Blogging About Research | Smart Speech Therapy

Posted on May 6, 2018January 5, 2022 by Tatyana Elleseff — 6 Comments

Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

In the past several years, I wrote a series of posts on the topic of improving clinical practices in speech-language pathology. Some of these posts were based on my clinical experience as backed by research, while others summarized key point from articles written by prominent colleagues in our field such as Dr. Alan Kamhi, Dr. David DeBonnis, Dr. Andrew Vermiglio, etc.

In the past, I have highlighted several articles from the 2014 LSHSS clinical forum entitled: Improving Clinical Practice. Today I would like to explicitly summarize another relevant article written by Dr. Wallach in 2014, entitled “Improving Clinical Practice: A School-Age and School-Based Perspective“, which discusses how to change the “persistence of traditional practices” in order to make our language interventions more functional and meaningful for students with language learning difficulties. Continue reading Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

Posted on March 10, 2018March 21, 2022 by Tatyana Elleseff — 5 Comments

It’s All Due to …Language: How Subtle Symptoms Can Cause Serious Academic Deficits

Scenario: Len is a 7-2-year-old, 2nd-grade student who struggles with reading and writing in the classroom. He is very bright and has a high average IQ, yet when he is speaking he frequently can’t get his point across to others due to excessive linguistic reformulations and word-finding difficulties. The problem is that Len passed all the typical educational and language testing with flying colors, receiving average scores across the board on various tests including the Woodcock-Johnson Fourth Edition (WJ-IV) and the Clinical Evaluation of Language Fundamentals-5 (CELF-5). Stranger still is the fact that he aced Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2), with flying colors, so he is not even eligible for a “dyslexia” diagnosis. Len is clearly struggling in the classroom with coherently expressing self, telling stories, understanding what he is reading, as well as putting his thoughts on paper. His parents have compiled impressively huge folders containing examples of his struggles. Yet because of his performance on the basic standardized assessment batteries, Len does not qualify for any functional assistance in the school setting, despite being virtually functionally illiterate in second grade.

The truth is that Len is quite a familiar figure to many SLPs, who at one time or another have encountered such a student and asked for guidance regarding the appropriate accommodations and services for him on various SLP-geared social media forums. But what makes Len such an enigma, one may inquire? Surely if the child had tangible deficits, wouldn’t standardized testing at least partially reveal them?

Well, it all depends really, on what type of testing was administered to Len in the first place. A few years ago I wrote a post entitled: “What Research Shows About the Functional Relevance of Standardized Language Tests“. What researchers found is that there is a “lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores” (Betz et al, 2012, 141). Furthermore, they also found that the most frequently used tests were the comprehensive assessments including the Clinical Evaluation of Language Fundamentals and the Preschool Language Scale as well as one-word vocabulary tests such as the Peabody Picture Vocabulary Test”. Most damaging finding was the fact that: “frequently SLPs did not follow up the comprehensive standardized testing with domain-specific assessments (critical thinking, social communication, etc.) but instead used the vocabulary testing as a second measure”.(Betz et al, 2012, 140)

In other words, many SLPs only use the tests at hand rather than the RIGHT tests aimed at identifying the student’s specific deficits. But the problem doesn’t actually stop there. Due to the variation in psychometric properties of various tests, many children with language impairment are overlooked by standardized tests by receiving scores within the average range or not receiving low enough scores to qualify for services.

Thus, “the clinical consequence is that a child who truly has a language impairment has a roughly equal chance of being correctly or incorrectly identified, depending on the test that he or she is given.” Furthermore, “even if a child is diagnosed accurately as language impaired at one point in time, future diagnoses may lead to the false perception that the child has recovered, depending on the test(s) that he or she has been given (Spaulding, Plante & Farinella, 2006, 69).”

There’s of course yet another factor affecting our hypothetical client and that is his relatively young age. This is especially evident with many educational and language testing for children in the 5-7 age group. Because the bar is set so low, concept-wise for these age-groups, many children with moderate language and literacy deficits can pass these tests with flying colors, only to be flagged by them literally two years later and be identified with deficits, far too late in the game. Coupled with the fact that many SLPs do not utilize non-standardized measures to supplement their assessments, Len is in a pretty serious predicament.

But what if there was a do-over? What could we do differently for Len to rectify this situation? For starters, we need to pay careful attention to his deficits profile in order to choose appropriate tests to evaluate his areas of needs. The above can be accomplished via a number of ways. The SLP can interview Len’s teacher and his caregiver/s in order to obtain a summary of his pressing deficits. Depending on the extent of the reported deficits the SLP can also provide them with a referral checklist to mark off the most significant areas of need.

In Len’s case, we already have a pretty good idea regarding what’s going on. We know that he passed basic language and educational testing, so in the words of Dr. Geraldine Wallach, we need to keep “peeling the onion” via the administration of more sensitive tests to tap into Len’s reported areas of deficits which include: word-retrieval, narrative production, as well as reading and writing.

For that purpose, Len is a good candidate for the administration of the Test of Integrated Language and Literacy (TILLS), which was developed to identify language and literacy disorders, has good psychometric properties, and contains subtests for assessment of relevant skills such as reading fluency, reading comprehension, phonological awareness, spelling, as well as writing in school-age children.

Given Len’s reported history of narrative production deficits, Len is also a good candidate for the administration of the Social Language Development Test Elementary (SLDTE). Here’s why. Research indicates that narrative weaknesses significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014). As such, it’s not just children with Autism Spectrum Disorders who present with impaired narrative abilities. Many children with developmental language impairment (DLD) (#devlangdis) can present with significant narrative deficits affecting their social and academic functioning, which means that their social communication abilities need to be tested to confirm/rule out presence of these difficulties.

However, standardized tests are not enough, since even the best-standardized tests have significant limitations. As such, several non-standardized assessments in the areas of narrative production, reading, and writing, may be recommended for Len to meaningfully supplement his testing.

Let’s begin with an informal narrative assessment which provides detailed information regarding microstructural and macrostructural aspects of storytelling as well as child’s thought processes and socio-emotional functioning. My nonstandardized narrative assessments are based on the book elicitation recommendations from the SALT website. For 2nd graders, I use the book by Helen Lester entitled Pookins Gets Her Way. I first read the story to the child, then cover up the words and ask the child to retell the story based on pictures. I read the story first because: “the model narrative presents the events, plot structure, and words that the narrator is to retell, which allows more reliable scoring than a generated story that can go in many directions” (Allen et al, 2012, p. 207).

As the child is retelling his story I digitally record him using the Voice Memos application on my iPhone, for a later transcription and thorough analysis. During storytelling, I only use the prompts: ‘What else can you tell me?’ and ‘Can you tell me more?’ to elicit additional information. I try not to prompt the child excessively since I am interested in cataloging all of his narrative-based deficits. After I transcribe the sample, I analyze it and make sure that I include the transcription and a detailed write-up in the body of my report, so parents and professionals can see and understand the nature of the child’s errors/weaknesses.

Now we are ready to move on to a brief nonstandardized reading assessment. For this purpose, I often use the books from the Continental Press series entitled: Reading for Comprehension, which contains books for grades 1-8. After I confirm with either the parent or the child’s teacher that the selected passage is reflective of the complexity of work presented in the classroom for his grade level, I ask the child to read the text. As the child is reading, I calculate the correct number of words he reads per minute as well as what type of errors the child is exhibiting during reading. Then I ask the child to state the main idea of the text, summarize its key points as well as define select text embedded vocabulary words and answer a few, verbally presented reading comprehension questions. After that, I provide the child with accompanying 5 multiple choice question worksheet and ask the child to complete it. I analyze my results in order to determine whether I have accurately captured the child’s reading profile.

Finally, if any additional information is needed, I administer a nonstandardized writing assessment, which I base on the Common Core State Standards for 2nd grade. For this task, I provide a student with a writing prompt common for second grade and give him a period of 15-20 minutes to generate a writing sample. I then analyze the writing sample with respect to contextual conventions (punctuation, capitalization, grammar, and syntax) as well as story composition (overall coherence and cohesion of the written sample).

The above relatively short assessment battery (2 standardized tests and 3 informal assessment tasks) which takes approximately 2-2.5 hours to administer, allows me to create a comprehensive profile of the child’s language and literacy strengths and needs. It also allows me to generate targeted goals in order to begin effective and meaningful remediation of the child’s deficits.

Children like Len will, unfortunately, remain unidentified unless they are administered more sensitive tasks to better understand their subtle pattern of deficits. Consequently, to ensure that they do not fall through the cracks of our educational system due to misguided overreliance on a limited number of standardized assessments, it is very important that professionals select the right assessments, rather than the assessments at hand, in order to accurately determine the child’s areas of needs.

References:

Allen, M, Ukrainetz, T & Carswell, A (2012) The narrative language performance of three types of at-risk first-grade readers. Language, Speech, and Hearing Services in Schools, 43(2), 205-221.
Betz et al. (2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment. Language, Speech, and Hearing Services in Schools, 44, 133-146.
Hasbrouck, J. & Tindal, G. A. (2006). Oral reading fluency norms: A valuable assessment tool for reading teachers. The Reading Teacher. 59(7), 636-644.).
Norbury, C. F., Gemmell, T., & Paul, R. (2014). Pragmatics abilities in narrative production: a cross-disorder comparison. Journal of child language, 41(03), 485-510.
Peña, E.D., Spaulding, T.J., & Plante, E. (2006). The Composition of Normative Groups and Diagnostic Decision Making: Shooting Ourselves in the Foot. American Journal of Speech-Language Pathology, 15, 247-254.
Spaulding, Plante & Farinella (2006) Eligibility Criteria for Language Impairment: Is the Low End of Normal Always Appropriate? Language, Speech, and Hearing Services in Schools, 37, 61-72.
Spaulding, Szulga, & Figueria (2012) Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers. Journal of Speech, Language and Hearing Research. 43, 176-190.

Posted on March 6, 2018January 5, 2022 by Tatyana Elleseff — 4 Comments

Making Our Interventions Count or What’s Research Got To Do With It?

Image result for effective intervention Two years ago I wrote a blog post entitled: “What’s Memes Got To Do With It?” which summarized key points of Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“. It delved into answering the following question: “Why do some terms, labels, ideas, and constructs [in our field] prevail whereas others fail to gain acceptance?”.

Today I would like to reference another article by Dr. Kamhi written in 2014, entitled “Improving Clinical Practices for Children With Language and Learning Disorders“.

This article was written to address the gaps between research and clinical practice with respect to the implementation of EBP for intervention purposes.

Dr. Kamhi begins the article by posing 10 True or False questions for his readers:

Learning is easier than generalization.
Instruction that is constant and predictable is more effective than instruction that varies the conditions of learning and practice.
Focused stimulation (massed practice) is a more effective teaching strategy than varied stimulation (distributed practice).
The more feedback, the better.
Repeated reading of passages is the best way to learn text information.
More therapy is always better.
The most effective language and literacy interventions target processing limitations rather than knowledge deficits.
Telegraphic utterances (e.g., push ball, mommy sock) should not be provided as input for children with limited language.
Appropriate language goals include increasing levels of mean length of utterance (MLU) and targeting Brown’s (1973) 14 grammatical morphemes.
Sequencing is an important skill for narrative competence.

Guess what? Only statement 8 of the above quiz is True! Every other statement from the above is FALSE!

Now, let’s talk about why that is!

First up is the concept of learning vs. generalization. Here Dr. Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful. He explains that when we are talking about generalization – what children truly have a difficulty with is “transferring narrow limited rules to new situations“. “Children with language and learning problems will have difficulty acquiring broad-based rules and modifying these rules once acquired, and they also will be more vulnerable to performance demands on speech production and comprehension (Kamhi, 1988)” (93). After all, it is not “reasonable to expect children to use language targets consistently after a brief period of intervention” and while we hope that “language intervention [is] designed to lead children with language disorders to acquire broad-based language rules” it is a hugely difficult task to undertake and execute.

Next, Dr. Kamhi addresses the issue of instructional factors, specifically the importance of “varying conditions of instruction and practice“. Here, he addresses the fact that while contextualized instruction is highly beneficial to learners unless we inject variability and modify various aspects of instruction including context, composition, duration, etc., we ran the risk of limiting our students’ long-term outcomes.

After that, Dr. Kamhi addresses the concept of distributed practice (spacing of intervention) and how important it is for teaching children with language disorders. He points out that a number of recent studies have found that “spacing and distribution of teaching episodes have more of an impact on treatment outcomes than treatment intensity” (94).

He also advocates reducing evaluative feedback to learners to “enhance long-term retention and generalization of motor skills“. While he cites research from studies pertaining to speech production, he adds that language learning could also benefit from this practice as it would reduce conversational disruptions and tunning out on the part of the student.

From there he addresses the limitations of repetition for specific tasks (e.g., text rereading). He emphasizes how important it is for students to recall and retrieve text rather than repeatedly reread it (even without correction), as the latter results in a lack of comprehension/retention of read information.

After that, he discusses treatment intensity. Here he emphasizes the fact that higher dose of instruction will not necessarily result in better therapy outcomes due to the research on the effects of “learning plateaus and threshold effects in language and literacy” (95). We have seen research on this with respect to joint book reading, vocabulary words exposure, etc. As such, at a certain point in time increased intensity may actually result in decreased treatment benefits.

His next point against processing interventions is very near and dear to my heart. Those of you familiar with my blog know that I have devoted a substantial number of posts pertaining to the lack of validity of CAPD diagnosis (as a standalone entity) and urged clinicians to provide language based vs. specific auditory interventions which lack treatment utility. Here, Dr. Kamhi makes a great point that: “Interventions that target processing skills are particularly appealing because they offer the promise of improving language and learning deficits without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (95) The problem is that we have numerous studies on the topic of improvement of isolated skills (e.g., auditory skills, working memory, slow processing, etc.) which clearly indicate lack of effectiveness of these interventions. As such, “practitioners should be highly skeptical of interventions that promise quick fixes for language and learning disabilities” (96).

Now let us move on to language and particularly the models we provide to our clients to encourage greater verbal output. Research indicates that when clinicians are attempting to expand children’s utterances, they need to provide well-formed language models. Studies show that children select strong input when its surrounded by weaker input (the surrounding weaker syllables make stronger syllables stand out). As such, clinicians should expand upon/comment on what clients are saying with grammatically complete models vs. telegraphic productions.

From there lets us take a look at Dr. Kamhi’s recommendations for grammar and syntax. Grammatical development goes much further than addressing Brown’s morphemes in therapy and calling it a day. As such, it is important to understand that children with developmental language disorders (DLD) (#DevLang) do not have difficulty acquiring all morphemes. Rather studies have shown that they have difficulty learning grammatical morphemes that reflect tense and agreement (e.g., third-person singular, past tense, auxiliaries, copulas, etc.). As such, use of measures developed by Hadley & Holt, 2006; Hadley & Short, 2005 (e.g., Tense Marker Total & Productivity Score) can yield helpful information regarding which grammatical structures to target in therapy.

With respect to syntax, Dr. Kamhi notes that many clinicians erroneously believe that complex syntax should be targeted when children are much older. The Common Core State Standards do not help this cause further, since according to the CCSS complex syntax should be targeted 2-3 grades, which is far too late. Typically developing children begin developing complex syntax around 2 years of age and begin readily producing it around 3 years of age. As such, clinicians should begin targeting complex syntax in preschool years and not wait until the children have mastered all morphemes and clauses (97)

Finally, Dr. Kamhi wraps up his article by offering suggestions regarding prioritizing intervention goals. Here, he explains that goal prioritization is affected by

clinician experience and competencies
the degree of collaboration with other professionals
type of service delivery model
client/student factors

He provides a hypothetical case scenario in which the teaching responsibilities are divvied up between three professionals, with SLP in charge of targeting narrative discourse. Here, he explains that targeting narratives does not involve targeting sequencing abilities. “The ability to understand and recall events in a story or script depends on conceptual understanding of the topic and attentional/memory abilities, not sequencing ability.” He emphasizes that sequencing is not a distinct cognitive process that requires isolated treatment. Yet many SLPs “continue to believe that sequencing is a distinct processing skill that needs to be assessed and treated.” (99)

Dr. Kamhi supports the above point by providing an example of two passages. One, which describes a random order of events, and another which follows a logical order of events. He then points out that the randomly ordered story relies exclusively on attention and memory in terms of “sequencing”, while the second story reduces demands on memory due to its logical flow of events. As such, he points out that retelling deficits seemingly related to sequencing, tend to be actually due to “limitations in attention, working memory, and/or conceptual knowledge“. Hence, instead of targeting sequencing abilities in therapy, SLPs should instead use contextualized language intervention to target aspects of narrative development (macro and microstructural elements).

Furthermore, here it is also important to note that the “sequencing fallacy” affects more than just narratives. It is very prevalent in the intervention process in the form of the ubiquitous “following directions” goal/s. Many clinicians readily create this goal for their clients due to their belief that it will result in functional therapeutic language gains. However, when one really begins to deconstruct this goal, one will realize that it involves a number of discrete abilities including: memory, attention, concept knowledge, inferencing, etc. Consequently, targeting the above goal will not result in any functional gains for the students (their memory abilities will not magically improve as a result of it). Instead, targeting specific language and conceptual goals (e.g., answering questions, producing complex sentences, etc.) and increasing the students’ overall listening comprehension and verbal expression will result in improvements in the areas of attention, memory, and processing, including their ability to follow complex directions.

There you have it! Ten practical suggestions from Dr. Kamhi ready for immediate implementation! And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation. They include:

References:

Kamhi, A. (2014). Improving clinical practices for children with language and learning disorders. Language, Speech, and Hearing Services in Schools, 45(2), 92-103

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

Posted on July 20, 2017November 23, 2022 by Tatyana Elleseff — 16 Comments

The Importance of Narrative Assessments in Speech Language Pathology (Revised)

As SLPs we routinely administer a variety of testing batteries in order to assess our students’ speech-language abilities. Grammar, syntax, vocabulary, and sentence formulation get frequent and thorough attention. But how about narrative production? Does it get its fair share of attention when the clinicians are looking to determine the extent of the child’s language deficits? I was so curious about what the clinicians across the country were doing that in 2013, I created a survey and posted a link to it in several SLP-related FB groups. I wanted to find out how many SLPs were performing narrative assessments, in which settings, and with which populations. From those who were performing these assessments, I wanted to know what type of assessments were they using and how they were recording and documenting their findings. Since the purpose of this survey was non-research based (I wasn’t planning on submitting a research manuscript with my findings), I only analyzed the first 100 responses (the rest were very similar in nature) which came my way, in order to get the general flavor of current trends among clinicians, when it came to narrative assessments. Here’s a brief overview of my [limited] findings. Continue reading The Importance of Narrative Assessments in Speech Language Pathology (Revised)

Posted on July 17, 2017January 5, 2022 by Tatyana Elleseff — 4 Comments

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

To date, I have written 3 posts on speech and language assessments of children under 3 years of age. My first post offered suggestions on what information to include in general speech-language assessments for this age group, my second post specifically discussed assessments of toddlers with suspected motor speech disorders and my third post described what information I tend to include in reports for children ~16-18 months of age.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To illustrate, below is a narrative sample from a typically developing 2-year-old child based on the Mercer Mayer’s classic wordless picture book: “Frog Where Are You?”

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

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

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

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

Communication w/t gestures
Communication w/t words
Longer sentences

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

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

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

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

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

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

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

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

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

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

References:

Hedberg, N.L., & Westby, C.E. (1993). Analyzing story-telling skills: Theory to practice. AZ: Communication Skill Builders.
Mundy P, Block J, Delgado C, Pomares Y, Vaughan Van Hecke A, Parlade MV. (2007) Individual Differences and the Development of Joint Attention in Infancy. Child Development. 78:938–954
LaRocque, M., & Leach, D. (2009). Increasing social reciprocity in young children with Autism. Intervention in School and Clinic, 10(5), 1-7.
O’Neill, D. (2009). Language Use Inventory: An assessment of young children’s pragmatic language development for 18- to 47-month-old children [Manual]. Waterloo, Ontario, Canada Knowledge in Development
Tomasello, M. (1995). Joint attention as social cognition. In C. Moore, & P. J. Dunham (Eds.), Joint attention: It’s origins and role in development (pp. 103–130). Hillsdale, NJ: Erlbaum.
Walden, T., & Ogan, T. (1988). The development of social referencing. Child Development, 59, 1230-1240.
Westby, C. & Robinson, L. (2014). A developmental perspective for promoting theory of mind. Topics in
Language Disorders, 34(4), 362-383.

Posted on June 5, 2017March 12, 2022 by Tatyana Elleseff — 3 Comments

Treatment of Children with “APD”: What SLPs Need to Know

Free stock photo of people, woman, cute, playing In recent years there has been an increase in research on the subject of diagnosis and treatment of Auditory Processing Disorders (APD), formerly known as Central Auditory Processing Disorders or CAPD.

More and more studies in the fields of audiology and speech-language pathology began confirming the lack of validity of APD as a standalone (or useful) diagnosis. To illustrate, in June 2015, the American Journal of Audiology published an article by David DeBonis entitled: “It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children.” In this article, DeBonis pointed out numerous inconsistencies involved in APD testing and concluded that “routine use of APD test protocols cannot be supported” and that [APD] “intervention needs to be contextualized and functional” (DeBonis, 2015, p. 124) Continue reading Treatment of Children with “APD”: What SLPs Need to Know

Posted on April 13, 2017January 5, 2022 by Tatyana Elleseff — 2 Comments

The End of See it, Zap it! Ankyloglossia (Tongue-Tie) Controversies in Research and Clinical Practice

Today it is my pleasure and privilege to interview 3 Australian lactation consultations: Lois Wattis, Renee Kam, and Pamela Douglas, the authors of a March 2017 article in the Breastfeeding Review: “Three experienced lactation consultants reflect upon the oral tie phenomenon” (which can be found HERE).

Tatyana Elleseff: Colleagues, as you very well know, the subject of ankyloglossia or tongue tie affecting breastfeeding and speech production has risen into significant prominence in the past several years. Numerous journal articles, blog posts, as well as social media forums have been discussing this phenomenon with rather conflicting recommendations. Many health professionals and parents are convinced that “releasing the tie” or performing either a frenotomy or frenectomy will lead to significant improvements in speech and feeding.

Image result for evidence based practice Presently, systematic reviews^1-3 demonstrate there is insufficient evidence for the above. However, when many professionals including myself, cite reputable research explaining the lack of support of surgical intervention for tongue tie, there has been a pushback on the part of a number of other health professionals including lactation consultants, nurses, dentists, as well as speech-language pathologists stating that in their clinical experience surgical intervention does resolve issues with tongue tie as related to speech and feeding.

So today, given your 33 combined years of practice as lactation consultants I would love to ask your some questions regarding the tongue tie phenomena.

I would like to begin our discussion with a description of normal breastfeeding and what can interfere with it from an anatomical and physiological standpoint for mothers and babies.

Now, many of this blog’s readers already know that a tongue tie occurs when the connective tissue under the tongue known as a lingual frenulum restricts tongue movement to some degree and adversely affects its function. But many may not realize that children can present with a normal anatomical variant of “ties” which can be completely asymptomatic. Can you please address that?

Lois Wattis: “Normal” breastfeeding takes time and skill to achieve. The breastfeeding dyad is multifactorial, influenced by maternal breast and nipple anatomy combined with the infant’s facial and oral structures, all of which are highly variable. Mothers who have successfully breastfed the first baby may encounter problems with subsequent babies due to size (e.g., smaller, larger, etc.), be compromised by birth interventions or drugs during labor, or incur birth injuries – all of which can affect the initiation of breastfeeding and progression to a happy and comfortable feeding relationship. Unfortunately, the overview of each dyad’s story can be lost when tunnel vision of either health provider or parents regarding the baby’s oral anatomy is believed to be the chief influencer of breastfeeding success or failure.

Tatyana Elleseff: Colleagues, what do we know regarding the true prevalence of various ‘tongue ties’? Are there any studies of good quality?

Image result for prevalence Pamela Douglas: In a literature review in 2005, Hall and Renfrew acknowledged that the true prevalence of ankyloglossia remained unknown, though they estimated 3-4% of newborns.⁴

After 2005, once the diagnosis of posterior tongue-tie (PTT) had been introduced,^{5, 6} attempts to quantify incidence of tongue-tie have remained of very poor quality, but estimates currently rest at between 4-10%.⁷

The problem is that there is a lack of definitional clarity concerning the diagnosis of PTT. Consequently, anterior or classic tongue tie CTT is now often conflated with PTT simply as ‘tongue-tie’ (TT).

Tatyana Elleseff: Thank you for clarifying it. In addition to the anterior and posterior tongue tie labels, many parents and professionals also frequently hear the terms lip tie and buccal ties. Is there’s reputable research behind these terms indicating that these ties can truly impact speech and feeding?

Pamela Douglas: Current definitions of ankyloglossia tend to confuse oral and tongue function (which is affected by multiple variables, and in particular by a fit and hold in breastfeeding) with structure (which is highly anatomically variable for both the tongue length and appearance and lingual and maxillary frenula).

For my own purposes, I define CTT as Type 1 and 2 on the Coryllos-Genna-Watson scale.⁸ In clinical practice, I also find it useful to rate the anterior membrane by the percentage of the undersurface of the tongue into which the membrane connects, applying the first two categories of the Griffiths Classification System.⁹

There is a wide spectrum of lingual frenula morphologies and elasticities, and deciding where to draw a line between a normal variant and CTT will depend on the clinical judgment concerning the infant’s capacity for pain-free efficient milk transfer. However, that means we need to have an approach to fit and hold that we are confident does optimize pain-free efficient milk transfer and at the moment, research shows that not only do the old ‘hands on’ approach to fit and hold not work, but that baby-led attachment is also not enough for many women. This is why at the Possums Clinic we’ve been working on developing an approach to fit and hold (gestalt breastfeeding) that builds on baby-led attachment but also integrates the findings of the latest ultrasound studies.

I personally don’t find the diagnoses of posterior tongue tie PTT and upper lip tie ULT helpful, and don’t use them. Lois, Renee and myself find that a wide spectrum of normal anatomic lingual and maxillary frenula variants are currently being misdiagnosed as a PTT and ULT, which has worried us and led Lois to initiate the article with Renee.

Tatyana Elleseff: Segueing from the above question: is there an established criterion based upon which a decision is made by relevant professionals to “release” the tie and if so can you explain how it’s determined?

Image result for release tongue tie Lois Wattis: When an anterior frenulum is attached at the tongue tip or nearby and is short enough to cause restriction of lift towards the palate, usually associated with extreme discomfort for the breastfeeding mother, I have no reservations about snipping it to release the tongue to enable optimal function for breastfeeding. If a simple frenotomy is going to assist the baby to breastfeed well it is worth doing, and as soon as possible. What I do encounter in my clinical practice are distressed and disempowered mothers whose baby has been labeled as having a posterior tongue tie and/or upper lip tie which is the cause of current and even future problems. Upon examination, the baby has completely normal oral anatomy and breastfeeding upskilling and confidence building of both mother and baby enables the dyad to go forward with strategies which address all elements of their unique story.

Although the Hazelbaker Assessment Tool for Lingual Frenulum Function (ATLFF) is a pioneering contribution, bringing us our first systematized approach to examination of the infant’s tongue and oral connective tissues, it is unreliable as a tool for decision-making concerning frenotomy.^10-12 In practice many of the item criteria are highly subjective. Although one study found moderate inter-rater reliability on the ATLFF’s structural items, the authors did not find inter-rater reliability on most of the functional items.¹³ In my clinical experience, there is no reliable correlation between what the tongue is observed to do during oral examinations and what occurs during breastfeeding, other than in the case of classic tongue-tie (excluding congenital craniofacial abnormalities from this discussion.

In my practice as a Lactation Consultant in an acute hospital setting I use a combination of the available assessment tools mainly for documentation purposes, however, the most important tools I use are my eyes and my ears. Observing the mother and baby physical combination and interactions, and suggesting adjustments where indicated to the positioning and attachment technique used (which Pam calls fit and hold) can very often resolve difficulties immediately – even if the baby also has an obvious frenulum under his/her tongue. Listening to the mother’s feedback, and observing the baby’s responses are primary indicators of whether further intervention is needed, or not. Watching how the baby achieves and retains the latch is key, then the examination of baby’s mouth to assess tongue mobility and appearance provide final information about whether baby’s ability to breastfeed comfortably is or is not being hindered by a restrictive lingual frenulum.

Tatyana Elleseff: So frenotomy is an incision (cut) of lingual frenum while frenectomy (complete removal) is an excision of lingual frenum. Both can be performed via various methods of “release”. What effects on breastfeeding have you seen with respect to healing?

Lois Wattis: The significant difference between both procedures involves the degree of invasiveness and level of pain experienced during and after the procedures, and the differing time it takes for the resumption and/or improvement in breastfeeding comfort and efficacy.

It is commonplace for a baby who has had a simple incision to breastfeed immediately after the procedure and exhibit no further signs of discomfort or oral aversion. Conversely, the baby who has had laser division(s) may breastfeed soon after the procedure while topical anesthetics are still working. However, many infants demonstrate discomfort, extreme pain responses and reluctance to feed for days or weeks following a laser treatment. Parents are warned to expect delays resuming feeding and the baby is usually also subjected to wound “stretches” for weeks following the laser treatments. Unfortunately, in my clinical practice I see many parents and babies who are very traumatized by this whole process, and in many cases, breastfeeding can be derailed either temporarily or permanently.

Tatyana Elleseff: Thank you! This is highly relevant information for both health professionals and parents alike. I truly appreciate your clinical expertise on this topic. While we are on the topic of restrictive lingual frenulums can we discuss several recent articles published on surgical interventions for the above? For example (Ghaheri, Cole, Fausel, Chuop & Mace, 2016), recently published the result of their study which concluded that: “Surgical release of tongue-tie/lip-tie results in significant improvement in breastfeeding outcomes”. Can you elucidate upon the study design and its findings?

Pamela Douglas: Pre-post surveys, such as Ghaheri et al’s 2016 study, are notoriously methodologically weak and prone to interpretive bias.¹⁴

Renee Kam: Research about the efficacy of releasing ULTs to improve breastfeeding outcomes is seriously lacking. There is no reliable assessment tool for upper lip-tie and a lack of evidence to support the efficacy of a frenotomy of labial frenula in breastfed babies. The few studies which have included ULT release have either included very small numbers of babies having upper lip-tie releases or have included babies having a release upper lip ties and tongue ties at the same time, making it impossible to know if any improvements were due to the tongue-tie release, upper lip-tie release or both. Here, to answer your previous question, to date, no research has looked into the treatment of buccal ties for breastfeeding outcomes.

There are various classification scales for labial frenulums such as the Kotlow scale. The title of this scale is misleading as it contains the word ‘tie’. Hence it can give some people the incorrect assumption that a class III or IV labial frenulum is somehow a problem. What this scale actually shows is the normal range of insertion sites for a labial frenulum. And, in normal cases, the vast majority of babies’ labial frenulums insert low down on the upper gum (class III) or even wrap around it (class IV). It’s important to note that, for effective breastfeeding, the upper lip does not have to flange out in order to create a seal. It just has to rest in a neutral position — not flanged out, not tucked in.

Lois Wattis: I entirely agree with Renee’s view about the neutrality of the upper lip, including the labial frenulum, in relation to latch for breastfeeding. Even babies with asymmetrical facial features, cleft lips and other permanent and temporary anomalies only need to achieve a seal with the upper lip to breastfeed successfully.

Tatyana Elleseff: Thank you for that. In addition to studies on tongue tie revisions and breastfeeding outcomes, there has been an increase in studies, specifically Kotlow (2016) and Siegel (2016), which claimed that surgical intervention improves outcomes for acid reflux and aerophagia in babies”. Can you discuss these studies design and findings?

Renee Kam: The AIR hypothesis has led to reflux being used as another reason to diagnose the oral anatomic abnormalities in infants in the presence of breastfeeding problems. More research with objective indicators and less vested interest is needed in this area. A thorough understanding of normal infant behavior and feeding problems which aren’t tie related are also imperative before any conclusions about AIR can be reached.

Tatyana Elleseff: One final question, colleagues are you aware of any studies which describe long-term outcomes of surgical interventions for tongue ties?

Pamela Douglas: The systematic reviews note that there is a lack of evidence demonstrating long-term outcomes of surgical interventions.

Tatyana Elleseff: Thank you for such informative discussion, colleagues.

Related image There you have it, readers. Both research and clinical practice align to indicate that:

There’s significant normal variation when it comes to most anatomical structures including the frenulum
Just because a child presents with restricted frenulum does not automatically imply adverse feeding as well as speech outcomes and immediately necessitates a tongue tie release
When breastfeeding difficulties arise, in the presence of restricted frenulum, it is very important to involve an experienced lactation specialist who will perform a differential diagnosis in order to determine the source of the baby’s true breastfeeding difficulties

Now, I’d like to take a moment and address the myth of tongue ties affecting speech production, which continues to persist among speech-language pathologists despite overwhelming evidence to the contrary.

For that purpose, I will use excerpts from an excellent ASHA Leader December 2005 article written by an esteemed Dr. Kummer who is certainly well qualified to discuss this issue. According to Dr. Kummer, “there is no empirical evidence in the literature that ankyloglossia typically causes speech defects. On the contrary, several authors, even from decades ago, have disputed the belief that there is a strong causal relationship (Wallace, 1963; Block, 1968; Catlin & De Haan, 1971; Wright, 1995; Agarwal & Raina, 2003).”

Related image Since many children with restricted frenulum do not have any speech production difficulties, Dr Kummer explains why that is the case by discussing the effect of tongue tip positioning for speech production.

“Lingual-alveolar sounds (t, d, n) are produced with the top of the tongue tip and therefore, they can be produced with very little tongue elevation or mobility.

The /s/ and /z/ sounds require the tongue tip to be elevated only slightly but can be produced with little distortion if the tip is down.

The most the tongue tip needs to elevate is to the alveolar ridge for the production of an /l/. However, this sound can actually be produced with the tongue tip down and the dorsum of the tongue up against the alveolar ridge. Even an /r/ sound can be produced with the tongue tip down as long as the back of the tongue is elevated on both sides.

The most the tongue needs to protrude is to the back of the maxillary incisors for the production of /th/. All of these sounds can usually be produced, even with significant tongue tip restriction. This can be tested by producing these sounds with the tongue tip pressed down or against the mandibular gingiva. This results in little, if any, distortion.” (Kummer, 2005, ASHA Leader)

In 2009, Dr. Sharynne McLeod, did research on electropalatography of speech sounds with adults. Her findings (below) which are coronal images of tongue positioning including bracing, lateral contact and groove formation for consonants support the above information provided by Dr. Kummer.

Once again research and clinical practice align to indicate that there’s insufficient evidence to indicate the effect of restricted frenulum on the production of speech sounds.

Finally, I would like to conclude this post with a list of links from recent systematic reviews summarizing the latest research on this topic.

Ankyloglossia/Tongue Tie Systematic Review Summaries to Date (2017):

A small body of evidence suggests that frenotomy may be associated with mother reported improvements in breastfeeding, and potentially in nipple pain, but with small, short-term studies with inconsistent methodology, the strength of the evidence is low to insufficient.
In an infant with tongue-tie and feeding difficulties, surgical release of the tongue-tie does not consistently improve infant feeding but is likely to improve maternal nipple pain. Further research is needed to clarify and confirm this effect.
Data are currently insufficient for assessing the effects of frenotomy on nonbreastfeeding outcomes that may be associated with ankyloglossia
Given the lack of good-quality studies and limitations in the measurement of outcomes, we considered the strength of the evidence for the effect of surgical interventions to improve speech and articulation to be insufficient.
Large temporal increases and substantial spatial variations in ankyloglossia and frenotomy rates were observed that may indicate a diagnostic suspicion bias and increasing use of a potentially unnecessary surgical procedure among infants.

References

Power R, Murphy J. Tongue-tie and frenotomy in infants with breastfeeding difficulties: achieving a balance. Archives of Disease in Childhood 2015;100:489-494.
Francis DO, Krishnaswami S, McPheeters M. Treatment of ankyloglossia and breastfeeding outcomes: a systematic review. Pediatrics. 2015;135(6):e1467-e1474.
O’Shea JE, Foster JP, O’Donnell CPF, Breathnach D, Jacobs SE, Todd DA, et al. Frenotomy for tongue-tie in newborn infants (Review). Cochrane Database of Systematic Reviews. 2017 (3):Art. No.:CD011065.
Hall D, Renfrew M. Tongue tie. Archives of Disease in Childhood. 2005;90:1211-1215.
Coryllos E, Watson Genna C, Salloum A. Congenital tongue-tie and its impact on breastfeeding. Breastfeeding: Best for Mother and Baby, American Academy of Pediatrics. 2004 Summer:1-6.
Coryllos EV, Watson Genna C, LeVan Fram J. Minimally Invasive Treatment for Posterior Tongue-Tie (The Hidden Tongue-Tie). In: Watson Genna C, editor. Supporting Sucking Skills. Burlington, MA: Jones and Bartlett Learning; 2013. p. 243-251.
National Health and Medical Research Council. Infant feeding guidelines: information for health workers. In: Government A, editor. 2012. p. https://www.nhmrc.gov.au/guidelines-publications/n56.
Watson Genna C, editor. Supporting sucking skills in breastfeeding infants. Burlington, MA: Jones and Bartlett Learning; 2016.
Griffiths DM. Do tongue ties affect breastfeeding? . Journal of Human Lactation. 2004;20:411.
Ricke L, Baker N, Madlon-Kay D. Newborn tongue-tie: prevalence and effect on breastfeeding. Journal of American Board of Family Practice. 2005;8:1-8.
Madlon-Kay D, Ricke L, Baker N, DeFor TA. Case series of 148 tongue-tied newborn babies evaluated with the assessment tool for lingual function. Midwifery. 2008;24:353-357.
Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110:e63.
Amir L, James JP, Donath SM. Reliability of the Hazelbaker Assessment Tool for Lingual Frenulum Function. International Breastfeeding Journal. 2006;1:3.
Douglas PS. Conclusions of Ghaheri’s study that laser surgery for posterior tongue and lip ties improve breastfeeding are not substantiated. Breastfeeding Medicine. 2017;12(3):DOI: 10.1089/bfm.2017.0008.

Author Bios (in alphabetical order):

Dr. Pamela Douglas is the founder of a charitable organization, the Possums Clinic, a general practitioner since 1987, an IBCLC (1994-2004; 2012-Present) and researcher. She is an Associate Professor (Adjunct) with the Centre for Health Practice Innovation, Griffith University, and a Senior Lecturer with the Discipline of General Practice, The University of Queensland. Pam enjoys working clinically with families across the spectrum of challenges in early life, many complex (including breastfeeding difficulty) unsettled infant behaviors, reflux, allergies, tongue-tie/oral connective tissue problems, and gut problems. She is author of The discontented little baby book: all you need to know about feeds, sleep and crying (UQP) www.possumsonline.com; www.pameladouglas.com.au

Renee Kam qualified with a Bachelor of Physiotherapy from the University of Melbourne in 2000. She then worked as a physiotherapist for 6 years, predominantly in the areas of women’s health, pediatric and musculoskeletal physiotherapy. She became an Australian Breastfeeding Association Breastfeeding (ABA) counselor in 2010 and obtained the credential of International Board Certified Lactation Consultant (IBCLC) in 2012. In 2013, Renee’s book, The Newborn Baby Manual, was published which covers the topics that Renee is passionate about; breastfeeding, baby sleep and baby behavior. These days, Renee spends most of her time being a mother to her two young daughters, writing breastfeeding content for BellyBelly.com.au, fulfilling her role as national breastfeeding information manager with ABA and working as an IBCLC in private practice and at a private hospital in Melbourne, Australia.

Lois Wattis is a Registered Nurse/Midwife, International Board Certified Lactation Consultant and Fellow of the Australian College of Midwives. Working in both hospital and community settings, Lois has enhanced her midwifery skills and expertise by providing women-centred care to thousands of mothers and babies, including more than 50 women who chose to give birth at home. Lois’ qualifications include Bachelor of Nursing Degree (Edith Cowan University, Perth WA), Post Graduate Diploma in Clinical Nursing, Midwifery (Curtin University, Perth WA), accreditation as Independent Practising Midwife by the Australian College of Midwives in 2002 and International Board Certified Lactation Consultant in 2004. Lois was inducted as a Fellow of the Australian College of Midwives (FACM) in 2005 in recognition of her services to women and midwifery in Australia. Lois has authored numerous articles which have been published internationally in parenting and midwifery journals, and shares her broad experience via her creations “New Baby 101” book, smartphone App, on-line videos and Facebook page. www.newbaby101.com.au Lois has worked for the past 10 years in Qld, Australia in a dedicated Lactation Consultant role as well as in private practice www.birthjourney.com

Posted on April 10, 2017January 5, 2022 by Tatyana Elleseff — 3 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Helpful Bilingual Smart Speech Therapy Resources:

Posted on February 12, 2017March 15, 2022 by Tatyana Elleseff — Leave a comment

What do Narratives and Pediatric Psychiatric Impairments Have in Common?

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

Posted on January 23, 2017January 5, 2022 by Tatyana Elleseff — Leave a comment

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

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

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

Secondary Data Source: Why Did International Adoption Suddenly End?

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

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

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

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

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

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

Demographics:

A greater number of older, preschool and school-aged children and fewer number of infants and toddlers are placed for adoption (Selman, 2012).

Significant increase in special needs adoptions from Eastern European countries (e.g., Ukraine, Kazhakstan, etc.) as well as China. The vast majority of Internationally Adopted children arrive to the United States with significant physical, linguistic, and cognitive disabilities as well as mental health problems. Consequently, it is important for schools to immediately provide the children with a host of services including speech-language therapy, immediately post-arrival.

It is also important to know that in the vast majority of cases the child’s linguistic, cognitive, or mental health deficits may not be documented in the adoption records due to poor record keeping, lack of access to adequate healthcare or often to ensure their “adoptability”. As such, parental interviews and anecdotal evidence become the primary source of information regarding these children’s social and academic functioning in their respective birth countries.

The question of bilingualism:

Internationally Adopted children are NOT bilingual children! In fact, the vast majority of internationally adopted children will very rapidly lose their birth language, in a period of 2-3 months post arrival (Gindis, 2005), since they are most often adopted by parents who do not speak the child’s birth language and as such are unable/unwilling to maintain it.

IA children do not need to be placed in ESL classes since they are not bilingual children. Not only are IA children not bilingual, they are also not ‘truly’ monolingual since their first language is lost rather rapidly, while their second language has been gained minimally at the time of loss.

IA children need to acquire Cognitive Language Mastery (CLM) which is language needed for formal academic learning. This includes listening, speaking, reading, and writing about subject area content material including analyzing, synthesizing, judging and evaluating presented information. This level of language learning is essential for a child to succeed in school. CLM takes years and years to master, especially because, IA children did not have the same foundation of knowledge and stimulation as bilingual children in their birth countries.

Assessment Parameters:

IA children’s language abilities should be retested and monitored at regular intervals during the first several years post arrival.

Glennen (2007) recommends 3 evaluations during the first year post arrival, with annual reevaluations thereafter.

Hough & Kaczmarek (2011) recommend a reevaluation schedule of 3-4 times a year for a period of two years, post arrival because some IA children continue to present with language-based deficits many years (5+) post-adoption.

If an SLP speaking the child’s first language is available the window of opportunity to assess in the first language is very limited (~2-3 months at most).

Similarly, an assessment with an interpreter is recommended immediately post arrival from the birth country for a period of approximately the same time.

If an SLP speaking the child’s first language is not available English-speaking SLP should consider assessing the child in English between 3-6 months post arrival (depending on the child and the situational constraints) in order to determine the speed with which s/he are acquiring English language abilities
- Children should be demonstrating rapid language gains in the areas of receptive language, vocabulary as well as articulation (Glennen 2007, 2009)
- Dynamic assessment is highly recommended

It is important to remember that language and literacy deficits are not always very apparent and can manifest during any given period post arrival

To treat or NOT to Treat?

“Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)

IA children with medical diagnoses, which impact their speech language abilities should be assessed and considered for S-L therapy services as well (Ladage, 2009).

Helpful Links: