Category: Assessment

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Recommendations for Assessing Language Abilities of Verbal Children with Down Syndrome (DS)

Kid-1Assessment of children with DS syndrome is often complicated due to the wide spectrum of presenting deficits (e.g., significant health issues in conjunction with communication impairment, lack of expressive language, etc) making accurate assessment of their communication a difficult task. In order to provide these children with appropriate therapy services via the design of targeted goals and objectives, we need to create comprehensive assessment procedures that focus on highlighting their communicative strengths and not just their deficits.

Today I’d like to discuss assessment procedures for verbal monolingual and bilingual children with DS 4-9 years of age, since testing instruments as well as assessment procedures for younger as well as older verbal and nonverbal children with DS do differ.

When it comes to dual language use and genetic disorders and developmental disabilities many educational and health care professionals are still under the erroneous assumption that it is better to use one language (English) to communicate with these children at home and at school.  However, studies have shown that not only can children with DS become functionally bilingual they can even become functionally trilingual (Vallar & Papagno, 1993; Woll & Grove, 1996).  It is important to understand that “bilingualism does not change the general profile of language strengths and weaknesses characteristic of DS—most children with DS will have receptive vocabulary strengths and expressive language weaknesses, regardless of whether they are monolingual or bilingual.” (Kay-Raining Bird, 2009, p. 194)

Furthermore, advising a bilingual family to only speak English with a child will cause a number of negative linguistic and psychosocial implications, such as create social isolation from family members who may not speak English well as well as adversely affect parent-child relationships (Portes & Hao, 1998).

Consequently, when preparing to assess linguistic abilities of children with DS we need to first determine whether these children have single or dual language exposure and design assessment procedures accordingly.

Pre-assessment Considerations

It is very important to conduct a parental interview no matter the setting you are performing the assessment in. One of your goals during the interview will be to establish the functional goals the parents’ desire for the child which may not always coincide with the academic expectations of the program in question.

Begin with a detailed case history and review of current records and obtain information about the child’s prenatal, perinatal and postnatal development, medical history as well as the nature of previous assessments and provided related services. Next, obtain a detailed history of the child’s language use by inquiring what languages are spoken by household members and how much time do these people spend with the child?

Choosing Testing Instruments 

A balanced assessment will include a variety of methods, including observations of the child as well as direct interactions in the form of standardized, informal and dynamic assessments. If you will be using standardized assessments (e.g., ROWPVT-4) YOU MUST use descriptive measures vs. standardized scores to describe the child’s functioning. The latter is especially applicable to bilingual children with DS. Consider using the following disclaimer: “The following test/s __________were normed on typically developing English speaking children. Testing materials are not available in standardized form for child’s unique developmental and bilingual/bicultural backgrounds. In accordance with IDEA 2004 (The Individuals with Disabilities Education Act) [20 U.S.C.¤1414(3)],official use of standard scores for this child would be inaccurate and misleading so the results reported are presented in descriptive form.  Raw scores are provided here only for comparison with future performance.”

Selecting Standardized Assessments 

Depending on the child’s age and level of abilities a variety of assessment measures may be applicable to test the child in the areas of Content (vocabulary), Form (grammar/syntax), and Use(pragmatic language).

For children over 3 years of age whose linguistic abilities are just emerging you may wish to use a vocabulary inventory such as the MacArthur-Bates (also available in other languages) as well as provide parents with the Developmental Scale for Children with Down Syndrome to fill out. This will allow you to compare where child with DS features in their development as compared to typically developing peers. For older, more verbal children who are using words, phrases, and/or sentences to express themselves, you may want to use or adapt (see above) one of the following standardized language tests:

Informal Assessment Procedures 

Depending on your setting (hospital vs. school), you may not perform a detailed assessment of the child’s feeding and swallowing skills. However, it is still important to understand that due to low muscle tone, respiratory problems, gastrointestinal disorders and cardiac issues, children with DSoften present with feeding dysfunction which is further exacerbated by concomitant issues such as obesity, GERD, constipation, malnutrition (restricted food group intake lacking in vitamins and minerals), and fatigue. With respect to swallowing, they may experience abnormalities in both the oral and pharyngeal phases of swallow, as well as present with silent aspiration, due to which instrumental assessment (MBS) may be necessary (Frazer & Friedman, 2006).

In contrast to feeding and swallowing the oral-peripheral assessment can be performed in all settings. When performing oral-peripheral exam, you need to carefully describe all structural (anatomical) and functional (physiological) abnormalities (e.g., macroglossia, micrognathia, prognathism, etc).   Note any issues with:

  • —  Dentition (e.g., dental overcrowding, occlusion, etc)
  • —  Tongue/jaw disassociation  (ability to separate tongue from jaw when speaking)
  • —  Mouth Posture (open/closed) and tongue positioning  at rest (protruding/retracted)
  • —  Control of oral secretions
  • —  Lingual and buccal strength, movement (e.g., lingual protrusion, elevation, lateralization, and depression for volitional tasks) and control
  • —  Mandibular (jaw) strength, stability and grading

Take a careful look at the child’s speech. Perform dual speech sampling (if applicable) by considering the child’s phonetic inventory, syllable lengths and shapes as well as articulatory/phonological error patterns.  Make sure to factor in the combined effect of the child’s craniofacial anomalies as well as system wide impairment (disturbances in respiration, voice, articulation, resonance, fluency, and prosody) on conversational intelligibility. Impaired intelligibility is a serious concern for individuals with DS, as it tends to persist throughout life for many of them and significantly interferes with social and vocational pursuits (Kent & Vorperian, 2013)

Don’t forget to assess the child’s voice, fluency, prosody, and resonance. Children with DS may have difficulty maintaining constant airstream for vocal production due to which they may occasionally speak with low vocal volume and breathiness (caused by air loss due to vocal fold hypotonicity). This may be directly targeted in treatment sessions and taught how to compensate for.  When assessing resonance make sure to screen the child for hypernasality which may be due to velopharyngeal insufficiency secondary to hypotonicity as well as rule out hyponasality which may be due to enlarged adenoids (Kent & Vorperian, 2013). Furthermore, since stuttering and cluttering occur in children with DS at rates of 10 to 45%, compared to about 1% in the general population, a detailed analysis of disfluencies may be necessary(Kent & Vorperian, 2013). Finally, due to limitations with perception, imitation, and spontaneous production of prosodic features secondary to motor difficulties, motor coordination issues, and segmental errors that impede effective speech production across multisyllabic sequences, the prosody of individuals with DS will be impaired and might require a separate intervention. (Kent & Vorperian, 2013)

When it comes to auditory function, formal hearing testing and retesting is mandatory due to the fact that many children with DS have high prevalence of conductive and sensorineural hearing loss (Park et al, 2012). So if the child in question is not receiving regular follow-ups from the audiologist, it is very important to make the appropriate referral. Similarly, it is also very important that the child’s visual perception is assessed as well since children with DS frequently experience difficulties with vision acuity as well as visual processing, consequentially a consultation with developmental optometrist may be recommended/needed.

Describe in detail the child’s adaptive behavior and learning style, including their social strengths and weaknesses. Observe the child’s eye contact, affect, attention to task, level of distractibility, and socialization patterns. Document the number of redirections and negotiations the child needed to participate as well as types and level of reinforcement used during testing.

Perform dual language sampling and look at functional vocabulary knowledge and use, grammar measures, sentence length, as well as the child’s pragmatic functions (what is the child using his/her language for: request, reject, comment, etc.) Perform a dynamic assessment to determine the child’s learnability (e.g., how quickly does the child learns and adapts to being taught new concepts?) since “even a minimal mediation in the form of ‘focusing’ improves the receptive language performance of children with DS” (Alony & Kozulin, 2007, p 323)

After all the above sections are completed, it is time to move on to the impressions section of the report.  While it is important to document the weaknesses exposed by the assessment, it is even more important to document the child’s strengths or all the things the child did well, since this will help you to determine the starting treatment point and allow you to formulate relevant treatment goals.

When making recommendations for treatment, especially for bilingual children with DS, make sure to provide a strong rationale for the provision of services in both languages (if applicable) as well as specify the importance of continued support of the first language in the home.

Finally, make sure to provide targeted and measurable [suggested] treatment goals by breaking the targets into measurable parts:

Given ___time period (1 year, 1 progress reporting period, etc), the student will be able to (insert specific goal) with ___accuracy/trials, given ___ level of, given _____type of prompts.

Assessing communication abilities of children with developmental disabilities may not be easy; however, having the appropriate preparation and training will ensure that you will be well prepared to do the job right!  Use multiple tasks and activities to create a balanced assessment, use descriptive measures instead of standard scores to report findings, and most importantly make your assessment functional by making sure that your testing yields relevant diagnostic information which could then be effectively used to provide effective quality treatments for clients with DS!

For comprehensive information on “Comprehensive Assessment of Monolingual and Bilingual Children with Down Syndrome” which discusses how to assess young (birth-early elementary age) verbal and nonverbal monolingual and bilingual children with Down Syndrome (DS) and offers comprehensive examples of write-ups based on real-life clients click HERE.

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Part IV: Components of Comprehensive Dyslexia Testing – Writing and Spelling

Recently I began writing a series of posts on the topic of comprehensive assessment of dyslexia.

In part I of my post (HERE), I discussed common dyslexia myths as well as general language testing as a starting point in the dyslexia testing battery.

In part II (HERE) I detailed the next two steps in dyslexia assessment: phonological awareness and word fluency testing.

In part III  (HERE) I discussed reading fluency and reading comprehension testing.

Today I would like to discuss part IV of comprehensive dyslexia assessment, which involves spelling and writing testing.

Spelling errors can tell us a lot about the child’s difficulties, which is why they are an integral component of dyslexia assessment battery.   There is a significant number of linguistic skills involved in spelling.   Good spellers  have well-developed abilities in the following areas (Apel 2006, Masterson 2014, Wasowicz, 2015):

  1. Phonological Awareness – segmenting, sequencing, identifying and discriminating sounds in words.
  2. Orthographic Knowledge – knowledge of alphabetic principle, sound-letter relationships; letter patterns and conventional spelling rules
  3. Vocabulary Knowledge -knowledge of word meanings and how they can affect spelling
  4. Morphological Knowledge- knowledge of “word parts”: suffixes, prefixes, base words, word roots, etc.; understanding the semantic relationships between base word and related words; knowing how to make appropriate modifications when adding prefixes and suffixes
  5. Mental Orthographic Images of Words- clear and complete mental representations of words or word parts

By administering and analyzing spelling test results  or  spelling samples and quizzes,  we can determine where students’  deficits lie,  and design appropriate interventions  to improve knowledge and skills in the affected areas.

twsWhile there are a number of spelling assessments currently available on the market  I personally prefer that the  Test of Written Spelling – 5 (TWS-5) (Larsen, Hammill & Moats, 2013). The  TWS-5  can be administered to students 6-18 years of age in about 20 minutes in either individual or group settings. It has two forms, each containing 50 spelling words drawn from eight basal spelling series and graded word lists. You can use the results in several ways: to identify students with significant spelling deficits or to determine progress in spelling as a result of RTI interventions.

Now,  lets  move on to assessments of writing.   Here, we’re looking to assess a number of abilities,  which include:

  • Mechanics – is there appropriate use of punctuation, capitalization, abbreviations, etc.?
  • Grammatical and syntactic complexity – are there word/sentence level errors/omissions? How is the student’s sentence structure?
  • Semantic sophistication-use of appropriate vs. immature vocabulary
  • Productivity – can the student generate  enough paragraphs, sentences, etc. or?
  • Cohesion and coherence-  Is the writing sample organized? Does it flow smoothly? Does it make sense? Are the topic shifts marked by appropriate transitional words?
  •  Analysis – can the student edit and revise his writing appropriately?

Again it’s important to note that much like the assessments of reading comprehension  there are no specific tests which can assess this area adequately and comprehensively.  Here, a combination of standardized tests, informal assessment tasks as well as analysis of the students’ written classroom output is recommended.

TEWL-3_EM-159

For standardized assessment purposes clinicians can select Test of Early Written Language–Third Edition (TEWL–3) or Test of Written Language — Fourth Edition  (TOWL-4). 

The TEWL-3 for children 4-12 years of age, takes on average 40 minutes to administer (between 30-50 mins.) and examines the following skill areas:

Basic Writing. This subtest consists of 70 items ordered by difficulty, which are scored as 0, 1, or 2. It measures a child’s understanding of language including their metalinguistic knowledge, directionality, organizational structure, awareness of letter features, spelling, capitalization, punctuation, proofing, sentence combining, and logical sentences. It can be administered independently or in conjunction with the Contextual Writing subtest.

Contextual Writing. This subtest consists of 20 items that are scored 0 to 3. Two sets of pictures are provided, one for younger children (ages 5-0 through 6-11) and one for older children (ages 7-0 through 11-11). This subtest measures a child’s ability to construct a story given a picture prompt. It measures story format, cohesion, thematic maturity, ideation, and story structure. It can be administered independently or in conjunction with the Basic Writing subtest.

Overall Writing. This index combines the scores from the Basic Writing and Contextual Writing subtests. It is a measure of the child’s overall writing ability; students who score high on this quotient demonstrate strengths in composition, syntax, mechanics, fluency, cohesion, and the text structure of written language. This score can only be computed if the child completes both subtests and is at least 5 years of age.

TOWL-4_EM-147The TOWL-4 for students 9-18 years of age, takes between 60-90 minutes to administer (often longer) and examines the following skill areas:

  1. Vocabulary – The student writes a sentence that incorporates a stimulus word. E.g.: For ran, a student writes, “I ran up the hill.”
  2. Spelling – The student writes sentences from dictation, making proper use of spelling rules.
  3. Punctuation – The student writes sentences from dictation, making proper use of punctuation and capitalization rules.
  4. Logical Sentences – The student edits an illogical sentence so that it makes better sense. E.g.:  “John blinked his nose” is changed to “John blinked his eye.”
  5. Sentence Combining – The student integrates the meaning of several short sentences into one grammatically correct written sentence. E.g.:  “John drives fast” is combined with “John has a red car,” making “John drives his red car fast.”
  6. Contextual Conventions – The student writes a story in response to a stimulus picture. Points are earned for satisfying specific arbitrary requirements relative to orthographic (E.g.: punctuation, spelling) and grammatic conventions (E.g.: sentence construction, noun-verb agreement).
  7. Story Composition – The student’s story is evaluated relative to the quality of its composition (E.g.: vocabulary, plot, prose, development of characters, and interest to the reader).

It has 3 composites:

  1. Overall Writing- results of all seven subtests
  2. Contrived Writing- results of 5 contrived subtests
  3. Spontaneous Writing-results of 2 spontaneous writing subtests

However, for the purposes of the comprehensive assessment only select portions of the above tests may need be administered  since other overlapping areas (e.g., spelling, punctuation, etc.) may have already been assessed by other tests, a analyzed via the review of student’s written classroom assignments or were encompassed by educational testing.

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Assessing and Treating Bilinguals Who Stutter: Facts for Bilingual and Monolingual SLPs

Introduction: When it comes to bilingual children who stutter there is still considerable amount of misinformation regarding the best recommendations on assessment and treatment. The aim of this article is to review best practices in assessment and treatment of bilingual children who stutter, to shed some light on this important yet highly misunderstood area in speech-language pathology.

Types of Bilingualism: Young bilingual children can be broadly divided into two categories: those who are learning several languages simultaneously from birth (simultaneous bilingual), and those who begin to learn a second language after two years of age (sequential bilingual) (De Houwer, 2009b). The language milestones for simultaneous bilinguals may be somewhat uneven but they are not that much different from those of monolingual children (De Houwer, 2009a). Namely, first words emerge between 8 and 15 months and early phrase production occurs around +/-20 months of age, with sentence production following thereafter (De Houwer, 2009b). In contrast, sequential bilinguals undergo a number of stages during which they acquire abilities in the second language, which include preproduction, early production, as well as intermediate and advanced proficiency in the second language.

Stuttering and Monolingual Children: With respect to stuttering in the monolingual children we know that there are certain risk factors associated with stuttering. These include family history (family members who stutter), age of onset (children who begin stuttering before the age of three have a greater likelihood of outgrowing stuttering), time since onset (depending on how long the child have been stuttering certain children may outgrow it), gender (research has shown that girls are more likely to outgrow stuttering than boys), presence of other speech/language factors (poor speech intelligibility, advance language skills etc.) (Stuttering Foundation: Risk Factors).  We also know that the symptoms of stuttering manifest via sound, syllable and word repetitions, sound prolongations as well as sound and word blocks. In addition to overt stuttering characteristics there could also be secondary characteristics including gaze avoidance, word substitutions, anxiety about speaking, muscle tension in the face, jaw and neck, as well as fist clenching, just to name a few.

Stuttering and Bilingual Children: So what do we currently know regarding the manifestations of stuttering in bilingual children?  Here is some information based on existing research. While some researchers believe that stuttering is more common in bilingual versus monolingual individuals, currently there is no data which supports such a hypothesis.  The distribution and severity of stuttering tend to differ from language to language and one language is typically affected more than the other (Van Borsel, Maes & Foulon, 2001). Lim and colleagues (2008) found that language dominance influences the severity but not the types of stuttering behaviors.  They also found that bilingual stutterers exhibit different stuttering characteristics in both languages such as displaying stuttering on content words in L1 and function words in L2 (less-developed language system). According to Watson & Kayser (1994) key features of ‘true’ stuttering include the presence of stuttering in both languages with accompanying self-awareness as well as secondary behaviors.   This is important to understand giving the fact that bilingual children in the process of learning another language may present with pseudo-stuttering characteristics related to word retrieval rather than true stuttering.

Assessment of Bilingual Stutterers: Now let’s talk about aspects of the assessment. Typically assessment should begin with the taking of detailed background history regarding stuttering risk factors, the extent of the child’s exposure and proficiency in each language, age of stuttering onset, the extent of stuttering in each language, as well as presence of any other concomitant concerns regarding the child’s speech and language (e.g., suspicion of language/articulation deficits etc.)  Shenker (2013) also recommends the parental use of perceptual rating scales to assess child’s proficiency in each language.

Assessment procedures, especially those for newly referred children (vs. children whose speech and language abilities were previously assessed), should include comprehensive assessments of speech and language in addition to assessment of stuttering in order to rule out any hidden concomitant deficits.  It is also important to obtain conversational and narrative samples in each language as well as reading samples when applicable.   When analyzing the samples it is very important to understand and make allowance for typical disfluencies (especially when it comes to preschool children) as well as understand the difference between true stuttering and word retrieval deficits (which pertain to linguistic difficulties), which can manifest as fillers, word phrase repetitions, as well as conversational pauses (German, 2005).

When analyzing the child’s conversational speech for dysfluencies it may be helpful to gradually increase linguistic complexity in order to determine at which level (e.g., word, phrase, etc.) dysfluencies take place (Schenker, 2013). To calculate frequency and duration of disfluencies, word-based (vs. syllable-based) counts of stuttering frequency will be more accurate across languages (Bernstein Ratner, 2004).

Finally during the assessment it is also very important to determine the family’s cultural beliefs toward stuttering since stuttering perceptions vary greatly amongst different cultures (Tellis & Tellis, 2003) and may not always be positive. For example, Waheed-Kahn (1998) found that Middle Eastern parents attempted to deal with their children’s stuttering in the following ways: prayed for change, asked them to “speak properly”, completed their sentences, changed their setting by sending them to live with a relative as well as asked them not to talk in public.  Gauging familial beliefs toward stuttering will allow clinicians to: understand parental involvement and acceptance of therapy services, select best treatment models for particular clients as well as gain knowledge of how cultural attitudes may impact treatment outcomes (Schenker, 2013).

 Image courtesy of mnsu.edu 

Treatment of Bilingual Stutterers: With respect to stuttering treatment delivery for bilingual children, research has found that treatment in one language results in spontaneous improvement in fluency in the untreated language (Rousseau, Packman, & Onslow, 2005). This is helpful for monolingual SLPs who often do not have the option of treating clients in their birth language.

For young preschool children both direct and indirect therapy approaches may be utilized.

For example, the Palin (PCI) approach for children 2-7 years of age uses play-based sessions, video feedback, and facilitated discussions to help parents support and increase their child’s fluency. Its primary focus is to modify parent–child interactions via a facilitative rather than an instructive approach by developing and reinforcing parents’ expertise via use of video feedback to set own targets and reinforce progress. In contrast, the Lidcombe Program for children 2-7 years of age is a behavioral treatment with a focus on stuttering elimination.  It is administered by the parents under the supervision of an SLP, who teaches the parents how to control the child’s stuttering with verbal response contingent stimulation (Onslow & Millard, 2012).   While the Palin PCI approach still requires further research to determine its use with bilingual children, the Lidcombe Program has been trialed in a number of studies with bilingual children and was found to be effective in both languages (Schenker, 2013).

For bilingual school-age children with persistent stuttering, it is important to focus on stuttering management vs. stuttering elimination (Reardon-Reeves & Yaruss, 2013).  Here we are looking to reduce frequency and severity of disfluencies, teach the children to successfully manage stuttering moments, as well as work on the student’s emotional attitude toward stuttering. Use of support groups for children who stutter (e.g., “FRIENDS”: http://www.friendswhostutter.org/), may also be recommended.

Depending on the student’s preferences, desires, and needs, the approaches may involve a combination of fluency shaping and stuttering modification techniques.  Fluency shaping intervention focuses on increasing fluent speech through teaching methods that reduce speaking rate such as easy onsets, loose contacts, changing breathing, prolonging sounds or words, pausing, etc. The goal of fluency shaping is to “encourage spontaneous fluency where possible and controlled fluency when it is not” (Ramig & Dodge, 2004). In contrast stuttering modification therapy focuses on modifying the severity of stuttering moments as well as on reduction of fear, anxiety and avoidance behaviors associated with stuttering. Stuttering modification techniques are aimed at assisting the client “to confront the stuttering moment through implementation of pre-block, in-block, and/or post-block corrections, as well as through a change in how they perceive the stuttering experience” (Ramig & Dodge, 2004). While studies on these treatment methods are still very limited it is important to note that each technique as well as a combination of both techniques have been trialed and found successful with bilingual and even trilingual speakers (Conture & Curlee, 2007; Howell & Van Borsel, 2011).

Finally, it is very important for clinicians to account for cultural differences during treatment. This can be accomplished by carefully selecting culturally appropriate stimuli, preparing instructions which account for the parents’ language and culture, attempting to provide audio/video examples in the child’s birth language, as well as finding/creating opportunities for practicing fluency in culturally-relevant contexts and activities (Schenker, 2013).

Conclusion:  Presently, no evidence has been found that bilingualism causes stuttering. Furthermore, treatment outcomes for bilingual children appear to be comparable to those of monolingual children. Bilingual SLPs encountering bilingual children who stutter are encouraged to provide stuttering treatment in the language the child is most proficient in. Monolingual SLPs encountering bilingual children are encouraged to provide stuttering treatment in English with the expectation that the treatment will carry over into the child’s birth language. All clinicians are encouraged to involve the children’s families in the stuttering treatment as well as utilize methods and interventions that are in agreement with the family’s cultural beliefs and values, in order to create optimum treatment outcomes for bilingual children who stutter.

References:

  1. Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual children. In B. Goldstein (ed.). Language Development: a focus on the Spanish-English speaker. Baltimore, MD: Brookes. (287-310).
  2. Conture, E. G., & Curlee, R. F. (2007). Stuttering and related disorders of fl uency. New York, NY: Thieme Medical Publishers.
  3. De Houwer, A. (2009a). Bilingual first language acquisition. Bristol: Multilingual Matters.
  4. De Houwer, A. (2009b). Assessing lexical development in bilingual first language acquisition: What can we learn from monolingual norms? In M. Cruz-Ferreira (Ed.), Multilingual norms (pp. 279-322). Frankfurt: Peter Lang.
  5. German, D.J. (2005) Word-Finding Intervention Program, Second Edition (WFIP-2)Austin Texas: Pro.Ed
  6. Howell, P & Van Borsel, , (2011). Multicultural Aspects of Fluency Disorders, Multilingual Matters, Bristol, UK.
  7. Lim, V. P. C., Rickard Liow, S. J., Lincoln, M., Chan, Y. H., & Onslow, M. (2008). Determining language dominance in English–Mandarin bilinguals: Development of a selfreport classification tool for clinical use. Applied Psycholinguistics, 29, 389–412.
  8. Onslow M, Millard S. (2012). Palin Parent Child Interaction and the Lidcombe Program: Clarifying some issues. Journal of Fluency Disorders37(1 ):1-8.
  9. Tellis, G. & Tellis, C. (2003). Multicultural issues in school settings. Seminars in Speech and Language, 24, 21-26.
  10. Ramig, P. R., & Dodge, D. (2004, September 08). Fluency shaping intervention: Helpful, but why it is important to know more. Retrieved from http://www.mnsu.edu/comdis/isad7/papers/ramig7.html
  11. Reardon-Reeves, N., & Yaruss, J.S. (2013). School-age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering Therapy Resources, Inc.
  12. Rousseau, I., Packman, A., & Onslow, M. (2005, June). A trial of the Lidcombe Program with school age stuttering children. Paper presented at the Speech Pathology National Conference, Canberra, Australia.
  13. Shenker, R. C. (2013). Bilingual myth-busters series. When young children who stutter are also bilingual: Some thoughts about assessment and treatment. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations, 20(1), 15-23.
  14. Stuttering Foundation website: Stuttering Risk Factors http://www.stutteringhelp.org/risk-factors
  15. Van Borsel, J. Maes, E., & Foulon, S. (2001). Stuttering and bilingualism: A review. Journal of Fluency Disorders, 26, 179-205.
  16. Waheed-Kahn, N. (1998). Fluency therapy with multilingual clients. In Healey, E. C. & Peters, H. F. M. (Eds.),Proceedings of the Second World Congress on Fluency Disorders, San Francisco, August 18. 22(pp. 195–199). Nijmegen, The Netherlands: Nijmegen University Press.
  17. Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural adults who stutter. Seminars in Speech and Language, 15, 149-163.

 

 

 

 

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Part II: Components of Comprehensive Dyslexia Testing – Phonological Awareness and Word Fluency Assessment

Lettere01gorgoA few days ago I posted my first installment in the comprehensive assessment of dyslexia series, discussing common dyslexia myths as well as general language testing as a starting point in the dyslexia testing battery. (You can find this post HERE).

Today I would like to discuss the next two steps in dyslexia assessment, which are phonological awareness and word fluency testing.

Let’s begin with phonological awareness (PA). Phonological awareness is a precursor to emergent reading. It allows children to understand and manipulate sounds in order to form or breakdown words. It’s one of those interesting types of knowledge, which is a prerequisite to everything and is definitive of nothing. I like to compare it to taking a statistics course in college. You need it as a prerequisite to entering a graduate speech pathology program but just because you successfully complete it does not mean that you will graduate the program.  Similarly, the children need to have phonological awareness mastery in order to move on and build upon existing skills to become emergent readers, however, simply having this mastery does not a good reader make (hence this is only one of the tests in dyslexia battery).

When a child has poor phonological awareness for his/her age it is a red flag for reading disabilities. Thus it is very important to assess the child’s ability to successfully manipulate sounds (e.g., by isolating, segmenting, blending, etc.,)  in order to produce real or nonsense words.

Why are nonsense words important?

According to Shaywitz (2003), “The ability to read nonsense words is the best measure of phonological decoding skill in children.” (p. 133-134) Being able to decode and manipulate (blend, segment, etc.) nonsense words is a good indication that the child is acquiring comprehension of the alphabetic principle (understands sound letter correspondence or what common sounds are made by specific letters). It is a very important part of a dyslexia battery since nonsense words cannot be memorized or guessed but need to be “truly decoded.”

While a number of standardized tests assess phonological awareness skills, my personal preference is the Comprehensive Test of Phonological Processing-2 (CTOPP-2), which assesses the following areas:

  • Phonological Segmentation
  • Blending Words
  • Sound Matching
  • Initial, Medial and Final Phoneme Isolation
  • Blending Nonwords 
  • Segmenting Nonwords 
  • Memory for Digits
  • Nonword Repetition 
  • Rapid Digit Naming 
  • Rapid Letter Naming 
  • Rapid Color Naming 
  • Rapid Object Naming 

 As you can see from above description, it not only assesses the children’s ability to manipulate real words but also their ability to manipulate nonsense words. It also assesses word fluency skills via a host of rapid naming tasks, so it’s a very convenient tool to have as part of your dyslexia testing battery.

This brings us to another integral part of the dyslexia testing battery which is word fluency testing (WF).  During word fluency tasks a child is asked to rapidly generate words on a particular topic given timed constraints (e.g., name as many animals as you can in 1 minute, etc.). We test this rapid naming ability because we want to see how quickly and accurately the child can process information. This ability is very much needed to become a fluent reader.

Poor readers can name a number of items but they may not be able to efficiently categorize these words. Furthermore, they will produce the items with a significantly decreased processing speed as compared to good readers. Decreased word fluency is a significant indicator of reading deficits. It is  frequently observable in children with reading disabilities when they encounter a text with which they lack familiarity. That is why this ability is very important to test.

Several tests can be used for this purpose including  CTOPP-2 and Rapid Automatized Naming and Rapid Alternating Stimulus Test (RAN/RAS) just to name a few. However, since CTOPP-2 already has a number of subtests which deal with testing this skill, I prefer to use it to test both phonological awareness and word fluency.

Read part III of this series which discusses components of Reading Fluency and Reading Comprehension testing HERE.

Helpful Links

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Components of Comprehensive Dyslexia Testing: Part I- Introduction and Language Testing

Image result for dyslexia lawsWith the passing of dyslexia laws in the state of New Jersey in 2014, there has been an increased focus on reading disabilities and dyslexia particularly in the area of effective assessment and remediation. More and more parents and health related professionals are looking to understand the components of effective dyslexia testing and who is qualified to perform it. So I decided to write a multi-part series regarding the components of comprehensive dyslexia testing in order to assist parents and professionals to better understand the steps of the testing process.

In this particular post I would like to accomplish two things: dispel several common myths regarding dyslexia testing as well as discuss the first step of SLP based testing which is a language assessment.

Myth 1: Dyslexia can be diagnosed based on a single test!

DYSLEXIA CANNOT BE CONFIRMED BY THE ADMINISTRATION OF ONE SPECIFIC TEST. A comprehensive battery of tests from multiple professionals including neuropsychologists, psychologists, learning specialists, speech-language pathologists and even occupational therapists needs to actually be administered in order to confirm the presence of reading based disabilities.

Myth 2: A doctor can diagnose dyslexia!

A doctor does not have adequate training to diagnose learning disabilities, the same way as a doctor cannot diagnose speech and language problems. Both lie squarely outside of their scope of practice! A doctor can listen to parental concerns and suggest an appropriate plan of action (recommend relevant assessments)  but they couldn’t possibly diagnose dyslexia which is made on the basis of team assessments.

Myth 3: Speech Pathologists cannot perform dyslexia testing!

SPEECH-LANGUAGE PATHOLOGISTS TRAINED IN IDENTIFICATION OF READING AND WRITING DISORDERS ARE FULLY QUALIFIED TO PERFORM SIGNIFICANT PORTIONS OF DYSLEXIA BATTERY.

So what are the dyslexia battery components?

Prior to initiating an actual face to face assessment with the child, we need to take down a thorough case history (example HERE) in order to determine any pre-existing risk factors. Dyslexia risk factors may include (but are not limited to):

  • History of language and learning difficulties in the family
  • History of language delay (impaired memory,  attention, grammar, syntax, sentence repetition ability, etc) as well as
  • History of impaired phonological awareness skills (difficulty remembering children’s songs, recognizing and making rhymes, confusing words that sound alike,  etc).

After that, we need to perform language testing to determine whether the child presents with any deficits in that area. Please note that while children with language impairments are at significant risk for dyslexia not all children with dyslexia present with language impairments. In other words, the child may be cleared by language testing but still present with significant reading disability, which is why comprehensive language testing is only the first step in the dyslexia assessment battery.

Image result for language testingLANGUAGE TESTING

Here we are looking to assess the child’s listening comprehension. processing skills, and verbal expression in the form of conversational and narrative competencies. Oral language is the prerequisite to reading and writing.   So a single vocabulary test, a grammar completion task, or even a sentence formulation activity is simply not going to count as a part of a comprehensive assessment.

In children without obvious linguistic deficits such as limited vocabulary, difficulty following directions, or grammatical/syntactic errors (which of course you’ll need to test) I like to use the following tasks, which are sensitive to language impairment:

Listening Comprehension (with a verbal response component)

  • Here it is important to assess the student’s ability to listen to short passages and answer a variety of story related questions vs. passively point at 1 of 4 pictures depicting a particular sentence structure (e.g., Point to the picture which shows: “The duck was following the girl”). I personally like to use the Listening Comprehension Tests for this task but any number of subtests from other tests have similar components.

Semantic Flexibility

  • Here it is important to assess the student’s vocabulary ability via manipulation of words to create synonyms, antonyms, multiple meaning words, definitions, etc. For this task I like to use the WORD Tests (3-Elementary and 2-Adolescent).

Narrative Production:

  • A hugely important part of a language assessment is an informal spontaneously produced narrative sample, which summarizes a book or a movie.  Just one few minute narrative sample can yield information on the following:
  • Sequencing Ability
  • Working MemoryRelated image
  • Grammar
  • Vocabulary
  • Pragmatics and perspective taking
  • Story grammar (Stein & Glenn, 1979)

Usually I don’t like to use any standardized testing for assessment of this skill but use the parameters from the materials I created myself based on existing narrative research (click HERE).

Social Pragmatic Language

  • Given my line of work (school in an outpatient psychiatric setting), no testing is complete without some for of social pragmatic language assessment in order to determine whether the student presents with hidden social skill deficits. It is important to note that I’ve seen time and time again students acing the general language testing only to bomb on the social pragmatic tasks which is why this should be a mandatory part of every language test in my eyes. Here, a variety of choices exists. For quick results I typically tends to use the Social Language Development Tests as well as portions of the Social Thinking Dynamic Assessment Protocol®.

Not sure what type of linguistic deficits your student is displaying? Grab a relevant checklist and ask the student’s teacher and parent fill it out (click HERE to see types of available checklists)

So there you have it! The first installment on comprehensive dyslexia testing is complete.

READ part II which discusses components of Phonological Awareness and Word Fluency testing HERE. 

Read part III of this series which discusses components of Reading Fluency and Reading Comprehension testing HERE.

Helpful Links

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What if Its More Than Just “Misbehaving”?

Frequently,  I see a variation of the following scenario on many speech and language forums.

The SLP is seeing a client with speech and/or language deficits through early intervention,  in the schools, or in private practice, who is having some kind of behavioral issues.

Some issues are described as mild such as calling out, hyperactivity, impulsivity, or inattention, while others are more severe and include refusal, noncompliance, or aggression such as kicking, biting,  or punching.

An array of advice from well-meaning professionals immediately follows.  Some behaviors may be labeled as “normal” due to the child’s age (toddler),  others may be “partially excused” due to a DSM-5  diagnosis (e.g., ASD).   Recommendations for reinforcement charts (not grounded in evidence) may be suggested. A call for other professionals to deal with the behaviors is frequently made (“in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved”). Specific judgments on the child may be pronounced: “There is nothing wrong with him/her, they’re just acting out to get what they want.” Some drastic recommendations could be made: “Maybe you should stop therapy until the child’s behaviors are stabilized”.

However, several crucial factors often get overlooked. First, a system to figure out why particular set of behaviors takes place and second, whether these behaviors may be manifestations of non-behaviorally based difficulties such as medical issues, or overt/subtle linguistically based deficits.

So what are some reasons kids may present with behavioral deficits? Obviously, there could be numerous reasons: some benign while others serious, ranging from lack of structure and understanding of expectations to manifestations of psychiatric illnesses and genetic syndromes. Oftentimes the underlying issues are incredibly difficult to recognize without a differential diagnosis. In other words, we cannot claim that the child’s difficulties are “just behavior” if we have not appropriately ruled out other causes which may be contributing to the “behavior”.

Here are some possible steps which can ensure appropriate identification of the source of the child’s behavioral difficulties in cases of hidden underlying language disorders (after of course relevant learning, genetic, medical, and psychiatric issues have been ruled out).

Let’s begin by answering a few simple questions. Was a thorough language evaluation with an emphasis on the child’s social pragmatic language abilities been completed? And by thorough, I am not referring to general language tests but to a variety of formal and informal social pragmatic language testing (read more HERE).

Please note that none of the general language tests such as the Preschool Language Scale-5 (PLS-5), Comprehensive Assessment of Spoken Language (CASL-2), the Test of Language Development-4 (TOLD-4) or even the Clinical Evaluation of Language Fundamentals Tests (CELF-P2)/ (CELF-5) tap into the child’s social language competence because they do NOT directly test the child’s social language skills (e.g., CELF-5 assesses them via a parental/teachers questionnaire).  Thus, many children can attain average scores on these tests yet still present with pervasive social language deficits. That is why it’s very important to thoroughly assess social pragmatic language abilities of all children  (no matter what their age is) presenting with behavioral deficits.

But let’s say that the social pragmatic language abilities have been assessed and the child was found/not found to be eligible for services, meanwhile, their behavioral deficits persist, what do we do now?

The first step in establishing a behavior management system is determining the function of challenging behaviors, since we need to understand why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2006)

We can begin by performing some basic data collection with a child of any age (even with toddlers) to determine behavior functions or reasons for specific behaviors. Here are just a few limited examples:

  • Seeking Attention/Reward
  • Seeking Sensory Stimulation
  • Seeking Control

Most behavior functions typically tend to be positively, negatively or automatically reinforced (Bobrow, 2002). For example, in cases of positive reinforcement, the child may exhibit challenging behaviors to obtain desirable items such as toys, games, attention, etc. If the parent/teacher inadvertently supplies the child with the desired item, they are reinforcing inappropriate behaviors positively and in a way strengthening the child’s desire to repeat the experience over and over again, since it had positively worked for them before.

In contrast, negative reinforcement takes place when the child exhibits challenging behaviors to escape a negative situation and gets his way. For example, the child is being disruptive in classroom/therapy because the tasks are too challenging and is ‘rewarded’ when therapy is discontinued early or when the classroom teacher asks an aide to take the child for a walk.

Finally, automatic reinforcements occur when certain behaviors such as repetitive movements or self-injury produce an enjoyable sensation for the child, which he then repeats again to recreate the sensation.

In order to determine what reinforces the child’s challenging behaviors, we must perform repeated observations and take data on the following:

  • Antecedent or what triggered the child’s behavior?
    • What was happening immediately before behavior occurred?
  • Behavior
    • What type of challenging behavior/s took place as a result?
  • Response/Consequence
    • How did you respond to behavior when it took place?

Here are just a few antecedent examples:

  • Therapist requested that child work on task
  • Child bored w/t task
  • Favorite task/activity taken away
  • Child could not obtain desired object/activity

In order to figure them out we need to collect data, prior to appropriately addressing them. After the data is collected the goals need to be prioritized based urgency/seriousness.  We can also use modification techniques aimed at managing interfering behaviors.  These techniques include modifications of: physical space, session structure, session materials as well as child’s behavior. As we are implementing these modifications we need to keep in mind the child’s maintaining factors or factors which contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits. 

We also need to choose our reward system wisely, since the most effective systems which facilitate positive change actually utilize intrinsic rewards (pride in self for own accomplishments) (Kohn, 2001).  We need to teach the child positive replacement behaviors  to replace the use of negative ones, with an emphasis on self-talk, critical thinking, as well as talking about the problem vs. acting out behaviorally.

Of course it is very important that we utilize a team based approach and involve all the professionals involved in the child’s care including the child’s parents in order to ensure smooth and consistent carryover across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired therapy outcomes.

So the next time the client on your caseload is acting out don’t be so hasty in judging their behavior, when you have no idea regarding the reasons for it. Troubleshoot using appropriate and relevant steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

For more detailed information on the topic of social pragmatic language assessment and behavior management in speech pathology see if the following Smart Speech Therapy LLC products could be of use:

 

References: 

  1. Bobrow, A. (2002). Problem behaviors in the classroom: What they mean and how to help. Functional Behavioral Assessment, 7 (2), 1–6.
  2. Chandler, L.K., & Dahlquist, C.M. Functional assessment: strategies to prevent and remediate challenging behavior in school settings (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.
  3. —Klein, H., & Moses, N. (1999). Intervention planning for children with communication disorders: A guide to the clinical practicum and professional practice. (2nd Ed.). Boston, MA.: Allyn & Bacon.
  4. —Kohn, A. (2001, Sept). Five reasons to stop saying “good job!’. Young Children. Retrieved from http://www.alfiekohn.org/parenting/gj.htm
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Simplifying Testing Results to Understand the Student’s Difficulties

image

Oftentimes explaining testing results in the form of standard scores, percentiles, and charts is labor-intensive for the SLP and confusing for parents and ancillary  professionals. Furthermore, just because you show testing results does not always ensure that the ramifications of testing are fully understood, especially when it comes to performance of high functioning students with deficits in isolated areas, which may significantly impact the student’s functioning in social and academic settings.

So finding an effective method of sharing testing results was fraught with difficulties until recently. In early January, I attended a Sarah Ward executive function conference, where Sarah shared one of her tricks of sharing testing results.  She used a picture of a bell curve and inserted testing results into it. So it looked a little similar to the picture I have below:

BELL CURVE

As you can see the student’s listening comprehension and expressive language performance fell in the average range as denoted on the bottom of the picture. In contrast, the student’s problem solving and social pragmatic testing abilities fell in the below average range as is denoted by both a red bar as well as the caption underneath the picture.

It is a visually simple way to see what areas need to be worked on in one snapshot.

Charts in Action: Students with Social Skills Deficits 

This system is even more effective for displaying testing results of higher functioning students with select deficit areas. To illustrate, I recently performed a comprehensive language assessment on a 12-year-old adolescent with suspected ASD. The student had a superior IQ, excellent vocabulary, and phenomenal memory.

When tested in school setting she did not qualify to receive language intervention. However, her comprehensive language testing with me showed a number of disparities. While the majority of her testing fell in the above average and superior range, in a number of testing areas she performed within average and below average range (combined SLP, ED, and Psych. testing results below).

BELL CURVE 3

When one looked at the student’s overall testing results, they clearly indicated cumulative performance in the average range of functioning. However, after I plotted all of her results on the bell curve her deficit areas became very clearly apparent and her testing discrepancy clearly indicated that intervention in select areas of functioning was needed.

So even though select scores were clearly in the average range of functioning on the bell curve, they were actually BELOW AVERAGE for this student as compared to significant strengths in all other areas.

Many would argue with me pointing out that scores in the average range mean average range. The student doesn’t qualify – end of story!  So let me explain the above scores in REAL-LIFE terms.

Why Students with Average Scores May Still Require Services 

This particular student was referred for a social pragmatic evaluation due to behavioral difficulties in the classroom which included verbal outbursts, difficulty engaging in cooperative group work and verbal confrontations with classmates.

Interactions with the student revealed an engaging adolescent who preferred the company of adults and was very likable. However, throughout testing she made comments indicating cognizance that she was not accepted by typically developing peers. She frustratedly stated that she “doesn’t get” peers, is not interested in the “typical” experiences and has “nothing in common” with peers her age because she “misses the point” of their verbal interchanges.

Due to her exceptional performance on standardized testing, many school-based professionals  believed that because she did so well well she did not have any “true” social learning deficits. In contrast the student’s peer group was able to see her social differences with very little effort.  In school, the student did not qualify for social pragmatic language therapy, on the basis of her challenges being perceived as too “mild” to merit services, however her social deficits were NOT mild as judged by her peers. They were only mild as compared to individuals with severe social learning challenges. Without appropriate intervention, these difficulties would  continue to pervasively impact her academic and social performance, as well as affect future employment and relationship status.

So this is why I now love plotting scores on the bell curve for parents and professionals. A simple picture clearly shows the significance of score distribution, the deficits areas in need of intervention, and is literally worth a 1000 words!

Helpful Resources Related to Social Pragmatic Language Overview, Assessment  and Remediation:

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Dear School Professionals Please Be Aware of This

Screen Shot 2014-11-12 at 5.26.00 PM

I frequently get  emails,  phone calls,  and questions from parents and professionals  regarding academic functioning of internationally adopted post institutionalized children.  Unfortunately despite the fact that  there is  a  fairly large body of research  on this topic  there still continue to be numerous misconceptions regarding how these children’s needs should be addressed  in academic settings.

Perhaps  one of the most serious and damaging misconceptions is that internationally adopted children are bilingual/multicultural children with Limited English Proficiency who need to be treated as ESL speakers. This erroneous belief often leads to denial or mismanagement of appropriate level of services for these children not only with respect to their  language processing and verbal expression but also their social pragmatic language abilities.

Even after researchers published a number of articles on this topic, many psychologists, teachers and speech language pathologists still don’t know that internationally adopted children rapidly lose their little birth language literally months post their adoption by English-speaking parents/families. Gindis (2005) found that children adopted between 4-7 years of age lose expressive birth language abilities within 2-3 months and receptive abilities within 3-6 months post- adoption. This process is further expedited in children under 4, whose language is delayed or impaired at the time of adoption (Gindis, 2008).    Even school-aged children of 10-12 years of age who were able to read and write in their birth language,  rapidly lose  their comprehension and expression of birth language  within their first year post adoption,  if adopted by English-speaking parents who are unable to support their birth language.

 So how does this translate into appropriate provision of speech language services you may ask?   To begin with,  I often see posts on the ASHA forums  or in Facebook speech pathology and special education groups seeking assistance with finding interpreters fluent in various exotic languages.  However, unless the child is “fresh off the boat” (several months post arrival to US)  schools shouldn’t be feverishly trying to locate interpreters to assist with testing in the child’s birth language.  They will not be able to obtain any viable results especially if the child had been residing in the United States for several years.

So if the post-institutionalized, internationally  adopted child is still struggling with academics  several years post adoption,  one should not immediately jump to the conclusion that this is an “ESL” issue,  but get relevant professionals (e.g., speech pathologists, psychologists) to perform thorough testing in order to determine whether it’s the lack of foundational abilities due to institutionalization which is adversely impacting the child’s academic abilities.

Furthermore, ESL itself is often not applicable as an educational method to internationally adopted children.  Here’s why:

Let’s literally take the first definition of ESL which pops-up on Google when you put in a query: “What is ESL?”  “English as a Second Language (ESL) is an instructional program for students whose dominant language is not English. The purpose of the program is to increase the English language proficiency of eligible students so they can attain academic standards and achieve success in the classroom.”

Here is our first problem.  These students don’t have a dominant language.   They are typically adopted by parents who do not speak their birth language and that are unable to support them in their birth language. So upon arrival to US, IA children will typically acquire English via the subtractive model of language acquisition (birth language is replaced and eliminated by English), which is a direct contrast to bilingual children, many of whom learn via the additive model (adding English to the birth language (Gindis, 2005). As a result, of subtractive language acquisition IA children experience very rapid birth language attrition (loss) post-adoption (Gindis, 2003; Glennen, 2009).   Thus they will literally undergo what some researchers have called: “second-first language acquisition” (Scott et al., 2011)  and their first language will “become completely obsolete as English is learned” (Nelson, 2012, p. 2). 

This brings us to our second problem: the question of “eligibility”.  Historically, ESL programs have been designed to assist children of immigrant families  acquire academic readiness skills.  This methodology is based on the fact that skills from first language was ultimately transfer to the  second language.  However, since post-institutionalized children don’t technically have a “first language”  and  their home language is English,  how could they technically be eligible for ESL services? Furthermore,  because of frequent lack of basic foundational skills in the birth language  internationally adopted post-institutionalized children will not benefit the same way from ESL instruction the same way bilingual children of immigrant families do.  So instead of focusing on these children’s questionable eligibility for ESL services  it is important to perform detailed review of their pre-adoption records in order to determine birth language deficits and consider eligibility for  speech language services with the emphasis on improving  these children’s  foundational skills.

If the child’s pre-adoption records specifically state that s/he has birth language delay then it should be taken seriously (Gindis, 1999) since language delays in the birth language transfer and affect the new language (McLaughlin, Gesi, & Osani, 1995). These delays will not “go away” without appropriate interventions.  “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)

Now that we have discussed the issue of ESL services, lets touch upon social pragmatic language abilities of internationally adopted children.  Here’s how erroneous beliefs can contribute to mismanagement of appropriate services in this area.

Different cultures have different pragmatic conventions,  therefore we are taught to be very careful when labeling  certain behaviors  of children from other cultures as atypical, just because they are not consistent with the conventions and behaviors of children from the mainstream culture. Here’s a recent example. A mainstream American parent consulted an SLP regarding the inappropriate social pragmatic skills of her teenaged daughter adopted almost a decade ago from Southeast Asia. The SLP was under the  impression that  some of the child’s deficits  were due to multicultural differences and had to do with the customs and traditions of the child’s country of origin. She was considering  advising the parent regarding requesting  an evaluation by a SLP who spoke the child’s birth language.

Here are two problems with the above scenario.  Firstly,  any internationally adopted post-institutionalized child who was adopted by American parents who were not part of the culture from which the child was adopted, the child will quickly become acculturated  and  immersed in the American culture.  These children “need functional English for survival”, and thus have a powerful incentive to acquire English (Gindis, 2005; p. 299).   consequently, any unusual or atypical behaviors they exhibit in social interactions and in academic setting with other individuals cannot be  attributed to customs and traditions of another culture.

Secondly,  It is very important to understand that  institutionalization and orphanage care have been closely linked to increase in mental health disorders  and psychiatric impairments.   As a result, internationally adopted children have a high incidence of social pragmatic deficits as compared to non-adopted peers as well as post-institutionalized children adopted at younger ages, (under 3).    Given this, if parents present with concerns regarding their internationally adopted post-institutionalized children’s social pragmatic and behavioral functioning it is very important not to  jump to erroneous conclusion pertaining to these children’s birth countries but rather preform comprehensive evaluations in order to determine whether these children can be assisted further in the realm of social pragmatic functioning in a variety of settings.

In order to develop a clear picture regarding appropriate service delivery for IA children, school based professionals need to educate themselves regarding the fundamental differences between development and learning trajectories of internationally adopted children and multicultural/bilingual children. Children, who struggle academically, after years of adequate schooling exposure, do not deserve a “wait and see” approach. They should start receiving appropriate intervention as soon as possible (Hough & Kaczmarek, 2011; Scott & Roberts, 2007).

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Review of Social Language Development Test Adolescent: What SLPs Need to Know

Product ImageA few weeks ago I reviewed the  Social Language Development Test Elementary  (SLDTE) and today I am reviewing the  Social Language Development Test Adolescent  (SLDTA) currently available from PRO-ED.

Basic overview

Release date: 2010
Age Range: 12-18
Authors:Linda Bowers, Rosemary Huisingh, Carolyn LoGiudice
Publisher: Linguisystems (PRO-ED as of 2014)

The Social Language Development Test: Adolescent (SLDT-A) assesses adolescent students’ social language competence. The test addresses the students ability to take on someone else’s perspective, make correct inferences, interpret social language, state and justify logical solutions to social problems, engage in appropriate social interactions, as well as interpret ironic statements.

The Making Inferences subtest of the SLDT-A assesses students’ ability to infer what someone in the picture is thinking as well as state what visual cues aided him/her in the making of that inference.

The first question asks the student to pretend to be a person in the photo and then to tell what the person is thinking by responding as a direct quote. The quote must be relevant to the person’s situation and the emotional expression portrayed in the photo.The second question asks the student to identify the relevant visual clues that he used to make the inference.

Targeted Skills include:

  1. detection of nonverbal and context clues
  2. assuming the perspective of a specific person
  3. inferring what the person is thinking and expressing the person’s thought
  4. stating the visual cues that aided with response production

A score of 1 or 0 is assigned to each response, based on relevancy and quality. However, in contrast to the SLDTE student must give a correct response to both questions to achieve a score of 1.

Errors can result due to limited use of direct quotes (needed for correct responses to indicate empathy/attention to task), poor interpretation of provided visual clues (attended to irrelevant visuals) as well as vague, imprecise, and associated responses.

The Interpreting Social Language subtest of the SLDT-A assesses students’ ability to demonstrate actions (including gestures and postures), tell a reason or use for an action, think and talk about language and interpret figurative language including idioms.

A score of 1 or 0 is assigned to each response, based on relevancy and quality. Student must give a correct response to both questions to achieve a score of 1.

Targeted Skills:

  1. Ability to demonstrate actions such as gestures and postures
  2. Ability to explain appropriate reasons or use for actions
  3. Ability to think and talk about language
  4.  Ability to interpret figurative language (e.g., idioms)

Errors can result due to vague, imprecise (off-target), or associated responses as well as lack of responses. Errors can result due to lack of knowledge of correct nonverbal gestures to convey meaning of messages.  Finally errors can result due to literal interpretations of idiomatic
expressions.

The Problem Solving subtest of the SLDT-A assesses students’ ability to offer a logical solution to a problem and explain why that would be a good way to solve the problem.

To receive a score of 1, the student has to provide an appropriate solution with relevant justification. A score of 0 is given if any of the responses to either question were incorrect or inappropriate.

Targeted Skills:

  1. Taking perspectives of other people in various social situations
  2. Attending to and correctly interpreting social cues
  3. Quickly and efficiently determining best outcomes
  4. Coming up with effective solutions to social problems
  5. Effective conflict negotiation

Errors can result due to illogical or irrelevant responses, restatement of the problem, rude solutions, or poor solution justifications.

The Social Interaction subtest of the SLDT-A assesses students’ ability to socially interact with others.

A score of 1 is given for an appropriate response that supports the situation. A score of 0 is given for negative, unsupportive, or passive responses as well as for ignoring the situation, or doing nothing.

Targeted Skills:

  1. Provision of appropriate, supportive responses
  2. Knowing when to ignore the situation

Errors can result due to inappropriate responses that were negative, unsupportive or illogical.

The Interpreting Ironic Statements subtest of the SLDT-A assesses sudents’ ability to recognize sarcasm and interpret ironic statements.

To get a score of 1, the student must give a response that shows s/he understands that the speaker is being sarcastic and is saying the opposite of what s/he means.  A score of 0 is given if the response is literal and ignores the irony of the situation.

Errors can result due to consistent provision of literal idiom meanings indicating lack of
understanding of the speaker’s intentions as well as “missing” the context of the situation. errors also can result due the the student identifying that the speaker is being sarcastic but being unable to explain the reason behind the speaker’s sarcasm (elaboration).

For example, one student was presented with a story of a brother and a sister who extensively labored over a complicated recipe. When their mother asked them about how it came out, the sister responded to their mother’s query: “Oh, it was a piece of cake”. The student was then asked: What did she mean?” Instead of responding that the girl was being sarcastic because the recipe was very difficult, student responded: “easy.”  When presented with a story of a boy who refused to help his sister fold laundry under the pretext that he was “digesting his food”, he was then told by her, “Yeah, I can see you have your hands full.” the student was asked: “What did she mean?” student provided a literal response and stated: “he was busy.”

goal-setting

The following goals can be generated based on the performance on this test:

  • Long Term Goals: Student will improve social pragmatic language skills in order to effectively communicate with a variety of listeners/speakers in all social and academic contexts
  • Short Term Goals
  1. Student will improve his/her ability to  make inferences based on social scenarios
  2. Student will improve his/her interpretation of facial expressions, body language, and gestures
  3. Student will improve his/her ability to interpret social language (demonstrate appropriate gestures and postures, use appropriate reasons for actions, interpret figurative language)
  4. Student will his/her ability to provide multiple interpretations of presented social situations
  5. Student will improve his/her ability to improve social interactions with peers and staff (provide appropriate supportive responses; ignore situations when doing nothing is the best option, etc)
  6. Student will improve his/her ability to  interpret abstract language (e.g., understand common idioms, understand speaker’s beliefs, judge speaker’s attitude, recognize sarcasm, interpret irony, etc)

Caution

A word of caution regarding testing eligibility: 

I would also not administer this test to the following adolescent populations:

  • Students with social pragmatic impairments secondary to intellectual disabilities (IQ <70)
  • Students with severe forms of Autism Spectrum Disorders
  • Students with severe language impairment and limited vocabulary inventories
  • English Language Learners (ELL) with suspected social pragmatic deficits 
  • Students from low SES backgrounds with suspected pragmatic deficits 

—I would not administer this test to Culturally and Linguistically Diverse (CLD)  students due to significantly increased potential for linguistic and cultural bias, which may result in test answers being marked incorrect due to the following:

  • Lack of relevant vocabulary knowledge will affect performance 
  • Lack of exposure to certain cultural and social experiences related to low SES status or lack of formal school instruction
    • How many of such students would know know the meaning of the word “sneer”?
    • —How many can actually show it?
  • Life experiences that the child simply hasn’t encountered yet
    • Has an —entire subtest devoted to idioms
  • —Select topics may be inappropriate for younger children
    • —Dieting
    • —Dating—
  • —Culturally biased when it comes to certain questions regarding friendship and personal values
    • —Individual vs. cooperative culture differences

What I like about this test: 

  • I like the fact that unlike the  CELF-5:M,  the test is composed of open-ended questions instead of offering orally/visually based multiple choice format as it is far more authentic in its representation of real world experiences
  • I really like how the select subtests (Making Inferences) require a response to both questions in order for the responder to achieve credit on the total subtest

Overall, when you carefully review what’s available in the area of assessment of social pragmatic abilities of adolescents this is an important test to have in your assessment toolkit as it provides very useful information for social pragmatic language treatment goal purposes.

Have YOU purchased SLDTA yet? If so how do you like using it? Post your comments, impressions and questions below.

Helpful Resources Related to Social Pragmatic Language Overview, Assessment  and Remediation:

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

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Dear Pediatrician: Please Don’t Say That!

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Recently, a new client came in for therapy.  He was a little over three years of age with limited verbal abilities,  and a number of stereotypical behaviors consistent with autism spectrum disorder.  During the course of parental interview, the child’s mother mentioned that he had previously briefly received early intervention services  but  aged out from the early intervention system after only a few months.  As we continued to discuss the case, his mother revealed that she  had significant concerns regarding her son’s language abilities and behavior from a very early age  because it  significantly differed from his older sister’s developmental trajectory. However,  every time she brought it up to her pediatrician  she invariably received the following answers:  “Don’t compare him to his sister, they are different  children”  and   “Don’t  worry,  he will catch up”,  which resulted in the child being referred for early intervention services when he was almost 3 years of age,  and unable to receive consistent  speech therapy services prior to aging out of the program all together.

This is not the first time I heard such a story,  and I’m sure it won’t be the last time as well.  Sadly, myself and other speech language therapists are very familiar with such cases and that is such a shame.  It is a shame, because  a parent was absolutely correct in trusting her instincts but was not validated by a medical professional she trusted the most, her child’s pediatrician.  Please don’t get me wrong,  I am not  playing the blame game  or trying to denigrate members of another profession.   My  aim  today is rather different and that is along with my colleagues to continue increasing awareness among all health professionals  regarding the early identification  of communication disorders  in children in order for them to receive  effective early intervention services  to improve their long-term outcomes.

getty_rf_photo_of_toddler_feeding_teddy_bear

 Whenever one “Googles” the term “Language Milestones In Children”  or “When  do children begin to talk?”   Numerous links pop-up,  describing developmental milestones in children.  Most of them contain  fairly typical information such as: first word emerge at approximately 12 months of age,   2 word combinations emerge when the child has a lexicon of approximately 50 words or more, which corresponds  to  a period between  18 months to 2 years of age,  and sentences emerge when a child is approximately 3 years of age. While most of this information is hopefully common knowledge for many healthcare professionals working with children including pediatricians,  is also important to understand that when the child comes in for a checkup one should not look at these abilities in isolation but  rather  look at the child  holistically.  That means  asking the parents the right questions to compare the child’s cognitive, adaptive,  social emotional, as well as communicative functioning  to that of typically developing peers  or siblings  in order to determine whether anything is amiss.  Thus, rather than to discourage the  parent  from  comparing their child to typically developing children his age, the parents  should actually be routinely asked the variation of the following question: “How  do your child’s abilities  and functioning compare to other typically developing children your child age?”

woman-talking-to-doctorWhenever I ask this question during the process of evaluation or initiation of therapy  services,  90% of the time I receive highly detailed and intuitive responses  from well-informed parents. They immediately begin describing in significant detail the difference in functioning  between their own delayed child  and  his/her  siblings/peers.   That is why in the majority of cases  I find the background information provided by the parent to be almost as valuable  as the evaluation itself.  For example, I recently assessed  a 3-5 year-old child  due to communication concerns.   The pediatrician was very reluctant to refer to the child for services due to the fact that the child was adequately verbal.   However,  the child’s  parents were insistent,  a script for services was written, and the child was brought to me for an evaluation.  Parents reported that while their child was very verbal and outgoing,  most of the time they had significant difficulty  understanding what she was trying to tell them due to poor grammar as well as nonsensical content of her messages.   They also reported that the child had a brother , who was older than her last several years.  However,  they stated that they had never experienced similar difficulties with the child’s brother when he was her age,  which is why they became so concerned with each passing day regarding the child’s language abilities.

Indeed, almost  as soon as the evaluation began, it became apparent that while the child’s verbal output was adequate, the semantic content of those messages  as well as the pragmatic use in conversational exchanges  was significantly impaired. In  other words,  the  child may have been adequately verbose but  the coherence of her discourse left a lot to be desired.   This child was the perfect candidate for therapy but had parents not insisted, the extent of her expressive language difficulties  may have been overlooked until she was old enough to go to kindergarten. By then  many valuable intervention  hours would have been lost  and the extent of the child deficits have been far greater.

So dear pediatrician,  the next time  a concerned parent utters the words: “I think something is wrong…” or “His language is nothing like his brother’s/sister’s when s/he was that age” don’t be so hasty in dismissing their concerns. Listen to them,  understand that while you are the expert in childhood health and diseases,   they are  the expert  in their own child,  and are highly attuned  to their child’s functioning and overall abilities. Encourage them to disclose their worries by asking follow-up questions and validating their concerns.

why_your_doctor_needs_to_know_your_life_story_4461_98044748There are significant benefits  to receiving early targeted  care  beyond the improvement in language abilities.  These include but are not limited to:  reduced chances of behavioral deficits or mental illness, reduced chances of reading, writing and learning difficulties  when older,  reduced chances of  impaired socialization abilities and self-esteem,  all of which can affect children with language deficits when appropriate services are delayed or never provided.  So please, err on the side of caution  and refer the children with suspected deficits to speech language pathologists.  Please give us an opportunity to thoroughly assess these children in order to find out  whether there truly is  speech/language disorder/delay.  Because by doing this you truly will be serving the interests of your clients.

Helpful Smart Speech Therapy Resources: