Category: Evidence-Based Practice (EBP)

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Tips on Reducing ‘Summer Learning Loss’ in Children with Language/Literacy Disorders

Related imageThe end of the school year is almost near. Soon many of our clients with language and literacy difficulties will be going on summer vacation and enjoying their time outside of school. However, summer is not all fun and games.  For children with learning needs, this is also a time of “learning loss”, or the loss of academic skills and knowledge over the course of the summer break.  Students diagnosed with language and learning disabilities are at a particularly significant risk of greater learning loss than typically developing students. Continue reading Tips on Reducing ‘Summer Learning Loss’ in Children with Language/Literacy Disorders

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Identifying Word Finding Deficits in Narrative Retelling of School-Aged Children

Image result for word-finding In the past, I have written several posts on the topic of word finding difficulties (HERE and HERE) as well as narrative assessments (HERE and HERE) of school-aged children. Today I am combining these posts  together by offering suggestions on how SLPs can identify word finding difficulties in narrative samples of school-aged children. Continue reading Identifying Word Finding Deficits in Narrative Retelling of School-Aged Children

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Analyzing Narratives of School-Aged Children

Related imageIn the past, I have written about why narrative assessments should be an integral part of all language evaluations.  Today, I’d like to share how I conduct my narrative assessments for comprehensive language testing purposes.

As mentioned previously, for elicitation purposes, I frequently use the books recommended by the SALT Software website, which include: ‘Frog Where Are You?’ by Mercer Mayer, ‘Pookins Gets Her Way‘ and ‘A Porcupine Named Fluffy‘ by  Helen Lester, as well as ‘Dr. DeSoto‘ by William Steig. Continue reading Analyzing Narratives of School-Aged Children

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Help, My Student has a Huge Score Discrepancy Between Tests and I Don’t Know Why?

Here’s a  familiar scenario to many SLPs. You’ve administered several standardized language tests to your student (e.g., CELF-5 & TILLS). You expected to see roughly similar scores across tests. Much to your surprise, you find that while your student attained somewhat average scores on one assessment, s/he had completely bombed the second assessment, and you have no idea why that happened.

So you go on social media and start crowdsourcing for information from a variety of SLPs located in a variety of states and countries in order to figure out what has happened and what you should do about this. Of course, the problem in such situations is that while some responses will be spot on, many will be utterly inappropriate. Luckily, the answer lies much closer than you think, in the actual technical manual of the administered tests.

So what is responsible for such as drastic discrepancy?  A few things actually. For starters, unless both tests were co-normed (used the same sample of test takers) be prepared to see disparate scores due to the ability levels of children in the normative groups of each test.  Another important factor involved in the score discrepancy is how accurately does the test differentiate disordered children from typical functioning ones.

Let’s compare two actual language tests to learn more. For the purpose of this exercise let us select The Clinical Evaluation of Language Fundamentals-5 (CELF-5) and the Test of Integrated Language and Literacy (TILLS).   The former is a very familiar entity to numerous SLPs, while the latter is just coming into its own, having been released in the market only several years ago.

Both tests share a number of similarities. Both were created to assess the language abilities of children and adolescents with suspected language disorders. Both assess aspects of language and literacy (albeit not to the same degree nor with the same level of thoroughness).  Both can be used for language disorder classification purposes, or can they?

Actually, my last statement is rather debatable.  A careful perusal of the CELF – 5 reveals that its normative sample of 3000 children included a whopping 23% of children with language-related disabilities. In fact, the folks from the Leaders Project did such an excellent and thorough job reviewing its psychometric properties rather than repeating that information, the readers can simply click here to review the limitations of the CELF – 5 straight on the Leaders Project website.  Furthermore, even the CELF – 5 developers themselves have stated that: “Based on CELF-5 sensitivity and specificity values, the optimal cut score to achieve the best balance is -1.33 (standard score of 80). Using a standard score of 80 as a cut score yields sensitivity and specificity values of .97. “

In other words, obtaining a standard score of 80 on the CELF – 5 indicates that a child presents with a language disorder. Of course, as many SLPs already know, the eligibility criteria in the schools requires language scores far below that in order for the student to qualify to receive language therapy services.

In fact, the test’s authors are fully aware of that and acknowledge that in the same document. “Keep in mind that students who have language deficits may not obtain scores that qualify him or her for placement based on the program’s criteria for eligibility. You’ll need to plan how to address the student’s needs within the framework established by your program.”

But here is another issue – the CELF-5 sensitivity group included only a very small number of: “67 children ranging from 5;0 to 15;11”, whose only requirement was to score 1.5SDs < mean “on any standardized language test”.  As the Leaders Project reviewers point out: “This means that the 67 children in the sensitivity group could all have had severe disabilities. They might have multiple disabilities in addition to severe language disorders including severe intellectual disabilities or Autism Spectrum Disorder making it easy for a language disorder test to identify this group as having language disorders with extremely high accuracy. ” (pgs. 7-8)

Of course, this begs the question,  why would anyone continue to administer any test to students, if its administration A. Does not guarantee disorder identification B. Will not make the student eligible for language therapy despite demonstrated need?

The problem is that even though SLPs are mandated to use a variety of quantitative clinical observations and procedures in order to reliably qualify students for services, standardized tests still carry more value then they should.  Consequently,  it is important for SLPs to select the right test to make their job easier.

The TILLS is a far less known assessment than the CELF-5 yet in the few years it has been out on the market it really made its presence felt by being a solid assessment tool due to its valid and reliable psychometric properties. Again, the venerable Dr. Carol Westby had already done such an excellent job reviewing its psychometric properties that I will refer the readers to her review here, rather than repeating this information as it will not add anything new on this topic. The upshot of her review as follows: “The TILLS does not include children and adolescents with language/literacy impairments (LLIs) in the norming sample. Since the 1990s, nearly all language assessments have included children with LLIs in the norming sample. Doing so lowers overall scores, making it more difficult to use the assessment to identify students with LLIs. (pg. 11)”

Now, here many proponents of inclusion of children with language disorders in the normative sample will make a variation of the following claim: “You CANNOT diagnose a language impairment if children with language impairment were not included in the normative sample of that assessment!” Here’s a major problem with such assertion. When a child is referred for a language assessment, we really have no way of knowing if this child has a language impairment until we actually finish testing them. We are in fact attempting to confirm or refute this fact, hopefully via the use of reliable and valid testing. However, if the normative sample includes many children with language and learning difficulties, this significantly affects the accuracy of our identification, since we are interested in comparing this child’s results to typically developing children and not the disordered ones, in order to learn if the child has a disorder in the first place.  As per Peña, Spaulding and Plante (2006), “the inclusion of children with disabilities may be at odds with the goal of classification, typically the primary function of the speech pathologist’s assessment. In fact, by including such children in the normative sample, we may be “shooting ourselves in the foot” in terms of testing for the purpose of identifying disorders.”(p. 248)

Then there’s a variation of this assertion, which I have seen in several Facebook groups: “Children with language disorders score at the low end of normal distribution“.  Once again such assertion is incorrect since Spaulding, Plante & Farinella (2006) have actually shown that on average, these kids will score at least 1.28 SDs below the mean, which is not the low average range of normal distribution by any means.  As per authors: “Specific data supporting the application of “low score” criteria for the identification of language impairment is not supported by the majority of current commercially available tests. However, alternate sources of data (sensitivity and specificity rates) that support accurate identification are available for a subset of the available tests.” (p. 61)

Now, let us get back to your child in question, who performed so differently on both of the administered tests. Given his clinically observed difficulties, you fully expected your testing to confirm it. But you are now more confused than before. Don’t be! Search the technical manual for information on the particular test’s sensitivity and specificity to look up the numbers.   Vance and Plante (1994) put forth the following criteria for accurate identification of a disorder (discriminant accuracy): “90% should be considered good discriminant accuracy; 80% to 89% should be considered fair. Below 80%, misidentifications occur at unacceptably high rates” and leading to “serious social consequences” of misidentified children. (p. 21)

Review the sensitivity and specificity of your test/s, take a look at the normative samples, see if anything unusual jumps out at you, which leads you to believe that the administered test may have some issues with assessing what it purports to assess. Then, after supplementing your standardized testing results with good quality clinical data (e.g., narrative samples, dynamic assessment tasks, etc.), consider creating a solidly referenced purchasing pitch to your administration to invest in more valid and reliable standardized tests.

Hope you find this information helpful in your quest to better serve the clients on your caseload. If you are interested in learning more regarding evidence-based assessment practices as well as psychometric properties of various standardized speech-language tests visit the SLPs for Evidence-Based Practice  group on Facebook learn more.

References:

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

Image result for effective interventionTwo 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:

  1. Learning is easier than generalization.
  2. Instruction that is constant and predictable is more effective than instruction that varies the conditions of learning and practice.
  3. Focused stimulation (massed practice) is a more effective teaching strategy than varied stimulation (distributed practice).
  4. The more feedback, the better.
  5. Repeated reading of passages is the best way to learn text information.
  6. More therapy is always better.
  7. The most effective language and literacy interventions target processing limitations rather than knowledge deficits.
  8. Telegraphic utterances (e.g., push ball, mommy sock) should not be provided as input for children with limited language.
  9. Appropriate language goals include increasing levels of mean length of utterance (MLU) and targeting Brown’s (1973) 14 grammatical morphemes.
  10. 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 ; (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

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

Unconscious Bias: The Power and Risks of Societal Narratives | by Phillip Yan | Left | Right | MediumAs 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)

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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:

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

Image result for bilingualFor 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.

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

  1. Working with Russian-speaking clients: implications for speech-language assessment 
  2. Strategies in the acquisition of segments and syllables in Russian-speaking children
  3. Language Development of Bilingual Russian/ English Speaking Children Living in the United States: A Review of the Literature
  4. The acquisition of syllable structure by Russian-speaking children with SLI

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:

  1. Checklist for Identification of Speech-Language Disorders in Bilingual and Multicultural Children
  2. Multicultural Assessment Bundle
  3. Best Practices in Bilingual Literacy Assessments and Interventions
  4. Dynamic Assessment of Bilingual and Multicultural Learners in Speech-Language Pathology
  5. Practical Strategies for Monolingual SLPs Assessing and Treating Bilingual Children
  6. Language Difference vs. Language Disorder: Assessment & Intervention Strategies for SLPs Working with Bilingual Children
  7. Impact of Cultural and Linguistic Variables On Speech-Language Services
  8. Assessment of sound and syllable imitation in Russian-speaking infants and toddlers
  9. Russian Articulation Screener 
  10. Creating Translanguaging Classrooms and Therapy Rooms