Category: Clinical Assessment

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Components of Qualitative Writing Assessments: What Exactly are We Trying to Measure?

Writing! The one assessment area that challenges many SLPs on daily basis! If one polls 10 SLPs on the topic of writing, one will get 10 completely different responses ranging from agreement and rejection to the diverse opinions regarding what should actually be assessed and how exactly it should be accomplished.

Consequently, today I wanted to focus on the basics involved in the assessment of adolescent writing. Why adolescents you may ask? Well, frankly because many SLPs (myself included) are far more likely to assess the writing abilities of adolescents rather than elementary-aged children.

Often, when the students are younger and their literacy abilities are weaker, the SLPs may not get to the assessment of writing abilities due to the students presenting with so many other deficits which require precedence intervention-wise. However, as the students get older and the academic requirements increase exponentially, SLPs may be more frequently asked to assess the students’ writing abilities because difficulties in this area significantly affect them in a variety of classes on a variety of subjects.

So what can we assess when it comes to writing? In the words of Helen Lester’s character ‘Pookins’: “Lots!”  There are various types of writing that can be assessed, the most common of which include: expository, persuasive, and fictional. Each of these can be used for assessment purposes in a variety of ways.

To illustrate, if we chose to analyze the student’s written production of fictional narratives then we may broadly choose to analyze the following aspects of the student’s writing: contextual conventions and writing composition.

The former looks at such writing aspects as the use of correct spelling, punctuation, and capitalization, paragraph formation, etc.

The latter looks at the nitty-gritty elements involved in plot development. These include effective use of literate vocabulary, plotline twists, character development,  use of dialogue, etc.

Perhaps we want to analyze the student’s persuasive writing abilities. After all, high school students are expected to utilize this type of writing frequently for essay writing purposes.  Actually, persuasive writing is a complex genre which is particularly difficult for students with language-learning difficulties who struggle to produce essays that are clear, logical, convincing, appropriately sequenced, and take into consideration opposing points of view. It is exactly for that reason that persuasive writing tasks are perfect for assessment purposes.

But what exactly are we looking for analysis wise? What should a typical 15 year old’s persuasive essays contain?

With respect to syntax, a typical student that age is expected to write complex sentences possessing nominal, adverbial, as well as relative clauses.

With the respect to semantics, effective persuasive essays require the use of literate vocabulary words of low frequency such as later developing connectors (e.g., first of all, next, for this reason, on the other hand, consequently, finally, in conclusion) as well as metalinguistic and metacognitive verbs (“metaverbs”) that refer to acts of speaking (e.g., assert, concede, predict, argue, imply) and thinking (e.g., hypothesize, remember, doubt, assume, infer).

With respect to pragmatics, as students  mature, their sensitivity to the perspectives of others improves, as a result, their persuasive essays increase in length (i.e., total number of words produced) and they are able to offer a greater number of different reasons to support their own opinions (Nippold, Ward-Lonergan, & Fanning, 2005).

Now let’s apply our knowledge by analyzing a writing sample of a 15-year-old with suspected literacy deficits. Below 10th-grade student was provided with a written prompt first described in the Nippold, et al, 2005 study, entitled: “The Circus Controversy”.   “People have different views on animals performing in circuses. For example, some people think it is a great idea because it provides lots of entertainment for the public. Also, it gives parents and children something to do together, and the people who train the animals can make some money. However, other people think having animals in circuses is a bad idea because the animals are often locked in small cages and are not fed well. They also believe it is cruel to force a dog, tiger, or elephant to perform certain tricks that might be dangerous. I am interested in learning what you think about this controversy, and whether or not you think circuses with trained animals should be allowed to perform for the public. I would like you to spend the next 20 minutes writing an essay. Tell me exactly what you think about the controversy. Give me lots of good reasons for your opinion. Please use your best writing style, with correct grammar and spelling. If you aren’t sure how to spell a word, just take a guess.”(Nippold, Ward-Lonergan, & Fanning, 2005)

He produced the following written sample during the allotted 20 minutes.

Analysis: This student was able to generate a short, 3-paragraph, composition containing an introduction and a body without a definitive conclusion. His persuasive essay was judged to be very immature for his grade level due to significant disorganization, limited ability to support his point of view as well as the presence of tangential information in the introduction of his composition, which was significantly compromised by many writing mechanics errors (punctuation, capitalization, as well as spelling) that further impacted the coherence and cohesiveness of his written output.

The student’s introduction began with an inventive dialogue, which was irrelevant to the body of his persuasive essay. He did have three important points relevant to the body of the essay: animal cruelty, danger to the animals, and potential for the animals to harm humans. However, he was unable to adequately develop those points into full paragraphs. The notable absence of proofreading and editing of the composition further contributed to its lack of clarity. The above coupled with a lack of a conclusion was not commensurate grade-level expectations.

Based on the above-written sample, the student’s persuasive composition content (thought formulation and elaboration) was judged to be significantly immature for his grade level and is commensurate with the abilities of a much younger student.  The student’s composition contained several emerging claims that suggested a vague position. However, though the student attempted to back up his opinion and support his position (animals should not be performing in circuses), ultimately he was unable to do so in a coherent and cohesive manner.

Now that we know what the student’s written difficulties look like, the following goals will be applicable with respect to his writing remediation:

Long-Term Goals:  Student will improve his written abilities for academic purposes.

  • Short-Term Goals
  1. Student will appropriately utilize parts of speech (e.g., adjectives, adverbs, prepositions, etc.)  in compound and complex sentences.
  2. Student will use a variety of sentence types for story composition purposes (e.g., declarative, interrogative, imperative, and exclamatory sentences).
  3. Student will correctly use past, present, and future verb tenses during writing tasks.
  4. Student will utilize appropriate punctuation at the sentence level (e.g., apostrophes, periods, commas, colons, quotation marks in dialogue, and apostrophes in singular possessives, etc.).
  5. Student will utilize appropriate capitalization at the sentence level (e.g., capitalize proper nouns, holidays, product names, titles with names, initials, geographic locations, historical periods, special events, etc.).
  6. Student will use prewriting techniques to generate writing ideas (e.g., list keywords, state key ideas, etc.).
  7. Student will determine the purpose of his writing and his intended audience in order to establish the tone of his writing as well as outline the main idea of his writing.
  8. Student will generate a draft in which information is organized in chronological order via use of temporal markers (e.g., “meanwhile,” “immediately”) as well as cohesive ties (e.g., ‘but’, ‘yet’, ‘so’, ‘nor’) and cause/effect transitions (e.g., “therefore,” “as a result”).
  9. Student will improve coherence and logical organization of his written output via the use of revision strategies (e.g., modify supporting details, use sentence variety, employ literary devices).
  10. Student will edit his draft for appropriate grammar, spelling, punctuation, and capitalization.

There you have it. A quick and easy qualitative writing assessment which can assist SLPs to determine the extent of the student’s writing difficulties as well as establish writing remediation targets for intervention purposes.

Using a different type of writing assessment with your students? Please share the details below so we can all benefit from each others knowledge of assessment strategies.

References:

  • Nippold, M., Ward-Lonergan, J., & Fanning, J. (2005). Persuasive writing in children, adolescents, and adults: a study of syntactic, semantic, and pragmatic development. Language, Speech, and Hearing Services in Schools, 36, 125-138.

 

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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:

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Adolescent Assessments in Action: Clinical Reading Evaluation

Related imageIn the past several years, due to an influx of adolescent students with language and learning difficulties on my caseload, I have begun to research in depth aspects of adolescent language development, assessment, and intervention.

While a number of standardized assessments are available to test various components of adolescent language from syntax and semantics to problem-solving and social communication, etc., in my experience with this age group, frequently, clinical assessments (vs. the standardized tests), do a far better job of teasing out language difficulties in adolescents.

Today I wanted to write about the importance of performing a clinical reading assessment as part of select* adolescent language and literacy evaluations.

There are a number of standardized tests on the market, which presently assess reading. However, not all of them by far are as functional as many clinicians would like them to be. To illustrate, one popular reading assessment is the Gray Oral Reading Tests-5 (GORT-5).  It assesses the student’s rate, accuracy, fluency, and comprehension abilities. While it’s a useful test to possess in one’s assessment toolbox, it is not without its limitations. In my experience assessing adolescent students with literacy deficits, many can pass this test with average scores, yet still present with pervasive reading comprehension difficulties in the school setting. As such, as part of the assessment process, I like to administer clinical reading assessments to students who pass the standardized reading tests (e.g., GORT-5),  in order to ensure that the student does not possess any reading deficits at the grade text level.

So how do I clinically assess the reading abilities of struggling adolescent learners?

First, I select a one-page long grade level/below grade-level text (for very impaired readers). I ask the student to read the text, and I time the first minute of their reading in order to analyze their oral reading fluency or words correctly read per minute (wcpm).

Content Reading: Science Gr6For this purpose, I often use the books from the Continental Press series entitled: Content Reading for Geography, Social Studies, & Science.   Texts for grades 5 – 7 of the series are perfect for assessment of struggling adolescent readers. In some cases using a below grade level text allows me to starkly illustrate the extent of the student’s reading difficulties. Below is an example of one of such a clinical reading assessments in action.

CLINICAL READING ASSESSMENT: 8th Grade Male   

A clinical reading assessment was administered to TS, a 15-5-year-old male, on a supplementary basis in order to further analyze his reading abilities. Given the fact that TS was reported to present with grade-level reading difficulties, the examiner provided TS a 7th-grade text by Continental Press. TS was asked to read aloud the 7 paragraph long text, and then answer factual and inferential questions, summarize the presented information, define select context embedded vocabulary words as well as draw conclusions based on the presented text. (Please note that in order to protect the client’s privacy some portions of the below assessment questions and responses were changed to be deliberately vague).

Image result for reading fluency componentsReading Fluency: TS’s reading fluency (automaticity, prosody, accuracy and speed, expression, intonation, and phrasing) during the reading task was marked by monotone vocal quality, awkward word stress, imprecise articulatory contacts, false-starts, self–revisions, awkward mid-sentential pauses, limited pausing for punctuation, as well as  misreadings and word substitutions, all of which resulted in an impaired reading prosody.

With respect to specific errors, TS was observed to occasionally add word fillers to text (e.g., and, a, etc.), change morphological endings of select words (e.g., read /elasticity/ as /elastic/, etc.) as well as substitute similar looking words (e.g., from/for; those/these, etc.) during reading.  He occasionally placed stress on the first vs. second syllable in disyllabic words, which resulted in distorted word productions (e.g., products, residual, upward, etc.), as well as inserted extra words into text (e.g., read: “until pressure inside the earth starts to build again” as “until pressure inside the earth starts to build up again”). He also began reading a number of his sentences with false starts (e.g., started reading the word “drinking” as ‘drunk’, etc.) and as a result was observed to make a number of self-corrections during reading.

During reading, TS demonstrated adequate tracking movements for text scanning as well as use of context to aid his decoding.  For example, TS was observed to read the phonetic spelling of select unfamiliar words in parenthesis (e.g., equilibrium) and then read them correctly in subsequent sentences. However, he exhibited limited use of metalinguistic strategies and did not always self-correct misread words; dispute the fact that they did not always make sense in the context of the read sentences.

TS’s oral reading rate during today’s reading was judged to be reduced for his age/grade levels. An average 8th grader is expected to have an oral reading rate between 145 and 160 words per minute. In contrast, TS was only able to read 114 words per minute. However, it is important to note that recent research on reading fluency has indicated that as early as by 4th grade reading faster than 90 wcpm will not generate increases in comprehension for struggling readers.  Consequently, TS’s current reading rate of off 114 words per minute was judged to be adequate for reading purposes. Furthermore, given the fact that TS’s reading comprehension is already compromised at this rate (see below for further details) rather than making a recommendation to increase his reading rate further, it is instead recommended that intervention focuses on slowing TS’s rate via relevant strategies as well as improving his reading comprehension abilities. Strategies should focus on increasing his opportunities to learn domain knowledge via use of informational texts; purposeful selection of texts to promote knowledge acquisition and gain of expertise in different domains; teaching morphemic as well as semantic feature analyses (to expand upon already robust vocabulary), increasing discourse and critical thinking with respect to informational text, as well as use of graphic organizers to teach text structure and conceptual frameworks.

Verbal Text Summary: TS’s text summary following his reading was very abbreviated, simplified, and confusing. When asked: “What was this text about?” Rather than stating the main idea, TS nonspecifically provided several vague details and was unable to elaborate further. When asked: “Do you think you can summarize this story for me from beginning to the end?” TS produced the two disjointed statements, which did not adequately address the presented question When asked: “What is the main idea of this text.” TS vaguely responded: “Science,” which was the broad topic rather than the main idea of the story.

Image result for vocabularyText Vocabulary Comprehension:

After that, TS was asked a number of questions regarding story vocabulary.  The first word presented to him was “equilibrium”.  When asked: “What does ‘equilibrium’ mean?” TS first incorrectly responded: “temperature”. Then when prompted: “Anything else?” TS correctly replied: “balance.” He was then asked to provide some examples of how nature leans towards equilibrium from the story. TS nonspecifically produced: “Ah, gravity.” When asked to explain how gravity contributes to the process of equilibrium TS again nonspecifically replied: “gravity is part of the planet”, and could not elaborate further. TS was then asked to define another word from the text provided to him in a sentence: “Scientists believe that this is residual heat remaining from the beginnings of the solar system.” What is the meaning of the word: “residual?” TS correctly identified: “remaining.” Then the examiner asked him to define the term found in the last paragraph of the text: “What is thermal equilibrium?” TS nonspecifically responded: “a balance of temperature”, and was unable to elaborate further.

Image result for reading comprehensionReading Comprehension (with/out text access):

TS was also asked to respond to a number of factual text questions without the benefit of visual support. However, he presented with significant difficulty recalling text details. TS was asked: When asked, “Why did this story mention ____? What did they have to do with ____?” TS responded nonspecifically, “______.” When prompted to tell more, TS produced a rambling response which did not adequately address the presented question. When asked: “Why did the text talk about bungee jumpers? How are they connected to it?” TS stated, “I am ah, not sure really.” 

Finally, TS was provided with a brief worksheet which accompanied the text and asked to complete it given the benefit of written support. While TS’s performance on this task was better, he still achieved only 66% accuracy and was only able to answer 4 out of 6 questions correctly. On this task, TS presented with difficulty identifying the main idea of the third paragraph, even after being provided with multiple choice answers. He also presented with difficulty correctly responding to the question pertaining to the meaning of the last paragraph.

Image result for impressionsImpressions: Clinical below grade-level reading comprehension assessment reading revealed that TS presents with a number of reading related difficulties.   TS’s reading fluency was marked by monotone vocal quality, awkward word stress, imprecise articulatory contacts, false-starts, self–revisions, awkward mid-sentential pauses, limited pausing for punctuation, as well as misreadings and word substitutions, all of which resulted in an impaired reading prosody. TS’s understanding as well as his verbal summary of the presented text was immature for his age and was characterized by impaired gestalt processing of information resulting in an ineffective and confusing summarization.  While TS’s text-based vocabulary knowledge was deemed to be grossly adequate for his age, his reading comprehension abilities were judged to be impaired for his age. Therapeutic intervention is strongly recommended to improve TS’s reading abilities. (See Impressions and Recommendations sections for further details).

There you have it! This is just one of many different types of informal reading assessments, which I occasionally conduct with adolescents who attain average scores on reading fluency and reading comprehension tests such as the GORT-5 or the Test of Reading Comprehension -4 (TORC-4), but still present with pervasive reading difficulties working with grade level text.

You can find more information on the topic of adolescent assessments (including other comprehensive informal write-up examples) in this recently developed product entitled: Assessment of Adolescents with Language and Literacy Impairments in Speech Language Pathology currently available in my online store.

What about you? What type of informal tasks and materials are you using to assess your adolescent students’ reading abilities and why do you like using them?

Helpful Smart Speech Therapy Adolescent Assessment Resources:

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

In this post, I am continuing my series of articles on speech and language assessments of children under 3 years of age. My first installment in this series offered suggestions regarding what information to include in general speech-language assessments for this age group, while my second post specifically discussed assessments of toddlers with suspected motor speech disorders.

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

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

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

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

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

RECEPTIVE LANGUAGE:

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

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

EXPRESSIVE LANGUAGE and ARTICULATION

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

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

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

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

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

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

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

 Attention/Gaze:

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

Reaching and Gestures:

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

Image result for playPlay Skills/Routines:

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

 Receptive (Listening Skills):

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

 Expressive (Speaking Skills): 

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

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

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

Strategies:

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

Related imageCore vocabulary categories for listening and speaking:

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

 Select References:

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

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

Stay Tuned for the next installment in this series:

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

 

 

 

 

 

 

 

 

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

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

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

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

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

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

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

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

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

Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.

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

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

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

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

TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender.  Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.

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

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

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

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

I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.

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

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

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

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

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

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

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

Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of questionable and even downright harmful bunk treatments for their children,  the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.

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

References:

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

Today, I’d  like to talk about speech and language assessments of children under three years of age.  Namely, the quality of these assessments.   Let me be frank,  I  am not happy with what I am seeing.  Often times,  when I receive a speech-language report on a child under three years of age,  I am struck by how little functional information it contains about the child’s  linguistic strengths and weaknesses.  Indeed,  conversations with parents often reveal that at best the examiner spent no more than half an hour or so playing with the child and performed very limited functional testing of their actual abilities.   Instead, they interviewed the parent and based their report on parental feedback alone.   Consequently, parents often end up with a report of very limited value,  which does not contain any helpful information on how delayed is the child as compared to peers their age.

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

Why 30 months, you may ask?   Well, there isn’t really any hard science to it. It’s just that I noticed that a significant percentage of parents who were already worried about their children’s speech-language abilities when they were younger, begin to act upon those worries as the child is nearing 3 years of age and their abilities are not improving or are not commensurate with other peers their age.

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

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

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

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

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

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

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

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

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

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

At this point, I am ready to move on to the language portion of the assessment.   Here it is important to note that a number of assessments for toddlers under 3 years of age contain numerous limitations. Some such as REEL-3 or Rosetti (a criterion-referenced vs. normed-referenced instrument) are observational or limitedly interactive in nature, while others such as PLS-5,  have a tendency to over inflate scores,  resulting in a significant number of children not qualifying for rightfully deserved speech-language therapy services.  This is exactly why it’s so important that SLPs have a firm knowledge of developmental milestones!  After all,  after they finish describing what the child is capable of,  they then need to describe what the developmental expectations are for a child this age (excerpts below).

RECEPTIVE LANGUAGE

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

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

EXPRESSIVE LANGUAGE:

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

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

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

Now I know that many of you will tell me,  that this is a ‘perfect world’ evaluation conducted by a private therapist with an unlimited amount of time on her hands.   And to some extent, many of you will be right! Yes,  such an evaluation was a result of more than 30 minutes spent face-to-face with the child.  All in all, it took probably closer to 90 minutes of face to face time to complete it and a few hours to write.   And yes,  this is a luxury only a few possess and many therapists in the early intervention system lack.  But in the long run, such evaluations pay dividends not only, obviously, to your clients but to SLPs who perform them.  They enhance and grow your reputation as an evaluating therapist. They even make sense from a business perspective.  If you are well-known and highly sought after due to your evaluating expertise, you can expect to be compensated for your time, accordingly. This means that if you decide that your time and expertise are worth private pay only (due to poor insurance reimbursement or low EI rates), you can be sure that parents will learn to appreciate your thoroughness and will choose you over other providers.

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

Selected References:

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

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