Category: Assessment

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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 

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Why (C) APD Diagnosis is NOT Valid!

Today’s post will make a number of people quite angry and is intended to be controversial!  Why? Because controversy promotes critical thinking, broadens perspectives, allows to acquire better knowledge of the construct in question as well as ultimately guides better decision making on the part of the parties in question. So why the lengthy disclaimer? Because today via the use of the latest research publications, I would like discuss the fact that the diagnosis of Auditory Processing Disorder (APD) or what some may know as Central Auditory Processing Disorder (CAPD) is NOT valid!

Here are just a few reasons why:

  1. There is a strong desire for the (C)APD label on the part of those encountering processing difficulties, yet once the label is given no direct/specific auditory interventions are provided by the audiologist. Subsequent to the diagnosis, confusion ensues regarding the type, frequency, and duration of service provision (typically performed by the SLP) as well as what those services should actually constitute 
  2. Recommendations for training deficits specific areas such as working memory, auditory discrimination, auditory sequencing, etc., do not functionally transfer into practice and fail to create generalization affect
  3. Recommendations for specific costly auditory training programs such Auditory Integration Training (AIT), The Listening Program (TLP), Fast ForWord® (FFW) at the exclusion of all others, without the provision of a detailed breakdown of the child’s deficit areas often cause an incursion of unnecessary expenses for parents and professionals and are found to be INEFFECTIVE or limitedly effective in the long run
  4. General audiological recommendations for accommodations (e.g., FM systems, etc.) are frequently unnecessary, and may actually exacerbate the isolation effect while in no way alleviating the student’s deficits, which require direct and targeted intervention
  5. Auditory deficits don’t cause speech, language, and academic learning difficulties
  6. Numerous non-linguistic based disorders can be misdiagnosed as (C)APD without differential diagnosis
  7. (C)APD testing is hugely influenced by non-auditory factors grounded in higher order cognitive and linguistic processes
  8. Presently there’s no no clear performance criteria to make the (C)APD diagnosis
  9. The diagnosis of (C)APD is appealing because it presents a more attractive explanation than the diagnoses of language and learning disabilities for children with processing deficits
  10. The diagnosis of (C)APD may often detract from identifying legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development, as the result of which these areas will not get adequate therapeutic attention by relevant professionals

A few words on (C)APD popularity, well sort of:

(C)APD  is currently rampantly diagnosed in the United States, Australia and New Zealand, and is even beginning to be diagnosed in the United Kingdom (Dawes & Bishop, 2009). However, presently, (C)APD is not a mainstream diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) nor is part of an actual educational classification in United States.  Already many of you can see the beginnings of the controversy.  If this diagnoses is so popular and so prevalent why is that major psychological and educational governing bodies such as American Psychiatric Association and the US Department of Education still do not officially recognize it?

(C)APD symptomology:

A. Student presents with difficulty processing information efficiently

  • Requires increased processing time to respond to questions
  • Presents like s/he are ignoring the speaker
  • May request frequent repetition of presented information from speakers
  • Difficulty following long sentences
  • Difficulty keeping up with class discussions in group settings
  • Poor listening abilities under noisy conditions may be interpreted as “distractibility”

B. Student has difficulty maintaining attention on presented tasks

  • Frequent loss of focus
  • Difficulty completing assignments on their own

C. Student has poor short term memory – difficulty remembering instructions and directions or verbally presented information

D.Student has difficulty with phonemic awareness, reading and spelling

  • Poor ability to recognize and produce rhyming words
  • Poor segmentation abilities (separation of sentences, syllables and sounds)
  • Poor sound manipulation abilities (isolation, deletion, substitution, blending, etc)
  • Poor sound letter identification abilities
  • Poor vowel recognition abilities
  • Poor decoding
  • Poor comprehension
  • Spelling errors
  • Limited/disorganized writing

E. The combination of above factors may result in generalized deficits across the board, affecting the child’s social and academic performance:

  • Poor reading comprehension
  • Poor oral and written expression
  • Disorganized thinking (e.g., disjointed narrative production)
  • Sequencing errors (recalling/retelling information in order, following recipes, etc)
  • Poor message interpretation
  • Difficulty making inferences
  • Misinterpreting the meaning of abstract information

I do not know what you see when you read the above description but to me those are the classical signs of a language impairment which has turned into a learning disability masking under the ambiguous label of  (C)APD. 

That is exactly what Dawes & Bishop, stated in 2009, when they asserted that “a child who is regarded as having a specific learning disability by one group of experts may be given an APD diagnosis by another.” They concluded that: “APD, as currently diagnosed, is not a coherent category, but that rather than abandoning the construct, we need to develop improved methods for assessment and diagnosis, with a focus on interdisciplinary evaluation“.

Let us now deconstruct each of the above statements with the assistance of direct quotes from current research.

1. (C)APD – what is it good for? Child goes to an audiologist and receives an ambiguous battery of (C)APD  testing with unclear qualification criteria (more on that below). There are some abnormal findings, so the audiologist states that the child has (C)APD, recommends accommodations and modifications, services in the form of speech language therapy with a focus on auditory training (more below) and/or some form of program similar to Fast ForWord®, and doesn’t see the child again for some time (maybe even years).  Since the child is now being seen by an SLP, who by the way frequently has no idea what to do with that child based on the ambiguous audiological findings, what exactly did the diagnosis of (C) APD just accomplish?

2. Processing Skills Training – Say What? In 2011 Fey and colleagues  (many notable audiologists and speech language pathologists) conducted a systematic review of  25 journal articles on the efficacy of interventions for school-age children with auditory processing disorder (C)APD. Their review found no compelling evidence that auditory interventions provided any unique benefit to auditory, language, or academic outcomes for children with diagnoses of (C)APD or language disorder.

Presently there is no valid evidence that targeting specific processing skills such as auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming actually improves children’s ‘auditory processing’, language or reading abilities (Fey et al., 2011).

To illustrate further, Melby-Lervåg & Hulme, 2013 performed a meta analysis  of 23 working memory training studies. They found no evidence that memory training was an effective intervention for children with ADHD or dyslexia as it did not lead to better performance outside of the tasks presented within the memory tests. They concluded: “In the light of such evidence, it seems very difficult to justify the use of working memory training programs in relation to the treatment of reading and language disorders.” Further adding: “Our findings also cast strong doubt on claims that working memory training is effective in improving cognitive ability and scholastic attainment.” (Melby-Lervåg, 2013, p. 282).

3. The trouble with prescriptive programs.  (C)APD assessments often yield recommendations for a number of specific costly prescriptive programs such as AIT, FFW, etc.. As humans we are “attracted to interventions that promise relatively rapid improvements in language and academic skills. Interventions that target processing abilities are appealing because they promise significant improvements in language and reading without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (Kamhi and Wallach, 2012)

These programs claim to improve the child’s processing abilities through music, phonics, hearing distortions, etc. When such recommendations are made parents and professionals are urged to carefully review evidence-based research supported information regarding these prescribed programs in order to determine their effectiveness. Presently, there’s no research to support the use of any of these programs with children presenting with processing difficulties. 

Let’s take a look at Fast ForWord®, which is a highly costly program frequently recommended for children with auditory processing deficits. It is designed to help children’s reading and spoken language by training their memory, attention, processing, and sequencing by training 3 to 5 days per week, for 8 to 12 weeks. However, systematic reviews found no sign of a reliable effect of Fast ForWord® on reading or on expressive or receptive spoken language. 

Now some of you may legitimately tell me: “How dare you? I’ve tried it with my child and seen great gains”. And that is terrific! However, it is important to note that ANY intervention is better than NO intervention! And there is currently no scientific proof out there that this program works better than other programs aimed directly at improving the children’s reading abilities and listening skills.  Furthermore, if the child needs assistance with reading rather than spending the money  on Fast ForWord® it would be far more effective to select a systematic Orton-Gillingham (OG) (or similar) reading based program to teach her/him reading!

4. The dreaded FM system! FM systems have become an almost automatic recommendation for children diagnosed with (C)APD but are they actually effective?

Here is what one notable audiologist had to say in the subject. “An FM system brings the speaker’s voice via the mic to the listener via loudspeakers or earphones through an amplifier. Only personal systems appropriate for children with TRUE APD-based auditory distractibility problems (understanding speech in the presence of background noise)”.  However, when he did his testing he found that only ~25% of children with (C)APD had issues with hearing speech in noise, the other ~75% didn’t. 

Guess what… a recent meta-analysis showed? Lemos et, al, 2009 did a systematic literature review of articles recommending the use of FM systems for APD. They concluded that: “Strong scientific evidence supporting the use of personal FM systems for APD intervention was not found. Since such device is frequently recommended for the treatment of APD, it becomes essential to carry out studies with high scientific evidence that could safely guide clinical decision making on this subject.“

5. (C)APD diagnosis does NOT Language Disorder Make. “There little evidence that auditory perceptual impairments (not referring to hearing deficits) are a significant risk factor for language and academic performance (e.g., Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009)” (Kamhi, 2011, p. 265).  

  • Watson et al., 2003 found that measures of auditory processing (NOT hearing) had no impact on children’s reading or language abilities in Grades 1 through 4.
  • Sharma, Purdy, and Kelly (2009)  found that having auditory processing difficulties did not increase the likelihood that a child would have a language or reading disorder.
  • Hazan et al., 2009; Ramus et al., 2006) found that despite poor phonological processing abilities, individuals with dyslexia perform within normal limits on measures of speech perception. 

(From Kamhi, 2011, p. 268)

6. Are you sure it’s (C)APD?

—Without a careful differential diagnosis, numerous non-linguistic based medical, psychiatric neurological, psychological, and cognitive conditions can be misdiagnosed as (C)APD including (but not limited):

  • —Respiratory Disorders
    • —Adenoid hypertrophy, asthma, allergic rhinitis
  • —Metabolic/Endocrine Disorders
    • —Diabetes  hypo/hyperthyroidism
  • —Hematological Disorders
    • —Anemia
  • —Immunological Disorders
    • —Acquired and congenital immune problems
  • —Cardiac Disorders
    • —Congenital and acquired heart disease, syncopy
  • —Digestive  Disorders
    • —Irritable bowel syndrome, GERD
  • —Neurological Disorders
    • —Traumatic Brain Injuries, Tumors, Encephalopathy
  • Genetic Disorders
    • —Fragile X Syndrome
  • —Toxin Exposure
    • —Lead, Mercury, Drug Exposure
  • —Infections and Infestations
    • —Yeast overgrowth , intestinal worms/parasites
  • —Sleep Disorders
    • Sleep Apnea
  • —Mental Health Disorders
    • —Trauma, Anxiety, mood disorders, adjustment disorders
  • ——Sensory Processing Disorders
    • —Vision, hearing, auditory, tactile
  • —Acquired Disorders
    • —FASD

7. (C)APD testing is NOT so PURE 

(C)APD testing does not simply consists of pure tone audiometry and is heavily comprised of higher order linguistic and cognitive tasks. Testing requires that the listeners attend to given directions, remember and label the presented auditory sequences, etc, in other words participate in tasks aimed to task their linguistic system and executive functions  (DeBonis, 2015)

So what does the research show?

  • Wallach (2011) has indicated that  (C) APD ‘symptomology’ “reflects broader underlying problems in language comprehension and metalinguistic awareness.
  • Dawes and Bishop (2009)  compared children with a CAPD to children diagnosed with dyslexia and found similar attention, reading, and language deficits in both groups.
  •  Kelly et al. (2009)  found that 76% of a sample of 68 children with suspected auditory processing disorder also had language impairment with 53% demonstrating decreased auditory attention and 59% demonstrated decreased auditory memory.
  • Ferguson et al. (2011)  concluded that “the current labels of CAPD and SLI [specific language impairment] may, for all practical purposes, be indistinguishable” (p. 225).

(From DeBonis, 2015 pgs. 126-127)

8. What to Test and How to do it – That IS the Question? 

“Despite lofty claims to the contrary, there is no clear consensus concerning the battery of tests that lead to a diagnosis of CAPD.”  (Burkard, 2009, p. vii) Presently, neither the American Academy of Audiology nor the American Speech Language Hearing Association have a clear criteria on what testing to administer, how many standard deviations the client has to be in order to qualify, as well as even who is a good candidate for (C)APD testing.  (DeBonis, 2015 pg. 125)

As such, presently children diagnosed with (C)APD are diagnosed purely in an arbitrary fashion rather than based on a specific widely accepted standard.  To illustrate W. J. Wilson and Arnott (2013) found that “in a sample of records of 150 school-aged children who had completed at least four CAPD tests, rates of diagnosis ranged from 7.3% to 96% depending on the criteria used” (DeBonis, 2015 pg. 125). Are you “processing” what I am saying? 

9. Looking for the “Right” Label 

As an SLP, I frequently hear the following statement from parents: “We were searching for what was wrong with our child for such a long time; we are so happy that we were finally able to identify that it’s (C)APD.

The above comment is certainly understandable.  After all (C)APD sounds manageable!  The appeal to it is that presumably if the child undergoes specific auditory interventions to improve deficit areas, s/he will get better and all the problems will go away.  In contrast, finding out that the child’s processing difficulties are the result of linguistic deficits in the areas of listening, speaking, reading, and writing can be incredibly overwhelming especially because what we know about the nature of language impairments and that is that more often than not they turn into lifelong learning disabilities.

Some parents and professionals may disagree.  They might point out that many children with (C)APD test just fine on generalized language testing and only present with isolated deficits in the areas of attention, memory, as well as phonological processing. Yet here is the problem! General language testing in the form of administration of tests such as the CELF-5 or the CASL does not complete language assessment make!

The same children who test ‘just fine’ on these assessments often test quite poorly on the measures of social communication, executive function, as well as reading.  In other words if the professionals dig deep enough they often find out that something which outwardly presents as (C)APD is part of much broader language related issues, which require relevant intervention services. This leads me to my final point below.

10. Missing the Big Picture

“The primacy given to auditory processing abilities has resulted at times in neglect of other cognitive factors” (Cowan et al. 2009, p. 192). Focusing on the diagnosis of (C)APD obscures REAL, language-based deficits in children in question. It forces SLPs to address erroneous therapeutic targets based on AuD recommendations. It makes us ignore the BIG Picture and  “Consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, language knowledge, conceptual abilities, attention, and motivation and consequently targeting language, literacy, and knowledge-based goals in therapy.” —(Kamhi &Wallach, 2012)

Conclusion:

So what will happen next? Well, I can tell you with certainty that the controversy will certainly not end here!  Presently, not only is that there is a fierce academic debate between speech language pathologist and audiologists but there is also a raging debate among audiologists themselves!  This controversy will continue for many years among some highly educated people.  And SLPs? Well, we will continue seeing numerous children diagnosed with (C)APD.  Except, I do hope something will change and that is our collective outlook on how we view ambiguously defined and assessed disorders such as (C)APD.

I sincerely hope that we do not blindly defer to other professions and reject current valid research regarding this controversial diagnosis without first spending some time reflecting and critically reviewing these findings in order to better assist us with making informed and educated decisions regarding our clients’ plan of care.

Click HERE to read the second part of this post, which describes how SLPs SHOULD assess and treat children diagnosed by audiologists with (C)APD. 

References:

  • Burkard, R. (2009). Foreword. In A. Cacace & D. McFarland (Eds.), Controversies in central auditory processing disorder (pp. vii-viii). San Diego, CA: Plural.
  • Cowan, J., Rosen, S., & Moore, D. (2009). Putting the auditory back into auditory processing disorder in children. In Cacace, A., & McFarland, D. (Eds.),Controversies in central auditory processing disorder(pp. 187–197). San Diego, CA: Plural Publishing.
  • Dawes, P., & Bishop, D. (2009). Auditiory processing disorder in relation to developmental disorders of language, communication and attention: A review and critique. International Journal of Language and Communication Disorders, 44, 440–465.
  • DeBonis, D. A. (2015) It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology. v. 24, 124-136.
  • Ferguson, M. A., Hall, R. L., Moore, D. R., & Riley, A. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54, 211–227.
  • Fey, M. E., Richard, G. J., Geffner, D., Kamhi, A. G., Medwetsky, L., Paul, D., Schooling, T. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.
  • Hazan, V., Messaoud-Galusi, S., Rosen, S., Nouwens, S., Shakespeare, B. (2009). Speech perception abilities of adults with dyslexia: Is there any evidence for a true deficit?. Journal of Speech, Language, and Hearing Research. 52 1510–1529
  • Kamhi, A. G. (2011). What speech-language pathologists need to know about auditory processing disorder. Language, Speech, and Hearing Services in Schools, 42, 265–272.
  • Kamhi, A & Wallach, G (2012) What Speech-Language Pathologists Need to Know about Auditory Processing Disorders. ASHA Convention Presentation. Atlanta, GA.
  • Kelly, A. S., Purdy, S. C., & Sharma, M. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research, 53, 706–722.
  • Lemos IC, Jacob RT, Gejao MG, et al. (2009) Frequency modulation (FM) system in auditory processing disorder: An evidence-based practice? Pró-Fono Produtos Especializados para Fonoaudiologia Ltda. 21(3):243-248.
  • Melby-Lervåg, M., & Hulme, C. (2013). Is working memory training effective? A meta-analytic review. Developmental Psychology, 49, 270–291.
  • Ramus, F., White, S., Frith, U. (2006). Weighing the evidence between competing theories of dyslexia.Developmental Science. 9 265–269
  • Sharma, M., Purdy, S. C., Kelly, A. S. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research. 52 706–722
  • Wallach, G. P. (2011). Peeling the onion of auditory processing disorder: A language/curricular-based perspective. Language, Speech, and Hearing Services in Schools, 42, 273–285.
  • Watson, C., Kidd, G. (2009). Associations between auditory abilities, reading, and other language skills in children and adults. Cacace, A., McFarland, D.Controversies in central auditory processing disorder.  218–242 San Diego, CA Plural.
  • Wilson, W. J., & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research, 56, 63–70.
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Show me the Data or Why I Hate the Phrase: “It’s Not So Bad”

KEEP CALMA few days ago I was asked by my higher-ups for a second opinion on a consult regarding a psychological evaluation on an 11-year-old boy, which was depicting a certain pattern of deficits without a reasonable justification as to why they were occurring. I had a working hypothesis but needed more evidence to turn it into a viable theory.  So I set out to collect more evidence by interviewing a few ancillary professionals who were providing therapy services to the student.

The first person I interviewed was his OT, whom I asked regarding the quality of his graphomotor skills. She responded: “Oh, they are not so bad”.

I was perplexed to say the least. What does that mean I asked her. She responded back with: “He can write.”

“But I am not asking you whether he can write”, I responded back.  “I am asking you to provide data that will indicate whether his visual perceptual skills, orthographic coding, motor planning and execution, kinesthetic feedback, as well as visual motor coordination,  are on par or below those of his grade level peers.”

Needless to say this student graphomotor abilities were nowhere near those of his peers.  The below “sample” took me approximately 12 minutes to elicit and required numerous prompts from myself as well as self-corrections from the student to produce.

FullSizeRenderThis got me thinking of all the parents and professionals who hear litotes such as “It’s not so bad”, or overgeneralized phrases such as: “Her social skills are fine“,  “He is functioning higher than what the testing showed“,”He can read“, etc., on daily basis, instead of being provided with detailed data regarding the student’s present level of functioning in a particular academic area.

This has to stop, right now!

If you are an educational or health professional who has a habit of making such statements – beware! You are not doing yourself any favors by saying it and you can actually get into some pretty hot water if you are ever involved in a legal dispute.

Here’s why:

SIGNIFY NOTHING

These statements are meaningless! 

They signify nothing!  Let’s use a commonly heard phrase: “He can read.”  Sounds fairly simple, right?

Wrong!

In order to make this “loaded” statement, a professional actually needs to understand what the act of reading entails.  The act of reading contains a number of active components:

In other words if the child can decode all the words on the page, but their reading rate is slow and labored, then they cannot read!

If the child is a fast but inaccurate reader and has trouble decoding new words then they’re not a reader either!

If the child reads everything quickly and accurately but comprehends very little then they are also not a reader!

Let us now examine another loaded statement, I’ve heard recently for a fellow SLP: “His skills are higher than your evaluation depicted.” Again, what does that mean? Do you have audio, video, or written documentation to support your assertion?   No professional should ever make that statement without having detailed data to support it. Otherwise, you will be hearing: “SHOW ME THE DATA!“

These statements are harmful!

They imply to parents that the child is doing relatively well as compared to peers when nothing could be further from the truth! As a good friend and colleague, Maria Del Duca of Communication Station Blog has stated: [By making these comments] “We begin to accept a range of behavior we believe is acceptable for no other reason than we have made that decision. With this idea of mediocrity we limit our client’s potential by unconsciously lowering the bar.”

You might as well be making comments such as: “Well, it’s as good as it going to get”, indicating that the child’s genetic predestination “imposes limits on what a child might achieve” (Walz Garrett, 2012 pg. 30)

These statements are subjective!

They fail to provide any objective evidence such as type of skills addressed within a subset of abilities, percentage of accuracy achieved, number of trials needed, or number of cues and prompts given to the child in order to achieve the aforementioned accuracy.

These statements make you look unprofessional! 

I can’t help but laugh when I review progress reports with the following comments:

Social Communication:  Johnny is a pleasant child who much more readily interacted with his peers during the present progress reporting period.

What on earth does that mean?  What were Johnny’s specific social communication goals? Was he supposed to initiate conversations more frequently with peers? Was he supposed to acknowledge in some way that his peers actually exist on the same physical plane? Your guess is as good as mine!

Reading:  Johnny is more willing to read short stories at this time.

Again, what on earth does that mean? What type of text can Johnny now decode? Which consonant digraphs can he consistently recognize in text? Can he differentiate between long and short vowels in CVC and CVCV words such as /bit/ and /bite/? I have no clue because none of that was included in his report.

These statements can cause legal difficulties! 

I don’t know about your graduate preparation but I’m pretty sure that most diagnostics professors, repeatedly emphasized to the graduate SLP students the importance of professional record-keeping.  Every professor in my acquaintance has that story – the one where they had to go to court and only their detailed scrupulous record-keeping has kept them from crying and cowering from the unrelenting verbal onslaught of the plaintiff’s educational attorney.

Ironically this is exactly what’s going to happen if you keep making these statements and have no data to support your client’s present level of functioning! Legal disputes between parents of developmentally/language impaired children and districts occur at an alarming rate throughout United States; most often over perceived educational deprivation and lack of access to FAPE (Free and Appropriate Education). I would not envy any educational/health related professional who is caught in the middle of these cases lacking data to support appropriate service provision to the student in question.

Conclusion: 

So there you have it! These are just a few (of many) reasons why I loathe the phrase: “It’s Not So Bad”.  The bottom line is that this vague and subjective statement does a huge disservice to our students as individuals and to us as qualified and competent professionals.  So the next time it’s on the tip of your tongue: “Just don’t say it!” And if you are on the receiving end of it, just calmly ask the professional making that statement: “Show me the data!”

 

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Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know

Image result for evaluationSeveral years after I started my private speech pathology practice, I began performing comprehensive independent speech and language evaluations (IEEs).

For those of you who may be hearing the term IEE for the first time, an Independent Educational Evaluation is “an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.” 34 C.F.R. 300.503. IEE’s can evaluate a broad range of functioning outside of cognitive or academic performance and may include neurological, occupational, speech language, or any other type of evaluations  as long as they bear direct impact on the child’s educational performance.

Independent evaluations can be performed for a wide variety of reasons, including but not limited to:

  • To determine the student’s present level of functioning
  • To determine whether the student presents with hidden, previously undiscovered deficits (e.g., executive function, social communication, etc.)
  • To determine whether the student’s educational classification requires a change
  • To determine if the student requires additional, previously not provided, related services (e.g., language therapy, etc.) or an increase in related services
  • To determine whether a student might benefit from an application of a particular therapy technique or program (e.g, Orton-Gillingham)
  • To determine whether a student with a severe impairment (e.g., severe emotional and behavioral disturbances, genetic syndrome, significant intellectual disability, etc.) is a good candidate for an out of district specialized school

Why can’t similar assessments be performed in school settings?

There are several reasons for that.

Why are IEE’s Needed?

The answer to that is simple:  “To strengthen the role of parents in the educational decision-making process.” According to one Disability Rights site: “Many disagreements between parents and school staff concerning IEP services and placement involve, at some stage, the interpretation of evaluation findings and recommendations. When disagreements occur, the Independent Educational Evaluation (IEE) is one option lawmakers make available to parents, to help answer questions about appropriate special education services and placement“.

Indeed, many of the clients who retain my services also retain the services of educational advocates as well as special education lawyers.  Many of them work on determining appropriate level of services as well as an out of district placement for the children with a variety of special education needs. However, one interesting reoccurring phenomenon I’ve noted over the years is that only a small percentage of special education lawyers, educational advocates, and even parents believed that children with autism spectrum disorders, genetic syndromes, social pragmatic deficits, emotional disturbances, or reading disabilities required a comprehensive language evaluation/reevaluation prior to determining an appropriate out of district placement or an in-district change of service provision.

So today I would like to make a case, in favor of comprehensive independent language evaluations being a routine component of every special education dispute involving a child with impaired academic performance. I will do so through the illustration of past case scenarios that clearly show that comprehensive independent language evaluations do matter, even when it doesn’t look like they may be needed.

Case A: “He is just a weak student”.

Several years ago I was contacted by a parent of a 12 year old boy, who was concerned with his son’s continuously failing academic performance. The child had not qualified for an IEP but was receiving 504 plan in school setting and was reported to significantly struggle due to continuous increase of academic demands with each passing school year.  An in-district language evaluation had been preformed several years prior. It showed that the student’s general language abilities were in the low average range of functioning due to which he did not qualify for speech language services in school setting. However, based on the review of available records it very quickly became apparent that many of the academic areas in which the student struggled (e.g., reading comprehension, social pragmatic ability, critical thinking skills, etc)  were simply not assessed by the general language testing. I had suggested to the parent a comprehensive language evaluation and explained to him on what grounds I was recommending this course of action.  That comprehensive 4 hour assessment broken into several testing sessions revealed that the student presented with severe receptive, expressive, problem solving and social pragmatic language deficits, as well as moderate executive function deficits, which required therapeutic intervention.

Prior to that assessment the parent, reinforced by the feedback from his child’s educational staff believed his son to be an unmotivated student who failed to apply himself in school setting.  However, after the completion of that assessment, the parent clearly understood that it wasn’t his child’s lack of motivation which was impeding his academic performance but rather a true learning disability was making it very difficult for his son to learn without the necessary related services and support. Several months after the appropriate related services were made available to the child in school setting on the basis of the performed IEE, the parent reported significant progress in his child academic performance.

Case B: “She’s just not learning because of her behavior, so there’s nothing we can do”.  

This case involved a six year old girl who presented with a severe speech – language disorder and behavioral deficits in school setting secondary to an intellectual disability of an unspecified origin.

In contrast to Case A scenario, this child had received a variety of assessments and therapies since a very early age; however, her parents were becoming significantly concerned regarding her regression of academic functioning in school setting and felt that a more specialized out of district program with a focus on multiple disabilities would be better suitable to her needs. Unfortunately the school disagreed with them and believed that she could be successfully educated in an in-district setting (despite evidence to the contrary).  Interestingly, an in-depth comprehensive speech language assessment had never been performed on this child because her functioning was considered to be “too low” for such an assessment.

Comprehensive assessment of this little girl’s abilities revealed that via an application of a variety of behavioral management techniques (of non-ABA origin), and highly structured language input, she was indeed capable of significantly better performance then she had exhibited in school setting.  It stood to reason that if she were placed in a specialized school setting composed of educational professionals who were trained in dealing with her complex behavioral and communication needs, her performance would continue to steadily improve.  Indeed, six months following a transfer in schools her parents reported a “drastic” change pertaining to a significant reduction in challenging behavioral manifestations as well as significant increase in her linguistic output.

Case C: “Your child can only learn so much because of his genetic syndrome”.  

This case scenario does not technically involve just one child but rather three different male students between 9 and 11 years of age with several ‘common’ genetic syndromes: Down, Fragile X, and Klinefelter.  All three were different ages, came from completely different school districts, and were seen by me in different calendar years.

However, all three boys had one thing in common, because of their genetic syndromes, which were marked by varying degrees of intellectual disability as well as speech language weaknesses, their parents were collectively told that there could be very little done for them with regards to expanding their expressive language as well as literacy development.

Similarly to the above scenarios, none of the children had undergone comprehensive language testing to determine their strengths, weaknesses, and learning styles. Comprehensive assessment of each student revealed that each had the potential to improve their expressive abilities to speak in compound and complex sentences. Dynamic assessment of literacy also revealed that it was possible to teach each of them how to read.

Following the respective assessments, some of these students had became my private clients, while others’s parents have periodically written to me, detailing their children’s successes over the years.  Each parent had conveyed to me how “life-changing”a comprehensive IEE was to their child.

Case D: “Their behavior is just out of control”

The final case scenario I would like to discuss today involves several students with an educational classification of “Emotionally Disturbed” (pg 71).  Those of you who are familiar with my blog and my work know that my main area of specialty is working with school age students with psychiatric impairments and emotional behavioral disturbances.  There are a number of reasons why I work with this challenging pediatric population. One very important reason is that these students continue to be grossly underserved in school setting. Over the years I have written a variety of articles and blog posts citing a number of research studies, which found that a significant number of students with psychiatric impairments and emotional behavioral disturbances present with undiagnosed linguistic impairments (especially in the area of social communication), which adversely impact their school-based performance.

Here, we are not talking about two or three students rather we’re talking about the numbers in the double digits of students with psychiatric impairments and emotional disturbances, who did not receive appropriate therapies in their respective school settings.

The majority of these students were divided into two distinct categories. In the first category, students began to manifest moderate-to-severe speech language deficits from a very early age. They were classified in preschool and began receiving speech language therapy. However by early elementary age their general language abilities were found to be within the average range of functioning and their language therapies were discontinued.   Unfortunately since general language testing does not assess all categories of linguistic functioning such as critical thinking, executive functions, social communication etc., these students continued to present with hidden linguistic impairments, which continued to adversely impact their behavior.

Students in the second category also began displaying emotional and behavioral challenges from a very early age. However, in contrast to the students in the first category the initial language testing found their general language abilities to be within the average range of functioning. As a result these students never received any language-based therapies and similar to the students in the first category, their hidden linguistic impairments continued to adversely impact their behavior.

Students in both categories ended up following a very similar pattern of behavior. Their behavioral challenges in the school continued to escalate. These were followed by a series of suspensions, out of district placements, myriad of psychiatric and neuropsychological evaluations, until many were placed on home instruction. The one vital element missing from all of these students’ case records were comprehensive language evaluations with an emphasis on assessing their critical thinking, executive functions and social communication abilities. Their worsening patterns of functioning were viewed as “severe misbehaving” without anyone suspecting that their hidden language deficits were a huge contributing factor to their maladaptive behaviors in school setting.

Conclusion:

So there you have it!  As promised, I’ve used four vastly different scenarios that show you the importance of comprehensive language evaluations in situations where it was not so readily apparent that they were needed.  I hope that parents and professionals alike will find this post helpful in reconsidering the need for comprehensive independent evaluations for students presenting with impaired academic performance.

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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

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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.

Other Helpful Resources

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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 III: Components of Comprehensive Dyslexia Testing – Reading Fluency and Reading Comprehension

Image result for child reading

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

Today I would like to discuss part III of comprehensive dyslexia assessment, which discusses reading fluency and reading comprehension testing.

Let’s begin with reading fluency testing, which assesses the students’ ability to read word lists or short paragraphs with appropriate speed and accuracy. Here we are looking for how many words the student can accurately read per minute orally and/or silently (see several examples  of fluency rates below).

Research indicates that oral reading fluency (ORF) on passages is more strongly related to reading comprehension than ORF on word lists. This is an important factor which needs to be considered when it comes to oral fluency test selection.

Oral reading fluency tests are significant for a number of reasons. Firstly, they allow us to identify students with impaired reading accuracy. Secondly, they allow us to identify students who can decode words with relative accuracy but who cannot comprehend what they read due to significantly decreased reading speed. When you ask such children: “What did you read about?” They will frequently respond: “I don’t remember because I was so focused on reading the words correctly.”

One example of a popular oral reading fluency test (employing reading passages) is the Gray Oral Reading Tests-5 (GORT-5). It yields the scores on the student’s:GORT-5: Gray Oral Reading Tests–Fifth Edition, Complete Kit

  • Rate
  • Accuracy
  • Fluency
  • Comprehension
  • Oral Reading Index (a composite score based on Fluency and Comprehension scaled scores)

Another types of reading fluency tests are tests of silent reading fluency. Assessments of silent reading fluency can at selectively useful for identifying older students with reading difficulties and monitoring their progress. One obvious advantage to silent reading tests is that they can be administered in group setting to multiple students at once and generally takes just few minutes to administer, which is significantly less then oral reading measures take to be administered to individual students.

Below are a several examples of silent reading tests/subtests.

TOSWRF-2: Test of Silent Word Reading Fluency–Second EditionThe Test of Silent Word Reading Fluency (TOSWRF-2) presents students with rows of words, ordered by reading difficulty without spaces (e.g., dimhowfigblue). Students are given 3 minutes to draw a line between the boundaries of as many words as possible (e.g., dim/how/fig/blue).

The Test of Silent Contextual Reading Fluency (TOSCRF-2) presents students with text passages with all words printed in uppercase letters with no separations between words and no punctuation or spaces between sentences and asks them to use dashes to separate words in a 3 minute period.

Similar to the TOSCRF-2, the Contextual Fluency subtest of the Test of Reading Comprehension – Fourth Edition (TORC-4) measures the student’s ability to recognize individual words in a series of passages (taken from the TORC-4′s Text Comprehension subtest) in a period of 3 minutes. Each passage, printed in uppercase letters without punctuation or spaces between words, becomes progressively more difficult in content, vocabulary, and grammar. As students read the segments, they draw a line between as many words as they can in the time allotted.  (E.g., THE|LITTLE|DOG|JUMPED|HIGH)

However, it is important to note oral reading fluency is a better predictor of reading comprehension than is silent reading fluency for younger students (early elementary age). In contrast, silent reading measures are more strongly related to reading comprehension in middle school (e.g., grades 6-8) but only for skilled vs. average readers, which is why oral reading fluency measures are probably much better predictors of deficits in this area in children with suspected reading disabilities.

Now let’s move on to the reading comprehension testing, which is an integral component for any dyslexia testing battery. Unfortunately, it is also the most trickiest. Here’s why.

Many children with reading difficulties will be able to read and comprehend short paragraphs containing factual information of decreased complexity. However, this will change dramatically when it comes to the comprehension of longer, more complex, and increasingly abstract age-level text. While a number of tests do assess reading comprehension, none of them truly adequately assess the students ability to comprehend abstract information.

For example, on the Reading Comprehension subtest of the CELF-5, students are allowed to keep the text and refer to it when answering questions. Such option will inflate the students scores and not provide an accurate idea of their comprehension abilities.

To continue, the GORT-5 contains reading comprehension passages, which the students need to answer after the stimuli booklet has been removed from them. However, the passages are far more simplistic then the academic texts the students need to comprehend on daily basis, so the students may do well on this test yet still continue to present with significant comprehension deficits.

Similar could be said for the text comprehension components of major educational testing batteries such as the Woodcock Johnson IV: Passage Comprehension subtest, which gives the student sentences with a missing word, and the student is asked to orally provide the word. However, filling-in a missing word does not text comprehension make.

Likewise, the Wechsler Individual Achievement Test®-Fourth Edition (WIAT-IV), Reading Comprehension subtest is very similar to the CELF-5. Student is asked to read a passage and answer questions by referring back to the text. However, just because a student can look up the answers in text does not mean that they actually understand the text.

So what could be done to accurately assess the student’s ability to comprehend abstract grade level text? My recommendation is to go informal. Select grade-level passages from the student’s curriculum pertaining to science, social studies, geography, etc. vs. language arts (which tends to be more simplistic) and ask the student to read them and answer factual questions regarding supporting details as well as non factual questions relevant to main ideas and implied messages.

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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.

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