with kindergarteners and first and second grade students from low SES homes: A feasibility study. Language, Speech, and Hearing Services in Schools, 44, 161-173.
  • Binder, K. & Borecki, C. (2007). The use of phonological, orthographic, and contextualinformation during reading: a comparison of adults who are learning to read and skilled adult readers. Reading and Writing, 21, 843-858.
  • Bowers, P.N., Kirby, J.R., Deacon, H.S. (2010). The effects of morphological instruction on literacy skills: A systematic review of the literature. Review of Educational Research, 80, 144-179.
  • Carlisle, J. F. (1995). Morphological awareness and early reading achievement. In L. B. Feldman (Ed.), Morphological aspects of language processing (pp. 189–209). Hillsdale, NJ: Erlbaum.
  • Carlisle, J. F. (2000). Awareness of the structure and meaning of morphologically complex words: Impact on reading. Reading and Writing: An Interdisciplinary Journal,12,169-190.
  • Carlisle, J. F. (2004). Morphological processes that influence learning to read. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy. NY: Guilford Press.
  • Carlisle, J. F. (2010). An integrative review of the effects of instruction in morphological awareness on literacy achievement. Reading Research Quarterly, 45(4), 464-487.
  • Goodwin, A.P. & Ahn, S. (2010). Annals of Dyslexia, 60, 183-208.
  • Green, L. (2009). Morphology and literacy: Getting our heads in the game. Language, Speech, and Hearing Services in the schools, 40, 283-285.
  • Green, L., & Wolter, J.A. (2011, November). Morphological Awareness Intervention: Techniques for Promoting Language and Literacy Success. A symposium presentation at the annual American Speech Language Hearing Association, San Diego, CA.
  • Guo, Y., Roehrig, A. D., & Williams, R. S. (2011). The relation of morphological awareness and syntactic awareness to adults’ reading comprehension: Is vocabulary knowledge a mediating variable? Journal of Literacy Research, 43, 159-183.
  • Tong, X., Deacon, S. H., Kirby, J. R., Cain, K., & Parrila, R. (2011). Morphological awareness: A key to understanding poor reading comprehension in English. Journal of Educational Psychology, 103 (3), 523-534.
Posted on by — 2 Comments

Assessing Social Communication Abilities of School-Aged Children

Recently, I’ve published an article in SIG 16 Perspectives on School Based Issues discussing the importance of social communication assessments of school aged children 2-18 years of age. Below I would like to summarize article highlights.

First, I summarize the effect of social communication on academic abilities and review the notion of the “academic impact”. Then, I go over important changes in terminology and definitions as well as explain the “anatomy of social communication”.

Next I suggest a sample social communication skill hierarchy to adequately determine assessment needs (assess only those abilities suspected of deficits and exclude the skills the student has already mastered).

After that I go over pre-assessment considerations as well as review standardized testing and its limitations from 3-18 years of age.

Finally I review a host of informal social communication procedures and address their utility.

What is the away message?

When evaluating social communication, clinicians need to use multiple assessment tasks to create a balanced assessment. We need to chose testing instruments that will help us formulate clear goals.  We also need to add descriptive portions to our reports in order to “personalize” the student’s deficit areas. Our assessments need to be functional and meaningful for the student. This means determining the student’s strengths and not just weaknesses as a starting point of intervention initiation.

Is this an article which you might find interesting? If so, you can access full article HERE free of charge.

Helpful Smart Speech Resources Related to Assessment and Treatment of Social Communication 

Posted on by — Leave a comment

SLP Efficiency Bundles™ for Graduating Speech Language Pathologists

Graduation time is rapidly approaching and many graduate speech language pathology students are getting ready to begin their first days in the workforce. When it comes to juggling caseloads and managing schedules, time is money and efficiency is the key to success. Consequently,  a few years ago I created  SLP Efficiency Bundles™, which are materials highly useful for Graduate SLPs working with pediatric clients. These materials are organized by areas of focus for efficient and effective screening, assessment, and treatment of speech and language disorders.   Continue reading SLP Efficiency Bundles™ for Graduating Speech Language Pathologists