Category: Smart Speech Therapy Article

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

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

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

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

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

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

Image result for evidence based practicePresently, systematic reviews1-3 demonstrate there is insufficient evidence for the above. However, when many professionals including myself, cite reputable research explaining the lack of support of surgical intervention for tongue tie, there has been a pushback on the part of a number of other health professionals including lactation consultants, nurses, dentists, as well as speech-language pathologists stating that in their clinical experience surgical intervention does resolve issues with tongue tie as related to speech and feeding.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References

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

Author Bios (in alphabetical order):

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

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

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

 

 

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What do Narratives and Pediatric Psychiatric Impairments Have in Common?

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

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APD Update: New Developments on an Old Controversy

In the past two years, I wrote a series of research-based posts (HERE and HERE) regarding the validity of (Central) Auditory Processing Disorder (C/APD) as a standalone diagnosis as well as questioned the utility of it for classification purposes in the school setting.

Once again I want to reiterate that I was in no way disputing the legitimate symptoms (e.g., difficulty processing language, difficulty organizing narratives, difficulty decoding text, etc.), which the students diagnosed with “CAPD” were presenting with.

Rather, I was citing research to indicate that these symptoms were indicative of broader linguistic-based deficits, which required targeted linguistic/literacy-based interventions rather than recommendations for specific prescriptive programs (e.g., CAPDOTS, Fast ForWord, etc.),  or mere accommodations.

I was also significantly concerned that overfocus on the diagnosis of (C)APD tended to obscure REAL, language-based deficits in children and forced SLPs to address erroneous therapeutic targets based on AuD recommendations or restricted them to a receipt of mere accommodations rather than rightful therapeutic remediation. Continue reading APD Update: New Developments on an Old Controversy

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Review of the Test of Integrated Language and Literacy (TILLS)

The Test of Integrated Language & Literacy Skills (TILLS) is an assessment of oral and written language abilities in students 6–18 years of age. Published in the Fall 2015, it is  unique in the way that it is aimed to thoroughly assess skills  such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school age children.   As I have been using this test since the time it was published,  I wanted to take an opportunity today to share just a few of my impressions of this assessment.

               

First, a little background on why I chose to purchase this test  so shortly after I had purchased the Clinical Evaluation of Language Fundamentals – 5 (CELF-5).   Soon after I started using the CELF-5  I noticed that  it tended to considerably overinflate my students’ scores  on a variety of its subtests.  In fact,  I noticed that unless a student had a fairly severe degree of impairment,  the majority of his/her scores  came out either low/slightly below average (click for more info on why this was happening HERE, HERE, or HERE). Consequently,  I was excited to hear regarding TILLS development, almost simultaneously through ASHA as well as SPELL-Links ListServe.   I was particularly happy  because I knew some of this test’s developers (e.g., Dr. Elena Plante, Dr. Nickola Nelson) have published solid research in the areas of  psychometrics and literacy respectively.

According to the TILLS developers it has been standardized for 3 purposes:

  • to identify language and literacy disorders
  • to document patterns of relative strengths and weaknesses
  • to track changes in language and literacy skills over time

The testing subtests can be administered in isolation (with the exception of a few) or in its entirety.  The administration of all the 15 subtests may take approximately an hour and a half, while the administration of the core subtests typically takes ~45 mins).

Please note that there are 5 subtests that should not be administered to students 6;0-6;5 years of age because many typically developing students are still mastering the required skills.

  • Subtest 5 – Nonword Spelling
  • Subtest 7 – Reading Comprehension
  • Subtest 10 – Nonword Reading
  • Subtest 11 – Reading Fluency
  • Subtest 12 – Written Expression

However,  if needed, there are several tests of early reading and writing abilities which are available for assessment of children under 6:5 years of age with suspected literacy deficits (e.g., TERA-3: Test of Early Reading Ability–Third Edition; Test of Early Written Language, Third Edition-TEWL-3, etc.).

Let’s move on to take a deeper look at its subtests. Please note that for the purposes of this review all images came directly from and are the property of Brookes Publishing Co (clicking on each of the below images will take you directly to their source).

TILLS-subtest-1-vocabulary-awareness1. Vocabulary Awareness (VA) (description above) requires students to display considerable linguistic and cognitive flexibility in order to earn an average score.    It works great in teasing out students with weak vocabulary knowledge and use,   as well as students who are unable to  quickly and effectively analyze  words  for deeper meaning and come up with effective definitions of all possible word associations. Be mindful of the fact that  even though the words are presented to the students in written format in the stimulus book, the examiner is still expected to read  all the words to the students. Consequently,  students with good vocabulary knowledge  and strong oral language abilities  can still pass this subtest  despite the presence of significant reading weaknesses. Recommendation:  I suggest informally  checking the student’s  word reading abilities  by asking them to read of all the words, before reading all the word choices to them.   This way  you can informally document any word misreadings  made by the student even in the presence of an average subtest score.

TIILLS-subtest-2-phonemic-awareness

2. The Phonemic Awareness (PA) subtest (description above) requires students to  isolate and delete initial sounds in words of increasing complexity.  While this subtest does not require sound isolation and deletion in various word positions, similar to tests such as the CTOPP-2: Comprehensive Test of Phonological Processing–Second Edition  or the The Phonological Awareness Test 2 (PAT 2),   it is still a highly useful and reliable measure of  phonemic awareness (as one of many precursors to reading fluency success).  This is especially because after the initial directions are given, the student is expected to remember to isolate the initial sounds in words without any prompting from the examiner.  Thus,  this task also  indirectly tests the students’ executive function abilities in addition to their phonemic awareness skills.

TILLS-subtest-3-story-retelling

3. The Story Retelling (SR) subtest (description above) requires students to do just that retell a story. Be mindful of the fact that the presented stories have reduced complexity. Thus, unless the students possess  significant retelling deficits, the above subtest  may not capture their true retelling abilities. Recommendation:  Consider supplementing this subtest  with informal narrative measures. For younger children (kindergarten and first grade) I recommend using wordless picture books to perform a dynamic assessment of their retelling abilities following a clinician’s narrative model (e.g., HERE).  For early elementary aged children (grades 2 and up), I recommend using picture books, which are first read to and then retold by the students with the benefit of pictorial but not written support. Finally, for upper elementary aged children (grades 4 and up), it may be helpful for the students to retell a book or a movie seen recently (or liked significantly) by them without the benefit of visual support all together (e.g., HERE).

TILLS-subtest-4-nonword-repetition

4. The Nonword Repetition (NR) subtest (description above) requires students to repeat nonsense words of increasing length and complexity. Weaknesses in the area of nonword repetition have consistently been associated with language impairments and learning disabilities due to the task’s heavy reliance on phonological segmentation as well as phonological and lexical knowledge (Leclercq, Maillart, Majerus, 2013). Thus, both monolingual and simultaneously bilingual children with language and literacy impairments will be observed to present with patterns of segment substitutions (subtle substitutions of sounds and syllables in presented nonsense words) as well as segment deletions of nonword sequences more than 2-3 or 3-4 syllables in length (depending on the child’s age).

TILLS-subtest-5-nonword-spelling

5. The Nonword Spelling (NS) subtest (description above) requires the students to spell nonwords from the Nonword Repetition (NR) subtest. Consequently, the Nonword Repetition (NR) subtest needs to be administered prior to the administration of this subtest in the same assessment session.  In contrast to the real-word spelling tasks,  students cannot memorize the spelling  of the presented words,  which are still bound by  orthographic and phonotactic constraints of the English language.   While this is a highly useful subtest,  is important to note that simultaneously bilingual children may present with decreased scores due to vowel errors.   Consequently,  it is important to analyze subtest results in order to determine whether dialectal differences rather than a presence of an actual disorder is responsible for the error patterns.

TILLS-subtest-6-listening-comprehension

6. The  Listening Comprehension (LC) subtest (description above) requires the students to listen to short stories  and then definitively answer story questions via available answer choices, which include: “Yes”, “No’, and “Maybe”. This subtest also indirectly measures the students’ metalinguistic awareness skills as they are needed to detect when the text does not provide sufficient information to answer a particular question definitively (e.g., “Maybe” response may be called for).  Be mindful of the fact that because the students are not expected to provide sentential responses  to questions it may be important to supplement subtest administration with another listening comprehension assessment. Tests such as the Listening Comprehension Test-2 (LCT-2), the Listening Comprehension Test-Adolescent (LCT-A),  or the Executive Function Test-Elementary (EFT-E)  may be useful  if  language processing and listening comprehension deficits are suspected or reported by parents or teachers. This is particularly important  to do with students who may be ‘good guessers’ but who are also reported to present with word-finding difficulties at sentence and discourse levels. 

TILLS-subtest-7-reading-comprehension

7. The Reading Comprehension (RC) subtest (description above) requires the students to  read short story and answer story questions in “Yes”, “No’, and “Maybe”  format.   This subtest is not stand alone and must be administered immediately following the administration the Listening Comprehension subtest. The student is asked to read the first story out loud in order to determine whether s/he can proceed with taking this subtest or discontinue due to being an emergent reader. The criterion for administration of the subtest is making 7 errors during the reading of the first story and its accompanying questions. Unfortunately,  in my clinical experience this subtest  is not always accurate at identifying children with reading-based deficits.

While I find it terrific for students with severe-profound reading deficits and/or below average IQ, a number of my students with average IQ and moderately impaired reading skills managed to pass it via a combination of guessing and luck despite being observed to misread aloud between 40-60% of the presented words. Be mindful of the fact that typically  such students may have up to 5-6  errors during the reading of the first story. Thus, according to administration guidelines these students will be allowed to proceed and take this subtest.  They will then continue to make text misreadings  during each story presentation (you will know that by asking them to read each story aloud vs. silently).   However,  because the response mode is in definitive (“Yes”, “No’, and “Maybe”) vs. open ended question format,  a number of these students  will earn average scores by being successful guessers. Recommendation:  I highly recommend supplementing the administration of this subtest with grade level (or below grade level) texts (see HERE and/or HERE),  to assess the student’s reading comprehension informally.

I present a full  one page text to the students and ask them to read it to me in its entirety.   I audio/video record  the student’s reading for further analysis (see Reading Fluency section below).   After the  completion of the story I ask  the student questions with a focus on main idea comprehension and vocabulary definitions.   I also ask questions pertaining to story details.   Depending on the student’s age  I may ask them  abstract/ factual text questions with and without text access.  Overall, I find that informal administration of grade level (or even below grade-level) texts coupled with the administration of standardized reading tests provides me with a significantly better understanding of the student’s reading comprehension abilities rather than administration of standardized reading tests alone.

TILLS-subtest-8-following-directions

8. The Following Directions (FD) subtest (description above) measures the student’s ability to execute directions of increasing length and complexity.  It measures the student’s short-term, immediate and working memory, as well as their language comprehension.  What is interesting about the administration of this subtest is that the graphic symbols (e.g., objects, shapes, letter and numbers etc.) the student is asked to modify remain covered as the instructions are given (to prevent visual rehearsal). After being presented with the oral instruction the students are expected to move the card covering the stimuli and then to executive the visual-spatial, directional, sequential, and logical if–then the instructions  by marking them on the response form.  The fact that the visual stimuli remains covered until the last moment increases the demands on the student’s memory and comprehension.  The subtest was created to simulate teacher’s use of procedural language (giving directions) in classroom setting (as per developers).

TILLS-subtest-9-delayed-story-retelling

9. The Delayed Story Retelling (DSR) subtest (description above) needs to be administered to the students during the same session as the Story Retelling (SR) subtest, approximately 20 minutes after the SR subtest administration.  Despite the relatively short passage of time between both subtests, it is considered to be a measure of long-term memory as related to narrative retelling of reduced complexity. Here, the examiner can compare student’s performance to determine whether the student did better or worse on either of these measures (e.g., recalled more information after a period of time passed vs. immediately after being read the story).  However, as mentioned previously, some students may recall this previously presented story fairly accurately and as a result may obtain an average score despite a history of teacher/parent reported  long-term memory limitations.  Consequently, it may be important for the examiner to supplement the administration of this subtest with a recall of a movie/book recently seen/read by the student (a few days ago) in order to compare both performances and note any weaknesses/limitations.

TILLS-subtest-10-nonword-reading

10. The Nonword Reading (NR) subtest (description above) requires students to decode nonsense words of increasing length and complexity. What I love about this subtest is that the students are unable to effectively guess words (as many tend to routinely do when presented with real words). Consequently, the presentation of this subtest will tease out which students have good letter/sound correspondence abilities as well as solid orthographic, morphological and phonological awareness skills and which ones only memorized sight words and are now having difficulty decoding unfamiliar words as a result.      TILLS-subtest-11-reading-fluency

11. The Reading Fluency (RF) subtest (description above) requires students to efficiently read facts which make up simple stories fluently and correctly.  Here are the key to attaining an average score is accuracy and automaticity.  In contrast to the previous subtest, the words are now presented in meaningful simple syntactic contexts.

It is important to note that the Reading Fluency subtest of the TILLS has a negatively skewed distribution. As per authors, “a large number of typically developing students do extremely well on this subtest and a much smaller number of students do quite poorly.”

Thus, “the mean is to the left of the mode” (see publisher’s image below). This is why a student could earn an average standard score (near the mean) and a low percentile rank when true percentiles are used rather than NCE percentiles (Normal Curve Equivalent). Tills Q&A – Negative Skew

Consequently under certain conditions (See HERE) the percentile rank (vs. the NCE percentile) will be a more accurate representation of the student’s ability on this subtest.

Indeed, due to the reduced complexity of the presented words some students (especially younger elementary aged) may obtain average scores and still present with serious reading fluency deficits.  

I frequently see that in students with average IQ and go to long-term memory, who by second and third grades have managed to memorize an admirable number of sight words due to which their deficits in the areas of reading appeared to be minimized.  Recommendation: If you suspect that your student belongs to the above category I highly recommend supplementing this subtest with an informal measure of reading fluency.  This can be done by presenting to the student a grade level text (I find science and social studies texts particularly useful for this purpose) and asking them to read several paragraphs from it (see HERE and/or HERE).

As the students are reading  I calculate their reading fluency by counting the number of words they read per minute.  I find it very useful as it allows me to better understand their reading profile (e.g, fast/inaccurate reader, slow/inaccurate reader, slow accurate reader, fast/accurate reader).   As the student is reading I note their pauses, misreadings, word-attack skills and the like. Then, I write a summary comparing the students reading fluency on both standardized and informal assessment measures in order to document students strengths and limitations.

TILLS-subtest-12-written-expression

12. The Written Expression (WE) subtest (description above) needs to be administered to the students immediately after the administration of the Reading Fluency (RF) subtest because the student is expected to integrate a series of facts presented in the RF subtest into their writing sample. There are 4 stories in total for the 4 different age groups.

The examiner needs to show the student a different story which integrates simple facts into a coherent narrative. After the examiner reads that simple story to the students s/he is expected to tell the students that the story is  okay, but “sounds kind of “choppy.” They then need to show the student an example of how they could put the facts together in a way that sounds more interesting and less choppy  by combining sentences (see below). Finally, the examiner will ask the students to rewrite the story presented to them in a similar manner (e.g, “less choppy and more interesting.”)

tills

After the student finishes his/her story, the examiner will analyze it and generate the following scores: a discourse score, a sentence score, and a word score. Detailed instructions as well as the Examiner’s Practice Workbook are provided to assist with scoring as it takes a bit of training as well as trial and error to complete it, especially if the examiners are not familiar with certain procedures (e.g., calculating T-units).

Full disclosure: Because the above subtest is still essentially sentence combining, I have only used this subtest a handful of times with my students. Typically when I’ve used it in the past, most of my students fell in two categories: those who failed it completely by either copying text word  for word, failing to generate any written output etc. or those who passed it with flying colors but still presented with notable written output deficits. Consequently, I’ve replaced Written Expression subtest administration with the administration of written standardized tests, which I supplement with an informal grade level expository, persuasive, or narrative writing samples.

Having said that many clinicians may not have the access to other standardized written assessments, or lack the time to administer entire standardized written measures (which may frequently take between 60 to 90 minutes of administration time). Consequently, in the absence of other standardized writing assessments, this subtest can be effectively used to gauge the student’s basic writing abilities, and if needed effectively supplemented by informal writing measures (mentioned above).

TILLS-subtest-13-social-communication

13. The Social Communication (SC) subtest (description above) assesses the students’ ability to understand vocabulary associated with communicative intentions in social situations. It requires students to comprehend how people with certain characteristics might respond in social situations by formulating responses which fit the social contexts of those situations. Essentially students become actors who need to act out particular scenes while viewing select words presented to them.

Full disclosure: Similar to my infrequent administration of the Written Expression subtest, I have also administered this subtest very infrequently to students.  Here is why.

I am an SLP who works full-time in a psychiatric hospital with children diagnosed with significant psychiatric impairments and concomitant language and literacy deficits.  As a result, a significant portion of my job involves comprehensive social communication assessments to catalog my students’ significant deficits in this area. Yet, past administration of this subtest showed me that number of my students can pass this subtest quite easily despite presenting with notable and easily evidenced social communication deficits. Consequently, I prefer the administration of comprehensive social communication testing when working with children in my hospital based program or in my private practice, where I perform independent comprehensive evaluations of language and literacy (IEEs).

Again, as I’ve previously mentioned many clinicians may not have the access to other standardized social communication assessments, or lack the time to administer entire standardized written measures. Consequently, in the absence of other social communication assessments, this subtest can be used to get a baseline of the student’s basic social communication abilities, and then be supplemented with informal social communication measures such as the Informal Social Thinking Dynamic Assessment Protocol (ISTDAP) or observational social pragmatic checklists. 

TILLS-subtest-14-digit-span-forward

14.  The Digit Span Forward (DSF) subtest (description above) is a relatively isolated  measure  of short term and verbal working memory ( it minimizes demands on other aspects of language such as syntax or vocabulary).

TILLS-subtest-15-digit-span-backward

15.  The Digit Span Backward (DSB) subtest (description above) assesses the student’s working memory and requires the student to mentally manipulate the presented stimuli in reverse order. It allows examiner to observe the strategies (e.g. verbal rehearsal, visual imagery, etc.) the students are using to aid themselves in the process.  Please note that the Digit Span Forward subtest must be administered immediately before the administration of this subtest.

SLPs who have used tests such as the Clinical Evaluation of Language Fundamentals – 5 (CELF-5) or the Test of Auditory Processing Skills – Third Edition (TAPS-3) should be highly familiar with both subtests as they are fairly standard measures of certain aspects of memory across the board.

To continue, in addition to the presence of subtests which assess the students literacy abilities, the TILLS also possesses a number of interesting features.

For starters, the TILLS Easy Score, which allows the examiners to use their scoring online. It is incredibly easy and effective. After clicking on the link and filling out the preliminary demographic information, all the examiner needs to do is to plug in this subtest raw scores, the system does the rest. After the raw scores are plugged in, the system will generate a PDF document with all the data which includes (but is not limited to) standard scores, percentile ranks, as well as a variety of composite and core scores. The examiner can then save the PDF on their device (laptop, PC, tablet etc.) for further analysis.

The there is the quadrant model. According to the TILLS sampler (HERE)  “it allows the examiners to assess and compare students’ language-literacy skills at the sound/word level and the sentence/ discourse level across the four oral and written modalities—listening, speaking, reading, and writing” and then create “meaningful profiles of oral and written language skills that will help you understand the strengths and needs of individual students and communicate about them in a meaningful way with teachers, parents, and students. (pg. 21)”

tills quadrant model

Then there is the Student Language Scale (SLS) which is a one page checklist parents,  teachers (and even students) can fill out to informally identify language and literacy based strengths and weaknesses. It  allows for meaningful input from multiple sources regarding the students performance (as per IDEA 2004) and can be used not just with TILLS but with other tests or in even isolation (as per developers).

Furthermore according to the developers, because the normative sample included several special needs populations, the TILLS can be used with students diagnosed with ASD,  deaf or hard of hearing (see caveat), as well as intellectual disabilities (as long as they are functioning age 6 and above developmentally).

According to the developers the TILLS is aligned with Common Core Standards and can be administered as frequently as two times a year for progress monitoring (min of 6 mos post 1st administration).

With respect to bilingualism examiners can use it with caution with simultaneous English learners but not with sequential English learners (see further explanations HERE).   Translations of TILLS are definitely not allowed as they will undermine test validity and reliability.

So there you have it these are just some of my very few impressions regarding this test.  Now to some of you may notice that I spend a significant amount of time pointing out some of the tests limitations. However, it is very important to note that we have research that indicates that there is no such thing as a “perfect standardized test” (see HERE for more information).   All standardized tests have their limitations. 

Having said that, I think that TILLS is a PHENOMENAL addition to the standardized testing market, as it TRULY appears to assess not just language but also literacy abilities of the students on our caseloads.

That’s all from me; however, before signing off I’d like to provide you with more resources and information, which can be reviewed in reference to TILLS.  For starters, take a look at Brookes Publishing TILLS resources.  These include (but are not limited to) TILLS FAQ, TILLS Easy-Score, TILLS Correction Document, as well as 3 FREE TILLS Webinars.   There’s also a Facebook Page dedicated exclusively to TILLS updates (HERE).

But that’s not all. Dr. Nelson and her colleagues have been tirelessly lecturing about the TILLS for a number of years, and many of their past lectures and presentations are available on the ASHA website as well as on the web (e.g., HERE, HERE, HERE, etc). Take a look at them as they contain far more in-depth information regarding the development and implementation of this groundbreaking assessment.

To access TILLS fully-editable template, click HERE

Disclaimer:  I did not receive a complimentary copy of this assessment for review nor have I received any encouragement or compensation from either Brookes Publishing  or any of the TILLS developers to write it.  All images of this test are direct property of Brookes Publishing (when clicked on all the images direct the user to the Brookes Publishing website) and were used in this post for illustrative purposes only.

References: 

Leclercq A, Maillart C, Majerus S. (2013) Nonword repetition problems in children with SLI: A deficit in accessing long-term linguistic representations? Topics in Language Disorders. 33 (3) 238-254.

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What Research Shows About the Functional Relevance of Standardized Language Tests

Image result for standardized language testsAs an SLP who routinely conducts speech and language assessments in several settings (e.g., school and private practice), I understand the utility of and the need for standardized speech, language, and literacy tests.  However, as an SLP who works with children with dramatically varying degree of cognition, abilities, and skill-sets, I also highly value supplementing these standardized tests with functional and dynamic assessments, interactions, and observations.

Since a significant value is placed on standardized testing by both schools and insurance companies for the purposes of service provision and reimbursement, I wanted to summarize in today’s post the findings of recent articles on this topic.  Since my primary interest lies in assessing and treating school-age children, for the purposes of today’s post all of the reviewed articles came directly from the Language Speech and Hearing Services in Schools  (LSHSS) journal.

We’ve all been there. We’ve all had situations in which students scored on the low end of normal, or had a few subtest scores in the below average range, which equaled  an average total score.  We’ve all poured over eligibility requirements trying to figure out whether the student should receive therapy services given the stringent standardized testing criteria in some states/districts.

Of course, as it turns out, the answer is never simple.  In 2006, Spaulding, Plante & Farinella set out to examine the assumption: “that children with language impairment will receive low scores on standardized tests, and therefore [those] low scores will accurately identify these children” (61).   So they analyzed the data from 43 commercially available child language tests to identify whether evidence exists to support their use in identifying language impairment in children.

Turns out it did not!  Turns out due to the variation in psychometric properties of various tests (see article for specific details), 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 (69).”

Consequently, they created a decision tree (see below) with recommendations for clinicians using standardized testing. They recommend using alternate sources of data (sensitivity and specificity rates) to support accurate identification (available for a small subset of select tests).

The idea behind it is: “if sensitivity and specificity data are strong, and these data were derived from subjects who are comparable to the child tested, then the clinician can be relatively confident in relying on the test score data to aid his or her diagnostic decision. However, if the data are weak, then more caution is warranted and other sources of information on the child’s status might have primacy in making a diagnosis (70).”

Fast forward 6 years, and a number of newly revised tests later,  in 2012, Spaulding and colleagues set out to “identify various U.S. state education departments’ criteria for determining the severity of language impairment in children, with particular focus on the use of norm-referenced tests” as well as to “determine if norm-referenced tests of child language were developed for the purpose of identifying the severity of children’s language impairment”  (176).

They obtained published procedures for severity determinations from available U.S. state education departments, which specified the use of norm-referenced tests, and reviewed the manuals for 45 norm-referenced tests of child language to determine if each test was designed to identify the degree of a child’s language impairment.

What they found out was “the degree of use and cutoff-point criteria for severity determination varied across states. No cutoff-point criteria aligned with the severity cutoff points described within the test manuals. Furthermore, tests that included severity information lacked empirical data on how the severity categories were derived (176).”

Thus they urged SLPs to exercise caution in determining the severity of children’s language impairment via norm-referenced test performance “given the inconsistency in guidelines and lack of empirical data within test manuals to support this use (176)”.

Following the publication of this article, Ireland, Hall-Mills & Millikin issued a response to the  Spaulding and colleagues article. They pointed out that the “severity of language impairment is only one piece of information considered by a team for the determination of eligibility for special education and related services”.  They noted that  they left out a host of federal and state guideline requirements and “did not provide an analysis of the regulations governing special education evaluation and criteria for determining eligibility (320).” They pointed out that “IDEA prohibits the use of ‘any single measure or assessment as the sole criterion’ for determination of disability  and requires that IEP teams ‘draw upon information from a variety of sources.”

They listed a variety of examples from several different state departments of education (FL, NC, VA, etc.), which mandate the use of functional assessments, dynamic assessments criterion-referenced assessments, etc. for their determination of language therapy eligibility.

But are the SLPs from across the country appropriately using the federal and state guidelines in order to determine eligibility? While one should certainly hope so, it does not always seem to be the case.  To illustrate, in 2012, Betz & colleagues asked 364 SLPs to complete a survey “regarding how frequently they used specific standardized tests when diagnosing suspected specific language impairment (SLI) (133).”

Their purpose was to determine “whether the quality of standardized tests, as measured by the test’s psychometric properties, is related to how frequently the tests are used in clinical practice” (133).

What they found out was 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. Furthermore, the date of publication seemed to be the only factor which affected the frequency of test selection.

They also found out 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.  They were understandably puzzled by that finding. “The emphasis placed on vocabulary measures is intriguing because although vocabulary is often a weakness in children with SLI (e.g., Stothard et al., 1998), the research to date does not show vocabulary to be more impaired than other language domains in children with SLI (140).“

According to the authors, “perhaps the most discouraging finding of this study was the lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores (141).”

If since the time (2012) SLPs have not significantly change their practices, the above is certainly disheartening, as it implies that rather than being true diagnosticians, SLPs are using whatever is at hand that has been purchased by their department to indiscriminately assess students with suspected speech language disorders. If that is truly the case, it certainly places into question the Ireland, Hall-Mills & Millikin’s response to Spaulding and colleagues.  In other words, though SLPs are aware that they need to comply with state and federal regulations when it comes to unbiased and targeted assessments of children with suspected language disorders, they may not actually be using appropriate standardized testing much less supplementary informal assessments (e.g., dynamic, narrative, language sampling) in order to administer well-rounded assessments.  

So where do we go from here? Well, it’s quite simple really!   We already know what the problem is. Based on the above articles we know that:

  1. Standardized tests possess significant limitations
  2. They are not used with optimal effectiveness by many SLPs
  3.  They may not be frequently supplemented by relevant and targeted informal assessment measures in order to improve the accuracy of disorder determination and subsequent therapy eligibility

Now that we have identified a problem, we need to develop and consistently implement effective practices to ameliorate it.  These include researching psychometric properties of tests to review sample size, sensitivity and specificity, etc, use domain specific assessments to supplement administration of comprehensive testing, as well as supplement standardized testing with a plethora of functional assessments.

SLPs can review testing manuals and consult with colleagues when they feel that the standardized testing is underidentifying students with language impairments (e.g., HERE and HERE).  They can utilize referral checklists (e.g., HERE) in order to pinpoint the students’ most significant difficulties. Finally, they can develop and consistently implement informal assessment practices (e.g., HERE and HERE) during testing in order to gain a better grasp on their students’ TRUE linguistic functioning.

Stay tuned for the second portion of this post entitled: “What Research Shows About the Functional Relevance of Standardized Speech Tests?” to find out the best practices in the assessment of speech sound disorders in children.

References:

  1. Spaulding, Plante & Farinella (2006) Eligibility Criteria for Language Impairment: Is the Low End of Normal Always Appropriate?
  2. Spaulding, Szulga, & Figueria (2012) Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers
  3. Ireland, Hall-Mills & Millikin (2012) Appropriate Implementation of Severity Ratings, Regulations, and State Guidance: A Response to “Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers” by Spaulding, Szulga, & Figueria (2012)
  4. Betz et al. (2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment

 

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Teaching Metalinguistic Vocabulary for Reading Success

In my therapy sessions I spend a significant amount of time improving literacy skills (reading, spelling, and writing) of language impaired students.  In my work with these students I emphasize goals with a focus on phonics, phonological awareness, encoding (spelling) etc. However, what I have frequently observed in my sessions are significant gaps in the students’ foundational knowledge pertaining to the basics of sound production and letter recognition.  Basic examples of these foundational deficiencies involve students not being able to fluently name the letters of the alphabet, understand the difference between vowels and consonants, or fluently engage in sound/letter correspondence tasks (e.g., name a letter and then quickly and accurately identify which sound it makes).  Consequently, a significant portion of my sessions involves explicit instruction of the above concepts.

This got me thinking regarding my students’ vocabulary knowledge in general.  We, SLPs, spend a significant amount of time on explicit and systematic vocabulary instruction with our students because as compared to typically developing peers, they have immature and limited vocabulary knowledge. But do we teach our students the abstract vocabulary necessary for reading success? Do we explicitly teach them definitions of a letter, a word, a sentence? etc.

A number of my colleagues are skeptical. “Our students already have poor comprehension”, they tell me, “Why should we tax their memory with abstract words of little meaning to them?”  And I agree with them of course, but up to a point.

I agree that our students have working memory and processing speed deficits as a result of which they have a much harder time learning and recalling new words.

However, I believe that not teaching them meanings of select words pertaining to language is a huge disservice to them. Here is why. To be a successful communicator, speaker, reader, and writer, individuals need to possess adequate metalinguistic skills.

In simple terms “metalinguistics” refers to the individual’s ability to actively think about, talk about, and manipulate language. Reading, writing, and spelling require active level awareness and thought about language. Students with poor metalinguistic skills have difficulty learning to read, write, and spell.  They lack awareness that spoken words are made up of individual units of sound, which can be manipulated. They lack awareness that letters form words, words form phrases and sentences, and sentences form paragraphs. They may not understand that letters make sounds or that a word may consist of more letters than sounds (e.g., /ship/). The bottom line is that students with decreased metalinguistic skills cannot effectively use language to talk about concepts like sounds, letters, or words unless they are explicitly taught those abilities.

So I do! Furthermore, I can tell you that explicit instruction of metalinguistic vocabulary does significantly improve my students understanding of the tasks involved in obtaining literacy competence. Even my students with mild to moderate intellectual disabilities significantly benefit from understanding the meanings of: letters, words, sentences, etc.

I even created a basic abstract vocabulary handout to facilitate my students comprehension of these words (FREE HERE). While by no means exhaustive, it is a decent starting point for teaching my students the vocabulary needed to improve their metalinguistic skills.

For older elementary aged students with average IQ, I only provide the words I want them to define, and then ask them to look up their meanings online via the usage of PC or an iPad. This turns of vocabulary activity into a critical thinking and an executive functions task.

Students need to figure out the appropriate search string needed to in order to locate the answer as well as which definition comes the closest to clearly and effectively defining the presented word. One of the things I really like about Google online dictionary, is that it provides multiple definitions of the same words along with word origins. As a result, it teaches students to carefully review and reflect upon their selected definition in order to determine its appropriateness.

A word of caution as though regarding using Kiddle, Google-powered search engine for children. While it’s great for locating child friendly images, it is not appropriate for locating abstract definition of words. To illustrate, when you type in the string search into Google, “what is the definition of a letter?” You will get several responses which will appropriately match  some meanings of your query.  However the same string search in Kiddle, will merely yield helpful tips on writing a letter as well as images of envelopes with stamps affixed to them.

In contrast to the above, I use a more structured vocabulary defining activities for younger elementary age students as well as students with intellectual impairments. I provide simple definitions of abstract words, attach images and examples to each definition as well as create cloze activities and several choices of answers in order to ensure my students’ comprehension of these words.

I find that this and other metalinguistic activities significantly improve my students comprehension of abstract words such as ‘communication’, ‘language’, as well as ‘literacy’. They cease being mere buzzwords, frequently heard yet consistently not understood.  To my students these words begin to come to life, brim with meaning, and inspire numerous ‘aha’ moments.

Now that you’ve had a glimpse of my therapy sessions I’d love to have a glimpse of yours. What metalinguistic goals related to literacy are you targeting with your students? Comment below to let me know.

 

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Assessing Behaviorally Impaired Students: Why Background History Matters!

As a speech language pathologist (SLP) who works in an outpatient psychiatric school-based setting, I frequently review incoming students previous speech language evaluation reports.  There are a number of trends I see in these reports which I have written about in the past as well as planned on writing about in the future.

For example, in the past I wrote about my concern regarding the lack of adequate or even cursory social communication assessments for students with documented psychiatric impairments and emotional behavioral deficits.

This leads many professionals to do the following: 

a. Miss vital assessment elements which denies students appropriate school based services and

b. Assume that the displayed behavioral challenges are mere results of misbehaving. 

Today however I wanted express my thoughts regarding another disturbing trend I see in numerous incoming speech-language reports in both outpatient school/hospital setting as well as in private practice  – and that is lack of background information in the students assessment reports.

Despite its key role in assessment, this section is frequently left bare. Most of the time it contains only the information regarding the students age and grade levels as well as the reasons for the referral (e.g., initial evaluation, triennial evaluation).  Some of the better reports will include cursory mention of the student’s developmental milestones but most of the time information will be sorely lacking.

Clearly this problem is not just prevalent in my incoming assessment reports. I frequently see manifestations of it in a variety of speech pathology related social media forums such as Facebook. Someone will pose a question regarding how to distinguish a _____ from ____ (e.g., language difference vs. language disorder, behavioral noncompliance vs. social communication deficits, etc.) yet when they’re questioned further many SLPs will admit that they are lacking any/most information regarding the students background history.

When questioned regarding the lack of this information, many SLPs get defensive. They cite a variety of reasons such as lack of parental involvement (“I can’t reach the parents”), lack of access to records (“it’s a privacy issue”), division of labor (e.g., “it’s the social worker’s responsibility and not mine to obtain this information”) as well as other justifications why this information is lacking.

Now, I don’t know about you, but one of my earliest memories of the ‘diagnostics’ class in graduate school involved collecting data and writing comprehensive ‘Background Information’ section of the report. I still remember multiple professors imparting upon me the vital importance is this section plays in the student’s evaluation report.

Indeed, many years later, I clearly see its vital role in assessment. Unearthing the student’s family history, developmental milestones, medical/surgical history, as well as history of past therapies is frequently the key to a successful diagnosis and appropriate provision of therapy services.  This is the information that frequently plays a vital role in subsequent referrals of “mystery” cases to relevant health professionals as well as often leads to resolution of particularly complicated diagnostic puzzles.

Of course I understand that frequently there are legitimate barriers to obtaining this information.  However, I also know that if one digs deep enough one will frequently find the information they’re seeking despite the barriers. To illustrate, at the psychiatric hospital level where I work,  I frequently encounter a number of barriers to accessing the student’s background information during the assessment process. This may include parental language/education barrier, parental absence, Division of Child Protective Services involvement,  etc.  Yet I always try to ensure that my reports contain all the background information that I’m able to unearth because I know how vitally important it is for the student in question.

In the past I have been able to use the student’s background information to make important discoveries, which were otherwise missed by other health professionals. This included undocumented history of traumatic brain injuries, history of language and literacy disabilities in the family, history of genetic disorders and/or intellectual disabilities in the family, history of maternal alcohol abuse during pregnancy, and much much more.

So what do I consider to be an adequate Background History section of the assessment report?

For starters, the basics, of course.

I begin by stating the child’s age and grade levels, who referred the child (and for what reason), as well as whether the child previously received any form of speech language assessment/therapy services in the past.

If I am preforming a reassessment (especially if it happens shortly after the last assessment took place) I provide a clear justification why the present reassessment is taking place. Here is an actual excerpt from one of my reevaluation reports. “Despite receiving average language scores on his _______ speech language testing which resulted in the  recommendation for speech therapy only, upon his admission to ______, student was referred for a language reassessment in _____, by the classroom staff who expressed significant concerns regarding validity and reliability of past speech and language testing on the ground of the student’s persistent “obvious” listening comprehension and verbal expression deficits.”

For those of you in need of further justification I’ve created a brief list of reasons why a reassessment, closely following recent testing may be needed.

  1. SLP/Parent feels additional testing is needed to create comprehensive goals for child.
  2. Previous testing was inadequate. Here it’s very important to provide comprehensive rationale  and list the reasons for it.
  3. A reevaluation was requested due to third party  concerns (e.g., psychiatrist, psychologist, etc.)

Secondly, it is important to document all relevant medical history, which includes: prenatal, perinatal, and early childhood diseases, surgical interventions and incidents. It is important to note that if a child has a long standing history of documented psychiatric difficulties, you may want to separate these sections and describe psychiatric history/diagnoses following the section that details the onset of the child’s emotional and behavioral deficits.

Let us now move on to the child’s developmental history, which should include, gross/fine motor, speech/ language milestones, and well as cognitive and socioemotional functioning.  This is a section where I typically add information regarding any early intervention services which may have been provided to the child prior to the age of three.

In my next section I discuss the child’s academic functioning to date. Here I mention whether the student qualified for a preschool disabled eligibility category and received services from the age of 3+.  I also discuss their educational classification (if one exists), briefly mention the results of previous most recent cognitive and educational testing (if available) as well as mention any academic struggles (if applicable).

After that I move on to the child’s psychiatric history. I briefly document when did the emotional behavioral problems first arose, and what had been done about them to date (out of district placements, variety of psychiatric services, etc.)  Here I also document  the student’s most recent psychiatric diagnoses (if available) and mention any medication they may be currently on (applicable due to the effect of psychiatric medications on language and memory skills).

The following section is perhaps the most important one in the  report. It is the family’s history of genetic disorders, psychiatric impairments, special education placements, as well as language, learning, and literacy deficits.  This section plays a vital importance in my determination of the contributions to the student’s language difficulties as well as guides my assessment recommendations in the presence of borderline assessment results.

I finish this section by briefly discussing the student’s Family Composition as well as Language Knowledge and Use.

I discuss family composition due to several factors.  For example, lack of consistent caregivers, prolonged absence of parental figures, as well as presence of a variety of people in the home can serve as significant stressor for children with psychiatric impairments and learning difficulties.  As a result of this information is pertinent to the report especially when it comes to figuring out the antecedents for the child’s behavior fluctuation on daily basis.

Language knowledge and use  is particularly relevant to culturally and linguistically diverse children. It is very important to understand what languages does the child understand and use at home and at school as well as what do the parents think about the child’s language abilities in both languages. These factors will guide my decision making process regarding what type of assessments would be most relevant for this child.

So there you have it.  This is the information I include in the background history section of every single one of my reports.  I believe that this information contributes to the making of the appropriate and accurate diagnosis of the child’s difficulties.

Please don’t get me wrong. This information is hugely relevant for all students that we SLPs are assessing.

However, the above is especially relevant for such vulnerable populations as children with emotional and behavioral disturbances, whose struggle with social communication is frequently misinterpreted as “it’s just behavior“. As a result, they are frequently denied social communication therapy services, which ultimately leads to denial of Free Appropriate Public Education (FAPE) that they are entitled to.

Let us ensure that this does not happen by doing all that we can to endure that the student receives a fair assessment, correct diagnosis, and can have access to the best classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.  And the first step of that process begins with obtaining a detailed background history!

Helpful Resources: 

 

 

 

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What’s Memes Got To Do With It?

Today, after a long hiatus, I am continuing my series of blog posts on “Scholars Who do Not Receive Enough Mainstream Exposure” by summarizing select key points from Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“.

Some of you may be wondering: “Why is she reviewing an article that is more than a decade old? The answer is simple.  It is just as relevant, if not more so today, as it was 12 years ago, when it first came out.

In this article, Dr. Kamhi, asks a provocative question: “Why do some terms, labels, ideas, and constructs [in the field of speech pathology] prevail whereas others fail to gain acceptance?“

He attempts to answer this question by explaining the vital role the concept of memes play in the evolution and spread of ideas.

—A meme (shortened from the Greek mimeme to imitate) is “an idea, behavior, or style that spreads from person to person within a culture”. The term was originally coined by British evolutionary biologist Richard Dawkins in The Selfish Gene (1976) to explain the spread of ideas and cultural phenomena such as tunes, ideas, catchphrases, customs, etc.

‘Selfish’ in this case means that memes “care only about their own self-replication“.  Consequently, “successful memes are those that get copied accurately (fidelity), have many copies (fecundity), and last a long time (longevity).” Therefore, “memes that are easy to understand, remember, and communicate to others” have the highest risk of survival and replication (pp. 105-106).

So what were some of the more successful memes which Dr. Kamhi identified in his article, which still persist more than a decade later?

  • Learning Disability
  • Auditory Processing Disorder
  • Sensory Integration Disorder
  • Dyslexia
  • Articulation disorder
  • Speech Therapist/ Pathologist

Interestingly the losers of the “contest” were memes that contained the word language in it:

  • Language disorder
  • Language learning disability
  • Speech-language pathologist (albeit this term has gained far more acceptance in the past decade)

Dr. Kamhi further asserts that ‘language-based disorders have failed to become a recognizable learning problem in the community at large‘ (p.106).

So why are labels with the words ‘language’ NOT successful memes?

According to Dr. Kamhi that is because “language-based disorders must be difficult to understand, remember, and communicate to others“. Professional (SLP) explanations of what constitutes language are lengthy and complex (e.g., ASHA’s comprehensive definition) and as a result are not frequently applied in clinical practice, even when its aspects are familiar to SLPs.

Some scholars have suggested that the common practice of evaluating language with standardized language tools, restricts full understanding of the interactions of all of its domains (“within larger sociocultural context“) because they only examine isolated aspects of language. (Apel, 1999)

Dr. Kamhi, in turn explains this within the construct of the memetic theory: namely “simple constructs are more likely to replicate than complex ones.” In other words: “even professionals who understand language may have difficulty communicating its meaning to others and applying this meaning to clinical practice” (p. 107).

Let’s talk about the parents who are interested in learning the root-cause of their child’s difficulty learning and using language.  Based on specific child’s genetic and developmental background as well as presenting difficulties, an educated clinician can explain to the parent the multifactorial nature of their child’s deficits.

However, these informed but frequently complex explanations are certainly in no way simplistic. As a result, many parents will still attempt to seek other professionals who can readily provide them with a “straightforward explanation” of their child’s difficulty.  Since parents are “ultimately interested in finding the most effective and efficient treatment for their children” it makes sense to believe/hope that “the professional who knows the cause of the problem will also know the most effective way to treat it“(p. 107).

This brings us back to the concept of successful memes such as Auditory Processing Disorder (C/APD) as well as Sensory Processing Disorder (SPD) as isolated diagnoses.

Here are just some of the reasons behind their success:

  • They provide a simple solution (which is not necessarily a correct one) that “the learning problem is the result of difficulty processing auditory information or difficulty integrating sensory information“.
  • The assumption is “improving auditory processing and sensory integration abilities” will improve learning difficulties
  • Both, “APD and SID each have only one cause“, so “finding an appropriate treatment …seems more feasible because there is only one problem to eliminate“
  • Gives parents “a sense of relief” that they finally have an “understandable explanation for what is wrong with their child“
  • Gives parents  hope that the “diagnosis will lead to successful remediation of the learning problem“

For more information on why APD and SPD are not valid stand-alone diagnoses please see HERE and HERE respectively.

A note on the lack of success of “phonological” memes:

  • They are difficult to understand and explain (especially due to a lack of consensus of what constitutes a phonological disorder)
  • Lack of familiarity with the term ‘phonological’ results in poor comprehension of “phonological bases of reading problems“ since its “much easier to associate reading with visual processing abilities, good instruction, and a literacy rich environment” (p. 108).

Let’s talk about MEMEPLEXES (Blackmore, 1999)  or what occurs when “nonprofessionals think they know how children learn language and the factors that affect language learning“ (Kamhi, 2004, p.108).

A memplex is a group of memes, which become much more memorable to individuals (can replicate more efficiently) as a team vs. in isolation.

Why is APD Memeplex So Appealing? 

According to Dr. Kamhi, if one believes that ‘a) sounds are the building blocks of speech and language and (b) children learn to talk by stringing together sounds and constructing meanings out of strings of sounds’ (both wrong assumptions) then its quite a simple leap to make with respect to the following fallacies:

  • Auditory processing are not influenced by language knowledge
  • You can reliably discriminate between APD and language deficits
  • You can validly and reliably assess “uncontaminated” auditory processing abilities and thus diagnose stand-alone APD
  • You can target auditory abilities in isolation without targeting language
  • Improvements in discrimination and identification of ‘speech sounds will lead to improvements in speech and language abilities‘

For more detailed information, why the above is incorrect, click: HERE

On the success of the Dyslexia Meme:

  • Most nonprofessionals view dyslexia as visually based “reading problem characterized by letter reversals and word transpositions that affects bright children and adults“
  • Its highly appealing due to the simple nature of its diagnosis (high intelligence and poor reading skills)
  • ‘The diagnosis of dyslexia has historically been made by physicians and psychologists rather than educators‘, which makes memetic replication highly successful
  • The ‘dyslexic’ label is far more appealing and desirable than calling self ‘reading disabled’

For more detailed information, why the above is far too simplistic of an explanation, click: HERE and HERE. 

Final Thoughts:

As humans we engage in transmission of  ideas (good and bad) on constant basis. The popularity of powerful social media tools such as Facebook and Twitter ensure their instantaneous and far reaching delivery and impact.  However, “our processing limitations, cultural biases, personal preferences, and human nature make us more susceptible to certain ideas than to others (p. 110).”

As professionals it is important that we use evidence based practices and the latest research to evaluate all claims pertaining to assessment and treatment of language based disorders. However, as Dr. Kamhi points out (p.110):

  • “Competing theories may be supported by different bodies of evidence, and the same evidence may be used to support competing theories.”
  • “Reaching a scientific consensus also takes time.”

While these delays may play a negligible role when it comes to scientific research, they pose a significant problem for parents, teachers and health professionals who are seeking to effectively assist these youngsters on daily basis. Furthermore, even when select memes such as APD are beneficial because they allow for a delivery of services to a student who may otherwise be ineligible to receive them, erroneous intervention recommendations (e.g., working on isolated auditory discrimination skills) may further delay the delivery of appropriate and targeted intervention services.

So what are SLPs to do in the presence of persistent erroneous memes?

“Spread our language-based memes to all who will listen” (Kamhi, 2004, 110) of course! Since we are the professionals whose job is to treat any difficulties involving words. Consequently, our scope of practice certainly includes assessment, diagnosis and treatment of children and adults with speaking, listening, reading, writing, and spelling difficulties.

As for myself, I intend to start that task right now by hitting the ‘publish’ button on this post!

I am a SLP

 References:

Kamhi, A. (2004). A meme’s eye view of speech-language pathology. [PDF] Language, Speech, and Hearing Services in Schools, 35, 105-112.