Dear SLPs, Don’t Base Your Language Intervention on Subtests Results

For years, I have been seeing a variation of the following questions from SLPs on social media on a weekly if not daily basis:

• “My student has slow processing/working memory and did poorly on the (insert standardized test here), what goals should I target?”
• “Do you have sample language/literacy goals for students who have the following subtest scores on the (insert standardized test here)?”
• “What goals should I create for my student who has the following subtest scores on the (insert standardized test here)?”

Let me be frank, these questions show a fundamental lack of understanding regarding the purpose of standardized tests, the knowledge of developmental norms for students of various ages, as well as how to effectively tailor and prioritize language intervention to the students’ needs.

So today, I wanted to address this subject from an evidence-based lens in order to assist SLPs with effective intervention planning with the consideration of testing results but not actually based on subtest results. So what do I mean by this seemingly confusing statement? Before I begin let us briefly discuss several highly common standardized assessment subtests:

• Word memory
• Sentence memory
• Nonword repetition
• Following directions
• Rapid digit/letter naming

We see students do poorly on these subtests on daily basis and as a result, numerous clinicians will create the following short-term intervention target goals:

• The student will increase auditory memory by repeating nonwords
• The student will follow directions of increased length and complexity
• The student will repeat sentences of increased length and complexity
• The student will rapidly name words based on semantic categories/beginning with a particular letter, etc.

Let’s pause for a minute and think about the above goals. Are they truly functional for generalization purposes? Will they actually result in functional academic outcomes of improved listening, speaking, reading, and writing? The answer is a resounding, “NO!”

All you are doing by targeting these goals is attempting to overload the student’s already restricted cognitive capacity with useless memorization tasks. By repetitively following the above goals, the students will indeed memorize something but that information will be stuck in their declarative memory and will never effectively generalize to functional academic outcomes. In other words, students will be able to execute these particular tasks in isolation but as time passes they will A. forget the information fairly quickly and B. will still not become better listeners, speakers, readers, and writers because the above goals are completely useless.

Research clearly indicates that one cannot improve processing speed and working memory (Melby-Lervåg, Redick, & Hulme, 2016) directly, but instead one needs to work indirectly on language, reading, spelling, and writing in order to improve both of these abilities for improved academic outcomes.

So then why do standardized tests assess the above abilities? The answer is because assessment of these areas is actually incredibly useful for disorder identification but these tasks DO NOT assess what you may think they assess. Let’s briefly take a look at what abilities certain assessment tasks actually target.

• Following directions tasks correlate with working memory functioning BUT are sensitive to reading deficits  (Lahey & Bloom, 1994; Cowan, 1996; Baddeley, 2003)
• Sentence recall is a useful indicator of learning difficulties including Developmental Language Disorder (DLD), dyslexia, phonological short-term memory deficits, as well as reading comprehension deficits (Alloway & Gathercole, 2005) 
• Nonword repetition is indicative of spoken and written deficits and reflects deficits in phonology and verbal short-term memory (Ramus et al, 2013; Gathercole & Baddeley, 1990; van der Lely and Howard, 1993; Montgomery, 1995; Gallon et al., 2007).
• Rapid Automatized Naming (RAN) has been found to be a consistent predictor of reading fluency in all orthographies (Landerl, et al, 2019). Poor rapid automatized naming abilities (on alphanumeric and nonalphanumeric tasks) have been found to be a long-term and universal symptom of reading deficits (Araújo & Faísca, 2019). 

As you can see from the above, not only is it not functional to target these goals in therapy but they also correlate with completely different skills than what was actually tested. That is why we cannot possibly create therapy goals based on subtest results, instead, we need to take into consideration developmental norms as well as students’ deficit areas in order to formulate thoughtful evidence-based assessment targets.

Now, no one is expected to remember in precise detail the developmental language expectations for various ages completely from memory. That is why I highly recommended several handy references where this information could be found. For example, the SLPs for Evidence-Based Practice group on Facebook has a post entitled Giant Milestones which contains numerous links to FREE milestone resources for a wide variety of ages. Similarly, the Common Core State Standards list academic expectations in the areas of reading and writing for grades K-12. Even your old college textbooks on Language Development from Infancy through Adolescence from various authors will have a lot of valuable tables summarizing pertinent information by age.

So now that we have addressed the first two points brought up in this post, how do we effectively prioritize intervention for our students based on testing results?

Firstly, look at the subjective severity of the student’s performance on standardized tests? Does the student display a mild degree of impairment or profound deficits? Are there any maintaining factors, which will further impede the student’s progress in therapy? According to (Klein, & Moses, 1999) these are factors that may maintain the disorder and delay therapy progress. They include:

• Cognitive
  • Intellectual Disability
  • Attention deficits
  • Memory deficits
  • Verbal reasoning deficits
• Sensorimotor
  • Impaired hearing
  • Impaired vision
  • Limited limb mobility
  • Poor handwriting
• Psychosocial
  • Psychiatric diagnoses
  • Pragmatic deficits
• Linguistic
  • Low vocabulary knowledge
  • Impaired sentence formulation
  • Poor story-telling abilities
  • Poor reading, writing, and, spelling

Clinicians must create thoughtful interventions accounting for the above maintaining factors in order to make progress with clients in therapy. These will include successful management of the physical space, session structure, students’ behavior as well as session materials in order to make academic progress.

But how do we prioritize therapy goals? Again we need to look at the student’s most significant areas of need to determine what needs to be addressed in therapy first.

First-grade student speaks in fragmented sentences? Addressing their syntax and grammar should be the top priority!

The student is illiterate in 5th grade? Then we need to work on their reading abilities since no amount of oral language input will produce the same learning effect as the steady acquisition of vocabulary and concepts from written texts as is received by the student’s literate age-level peers.

Twelve-grade student aces standardized tests but is significantly socially isolated, then thoughtfully designed neuroaffirming higher-order pragmatic intervention, will be hugely helpful for the student.

Finally, what evidence-based interventions will give you the most “bang for your buck”? Let’s take a look at what the research shows. For example, contextualized language intervention (CLI) is a treatment approach in which specific teaching steps are used to train multiple linguistic targets (Ukrainetz, 2006), with the key being – topic continuity across activities. Intervention emphasizes improving multiple areas of language at once (e.g., form, content, and use) through purposeful, functional activities in salient contexts that have a purpose beyond instructional objectives or generalization to other areas of academics  (Harris-Schmidt & McNamee, 1986; Gillam et al, 2012). Gillam, et al, 2012 found that contextualized language intervention resulted in larger effect sizes compared to decontextualized intervention. Instead of focusing only on short-term, situation-specific isolated intervention session skills, contextual interventions aim to accomplish long-term, situation-independent, generalizable skills learning (Kamhi, 2014). Targeting language in meaningful contexts increases saliency and allows the students to better integrate new information with what they already know (background knowledge), which in turn promotes deeper vs. shallow knowledge and greater retention of information. 

Hence, intervention with school-aged students should be contextually based and educationally relevant (Whitmire, 2002). Language and literacy cannot be artificially separated but need to be addressed meaningfully together in sessions. Integrating literacy into language goals shortens the time spent in therapy and improves outcomes. SLPs must target academic language goals which will produce a “robust and generalizable impact on educational outcomes”  (Kelley & Spencer 2021, p. 102). Targeting academic language in intervention “produces meaningful effects on academic performance” (Kelley & Spencer 2021, p. 102).

There you have it, some evidence-based recommendations on how you can create functional therapy goals based on assessment findings. And stay tuned for the second part of this post that will address aspects of academic language as well as identify relevant academic language targets for therapy purposes.

Helpful Smart Speech Therapy Resources:

• Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation
• Evidence-Based Use of Animated Films to Target Therapy Goals
• Evidence-Based Narrative Interventions via Use of Picture Books
• Improving Critical Thinking Skills via Picture Books in Children with Language Disorders
• From Wordless Picture Books to Reading Instruction: Effective Strategies for SLPs Working with Intellectually Impaired Students

References:

1. Alloway, T. P., & Gathercole, S. E. (2005). The role of sentence recall in reading and language skills of children with learning difficulties. Learning and Individual Differences, 15, 271–282.
2. Araújo, S &Faísca, L (2019) A Meta-Analytic Review of Naming-Speed Deficits in Developmental Dyslexia, Scientific Studies of Reading, 23:5, 349-368
3. Baddeley, A. (2003). Working memory and language: an overview. Journal of Communication Disorders, 36 (3), 189- 208.
4. Cowan, N. (1996, November). Short-term memory, working memory, and their importance in language processing. Topics in Language Disorders, 17(1), 1-18.
5. Dollaghan, C., & Campbell, T. F. (1998). Nonword repetition and child language impairment. Journal of Speech, Language, and Hearing Research, 41, 1136-1146.
6. Gallon N, Harris J, van der Lely HK (2007) Non-word repetition: an investigation of phonological complexity in children with Grammatical SLI. Clinical Linguistics and Phonetics 21: 435–455.
7. Gathercole S, Baddeley A. (1990) Phonological memory deficits in language-disordered children: is there a causal connection?Journal of Memory and Language, 29(3), 336–360.  
8. Gillam, S. L., Gillam, R. B., & Reece, K. (2012). Language outcomes of contextualized and decontextualized language intervention: Results of an early efficacy study. Language, Speech, and Hearing Services in Schools, 43, 276–291.
9. Harris-Schmidt, G., & McNamee, G.D. (1986). Children as authors and actors: Literacy development through basic activities. Child Language, Teaching and Therapy, 2(1).
10. Herrmann, J.A., Matyas, T., & Pratt, C. (2006). Meta-analysis of the nonword reading deficit in specific reading disorder. Dyslexia, 12 3, 195-221 .
11. Kamhi, A. G. (2014). Improving clinical practices for children with language and learning disorders. Language, Speech, and Hearing Services in Schools, 45(2), 92–103.
12. Kelley, E.S., & Spencer, T.D. (2021). Feasible and Effective Language Intervention Strategies that Accelerate Students’ Academic Achievement. Seminars in speech and language, 42 2, 101-116 .
13. Klein, H., & Moses, N. (1999). Intervention planning for children with communication disorders: A guide to the clinical practicum and professional practice.(2nd Ed.). Boston, MA.: Allyn & Bacon.
14. Lahey, M., & Bloom, L. (1994). Variability and language learning disabilities. In G. Wallach and K. Butler (Eds), Language learning disabilities in school-age children and adolescents (Ch. 13. pp. 354-372). New York.: Macmillan.
15. Landerl et al, (2019).  Phonological Awareness and Rapid Automatized Naming as Longitudinal Predictors of Reading in Five Alphabetic Orthographies with Varying Degrees of Consistency, Scientific Studies of Reading, 23:3, 220-234.
16. Montgomery, J. W. (1995). Examination of phonological working memory in specifically language impaired children. Applied Psycholinguistics, 16, 335–378.
17. Ramus, F., Marshall, C. R., Rosen, S., & van der Lely, H. K. J. (2013). Phonological deficits in specific language impairment and developmental dyslexia: towards a multidimensional model. Brain, 136, 630-645.
18. Ukrainetz, T. M. (2006). Language intervention through literature-based units. Austin, TX: Pro-Ed
19. Whitmire K. (2002) The Evolution of School-Based Speech-Language Services: A Half Century of Change and a New Century of Practice. Communication Disorders Quarterly. 23(2):68-76