Orofacial assessments article has been published in the International Adoption Directory Newsletter

 genetic syndromes, internationally adopted children, News Release, orofacial assessment, Smart Speech Therapy Article  No Responses »
Nov 222011
 

My article regarding the Importance of  Orofacial Observations has been published in 156th Issue of the International Adoption Directory Newsletter

Article Title: Orofacial Observations of Internationally Adopted Children: Recommendations for Parents and Non-Medical Adoption Professionals

Article Summary:  This article explains what parents should initially do if they note anything unusual regarding their internationally adopted child’s orofacial appearance. It explains how orofacial observations may be relevant to diagnosis of medical, genetic or neurological disorders via clinical case examples. It offers parents general guidelines for noting atypical orofacial features and explains why in some select circumstances, parents may be the first individuals to note unusual facial characteristics in their adopted children.  

 Posted by telleseff at 12:45 pm

Orofacial Observations of Internationally Adopted Children: Recommendations for Parents and Non-Medical Adoption Professionals

 genetic syndromes, internationally adopted children, News Release, Smart Speech Therapy Article  No Responses »
Nov 222011
 

Portions of this article were originally published in November 17, 2011 Issue of Advance Magazine for Speech Language Pathologists & Audiologists, Online Newsletter, under the title: “Orofacial Assessments: Pediatric Case Studies Illustrate Their Importance”

 Several months ago, I’ve administered speech-language testing to a 3-8 year old boy, adopted from Russia at the age of 3.  During the course of my assessment I noticed his atypical facial features.  He had a very small head, inward set eyes, and widely set ears.  At that time, even though this boy had already seen a number of other adoption professionals (including a neurologist, an occupational therapist and another speech language pathologist), I felt that it was very important to record my findings and refer the parent for a second opinion with a pediatrician specializing in working with internationally adopted children.  My rationale for seeking a second opinion for this child was further reinforced by a number of additional red flags, which included his significantly decreased play skills, severely impaired language ability, as well as significant social emotional and behavioral manifestations characterized by excessive impulsivity, distractibility, hyperactivity, decreased self-regulation, rapid over-stimulation, as well as anger outbursts and tantrums when others refused to follow his agenda and attempted to set limits on his behavior.

Subsequent, second opinion consultations for this child resulted in a diagnosis of Fetal Alcohol Spectrum Disorder, a term which describes the range of physical, mental, behavioral, and learning disabilities that can occur in children whose prenatal history is remarkable for excessive maternal alcohol consumption.

I use this case to illustrate a point.  At the time of adoption this child presented with significant unrecognized deficits, which continued to persist unrecognized and unaddressed post adoption.  While I acknowledge that oftentimes little could be done done before a child is adopted, I also want to emphasize that this child could have been receiving relevant and necessary services for 8 months post adoption, but didn’t because his deficits were missed!

The above case is not an isolated occurrence by any means. As a speech language pathologist who works exclusively with various at-risk pediatric populations (including internationally adopted children), I have numerous clinical examples I can share with you. In the past I have encountered undiagnosed feeding and swallowing issues, submucous clefts, vocal webs, Cerebral Palsy, Wilson’s Syndrome, a number of undiagnosed Fetal Alcohol Spectrum Disorder cases, and even several cases of severe infections due to excessive tooth decay and poor oral hygiene.   I can go on for a while but I do believe that I have sufficiently demonstrated my point.

Fact is that oftentimes internationally adopted children arrive to US with a host of undetected disorders and deficits.  Lack of detection is further increased in children adopted from economically developing countries or from hard to access insular regional orphanages, where they may fail to receive consistent and appropriate medical care, or where overcrowded conditions coupled with staff shortages may cause for deficits to be missed or unrecognized.

Consequently, oftentimes it is the parent(s) who are the first individuals to observe something different or unusual regarding their child’s facial features, oral structures, or any other appearance anomalies.

While many parents, of course, are not professionally trained in recognizing physical signs and symptoms of serious disorders, it is important to note that detection of unusual features is not as difficult as it sounds.

Here are some basic guidelines:

Does your child’s face look symmetrical or do you see any obvious signs of weakness (paralysis) on either side of the face (particularly evident when the child smiles and one side of the face droops or doesn’t move).

Do you find that your child’s features look odd or unusual in any way? Examples may include, but are not limited to: unusually wide or narrow set eyes, unusually set ears, virtual absence of a nose bridge, excessively thin upper lip, flatness of a groove above the lip, and so on (although with respect to facial appearance one needs to be very careful and account for differences in normal facial variation among various ethnic groups).

Do you notice any unusual spots, nodules, or openings on your child’s face or body or in his/her mouth?

In what condition is your child’s mouth? Is there excessive tooth decay? Do you see an unusual absence of teeth (in older children), or unusual bite (open bite, cross bite, etc)?  Is there excessive drooling?

Does your child have a usual voice or unusual cough in the absence of a documented illness?

If you do, then it would be a good reason to consult with a pediatrician specializing in international adoptions, to see whether your observations merit a referral to a specialist (e.g., neurologist, orthodontist, etc).

I realize of course that parents are not trained professionals, but they are observant individuals!  Moreover, there is a great likelihood that they are actually the first people to spend a prolonged period of time with the child.  There’s an even greater likelihood that they are the first people to actually “see” the child vs. the orphanage staff who may have fulfilled the child’s basic needs (feeding, diapering, etc) but who in reality may have actually spent very little face to face time with the child.

Furthermore, parents should not worry whether something that may see may not be a cause of concern.  What if it is and is not addressed?   That is why it is so important to share your concerns with relevant medical professionals.  It is up to them to investigate further whether your observations merit additional follow ups. If you are concerned, bring it up! You never know! You may paving the way to timely diagnosis and relevant intervention provision for your adopted child.

References:

  • Golper, L (2009) Medical Speech Language Pathology: A Desk Reference. Clifton Park, NY: Delmar Cengage Learning
  • Shipley, K, & McAfee, J (2008) Assessment in Speech Language Pathology: A Resource Manual. 4th Ed. Clifton Park, NY: Delmar Cengage Learning
 Posted by telleseff at 12:38 pm  Tagged with: , , , , , , ,

Speech-Language Activity Suggestions for Multisensory Stimulation of At-Risk Children

 Multisensory Stimulation, News Release, Smart Speech Therapy Article  No Responses »
Nov 012011
 

In recent years the percentage of “at-risk children” has been steadily increasing across pediatric speech-language pathology caseloads.  These include adopted and foster care children, medically fragile children (e.g., failure to thrive), abused and neglected children, children from low socioeconomic backgrounds or any children who for any reason lack the adequate support system to encourage them to function optimally socially, emotionally, intellectually, or physically.

At times speech-language pathologists encounter barriers when working with this population, which include low motivation, inconsistent knowledge retention, as well as halting or labored progress in therapy.

As a speech-language pathologist whose caseload consists entirely of at-children, I have spent countless of hours on attempting to enhance service delivery for my clients. One method that I have found to be highly effective for greater knowledge retention as well as for increasing the kids’ motivation is incorporating multisensory stimulation in speech and language activities.

To date, a number of studies have described the advantages of multisensory stimulation for various at risk populations. For example, in 2003 a study published in Journal of Research in Nursing and Health described the advantages of multisensory stimulation for 2 week old Korean orphans who received auditory, tactile, and visual stimulation twice a day, 5 days a week, for 4 weeks. This resulted in significantly fewer illnesses as well as significant gains in weight, length and head circumference, after the 4-week intervention period and at 6 months of age. Another 2009 study by White Traut and colleagues published in the Journal of Obstetric, Gynecologic, & Neonatal Nursing, found that multi sensory stimulation consisting of auditory, tactile, visual, and vestibular intervention contributed to a reduction of infant stress reactivity (steady decline in cortisol levels).   Moreover, multisensory stimulation is not just beneficial for young children. Other studies found benefits of multisensory stimulation for dementia (Milev et al, 2008) and coma patients (Doman & Wilkinson, 1993), indicating the usefulness of multisensory stimulation for a variety of at risk populations of different age groups.

After reviewing some studies and successfully implementing a number of strategies I wanted to share with you some of my favorite multisensory activities for different age-groups.

Before initiating any activities please remember to obtain parental permissions as well as a clearance from the occupational therapist (if the child is receiving related services), particularly if the child presents with significant sensory issues.  It is also very important to ensure that there are no food allergies, or nutritional restrictions, especially when it comes to working with new and unfamiliar clients on your caseload.

Multisensory stimulation for young children does not have to involve stimulation of all the senses at once. However, there are a number of activities which come quite close, especially when one combines “touch ‘n’ feel” books, musical puzzles as well as paper and edible crafts.

Here’s one of my favorite speech language therapy session activities for children 2-4 years of age. I use a board book called Percival Touch ‘n’ Feel Book to teach insect and animal related vocabulary words as well as talk about adjectives describing textures (furry, smooth, bumpy, sticky, etc).  As I help the children navigate the book, they get to touch the pages and talk about various plant and animals parts such as furry caterpillar dots, shiny flower petals, bumpy frog skin, or sticky spider web.   We also work on appropriately producing multisyllabic words and on combining the words into short sentences, depending of course, on the child’s age, skills, and abilities.   With this activity I often use animal and insect musical puzzles so the children can hear and then imitate select animal and insect noises.

Also, since all of Percival’s friends are garden insects and animals, it’s fairly easy to turn the book characters into paper crafts. Color paper templates are available from free websites such as www.dltk-kids.com, and range in complexity based on the child’s age (e.g., 2+, 3+ etc).  While looking innocuously like simple paper cutouts, in reality these crafts are a linguistic treasure trove and can be used for teaching simple and complex directions (e.g., after you glue the frog’s arm, glue on his foot) as well as prepositional concepts (e.g., glue the eyes on top of the head; glue the mouth below the nose, etc).

So far we have combined the tactile with the auditory and the visual but we are still missing the stimulation of a few other senses such as the olfactory and the gustatory.  For these we need a bit more creativity, and that’s where edible crafts come in (inspired by Janell Cannon’s ‘Crickwing’).  The child and I begin by constructing and gluing together a large paper flower and dabbing it’s petals with various food extracts (almond, vanilla, raspberry, lemon, root beer, banana, cherry, coconut, etc).  Then, using the paper flower as a model, we make an edible flower using various foods.  Pretzel sticks serve as stems, snap peas become leaves while mango, tomato, apple, peach and orange slices can serve as petals.  After our food craft is finished the child (and all other therapy participants) are encouraged to take it apart and eat it.  The edible flower is not just useful to stimulate the visual, tactile, gustatory, and olfactory senses but it also encourages picky eaters to trial new foods with a variety of textures and tastes, as well as serves to develop symbolic play and early abstract thinking skills.

It is also important to emphasize that multisensory activities are not just for younger children; they can be useful for school-age children as well (including middle school and high school aged kids). In the past, I have incorporated multisensory activities into thematic language and vocabulary units for older children (see resources below) while working on the topics such as the senses (e.g., edible tasting plate), nutrition (e.g., edible food pyramid), the human body (e.g., computer games such as whack a bone by anatomy arcade), or even biology (building plant and animal cell structures out of jello and candy). From my personal clinical experience I have noticed that when I utilized the multisensory approach to learning vs. auditory and visual approaches alone (such as paper based or computer based tasks only), the children evidenced greater task participation, were able to understand the material much faster and were still able to recall learned information appropriately several therapy sessions later.

I find multisensory stimulation to be a fun and interactive way to increase the child’s learning potential, decrease stress levels, as well as increase retention of relevant concepts.  Try it and let me know how it works for you!

 References:

·         Doman, G & Wilkinson, R (1993) The effects of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation. 3 (2): 203-212.

·         Ti, K, Shin YH, & White-Traut, RC (2003), Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Research in Nursing Health.  26 (6): 424-33.

·         Milev et al (2008) Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study. American Journal of Alzheimer’s Disease and Other Dementias. 23 (4): 372-376.

·         Tarullo, A & Gunnar, M (2006). Child Maltreatment and Developing HPA Axis. Hormones and Behavior 50, 632-639.

  • White Traut (1999) Developmental Intervention for Preterm Infants Diagnosed with Periventricular Leukomalacia. Research in Nursing Health.  22: 131-143.

·         White Traut et al (2009) Salivary Cortisol and Behavioral State Responses of Healthy Newborn Infants to Tactile-Only and Multisensory Interventions. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38(1): 22–34

 Resources:

 Posted by telleseff at 9:00 pm

Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention.

 assessment, internationally adopted children, language delay, Smart Speech Therapy Article  2 Responses »
Oct 012011
 

Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention.

Tatyana Elleseff MA CCC-SLP

 

Note: This article was first published in October 2011 Issue of Adoption Today Magazine (pp. 32-35) http://www.adoptinfo.net/catalog_g111.html?catId=55347

 According to US State Department statistics, over 11,000 children were adopted internationally in the year 2010, with 2,803 of those children being school-aged (between 5-17 years old). Despite a staggering 50% decline in overall inter-country adoptions in the last 10 years, statistics on adoption of older children continue to remain steady (appropriately 3,000 older children were adopted each year, for the past decade). (Retrieved from http://adoption.state.gov/about_us/statistics.php Jul 29, 2011).

 Subsequent to the school aged child’s arrival to US, one of the first considerations that arises, secondary to health concerns and transitional adjustments, is the issue of schooling and appropriate school based services provision. In contrast to children adopted at younger ages, who typically have an opportunity to acquire some English language skills before an academic placement takes place, older international adoptees lack this luxury. Unfortunately, due to their unique linguistic status, many school districts are at a loss regarding best services options for these children.

 Despite the prevalence of available research on this subject, one myth that continues to persist is that older internationally adopted children are “bilingual” and as such should receive remedial services similar to those received by newly entering the country bilingual children (e.g., ESL classes).

 It is very important to understand that most internationally adopted children rapidly lose their birth language, sometimes in as little as several months post arrival (Gindis, 2005), since they are often adopted by parents who do not speak the child’s first language and as such are unable/unwilling to maintain it. Not only are these children not bilingual, they are also not ‘truly’ monolingual, since their first language is lost rather rapidly, while their second language has been gained minimally at the time of loss. Moreover, even during the transition period during which international adoptees are rapidly losing their native language, their birth language is still of no use to them, since it’s not functional in their monolingual, English speaking only, home and school environments. As a result of the above constraints, select researchers have referred to this pattern of language gain, as “second, first language acquisition” (e.g., Roberts, et al., 2005), since the child is acquiring his/her new language literally from scratch.

 This brings me to another myth, that given several years of immersion in a new language rich, home and school environments, most internationally adopted children with (mild) language delays will catch up to their non-adopted monolingual peers academically, without the benefit of any additional services.

 This concept requires clarification, since the majority of parents adopting older children, often have difficulty understanding the extent of their child’s speech and language abilities in their native language at the time of adoption, and the implications for new language transference.

 Research on speech language abilities of older internationally adopted children is still rather limited, despite available studies to date. Some studies (e.g., Glennen & Masters, 2002; Krakow & Roberts, 2003, etc) suggest that age of adoption is strongly correlated with language outcomes. In other words, older internationally adopted children are at risk of having poorer language outcomes than children adopted at younger ages. That is because the longer the child stays in an institutional environment the greater is the risk of a birth language delay. Children in institutional care frequently experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which have long lasting negative impact on their language development. It is also important to understand that language delays in birth language transfer and become language delays in a new language. These delays will typically continue to persist unless appropriate intervention, in the form of speech language services, is provided.

So what are the options available to parents adopting older school age children with respect to determination of their child’s speech and language abilities?

For starters, at the time of adoption, it is very important to gain as much information regarding their child’s birth language abilities (and academic abilities, when applicable) as possible. In many older children (3+ years of age), speech and language delays in birth language (e.g., sound and word mispronunciations, limited vocabulary, grammatical errors, inability to answer simple or abstract questions, short sentence length) can be easily determined based on orphanage staff interviews, observations, and/or review of documentation included in the adoption record. In the Russian Federation, for example, speech language pathologists are assigned to orphanages, so when working with older international adoptees from the Russian Federation, one often finds a short statement in adoption records stating that the child presented with a speech and language delay for which he was receiving services.

If possible, prior to adoption, parents may wish to explore the option of obtaining an independent comprehensive speech language evaluation of the child’s birth language abilities, while the child is still located in the birth country. The above may be significant for a number of reasons. Firstly, it will allow the parents to understand the extent of the child’s language delay in their birth tongue. Secondly, it will increase the parents’ chances of obtaining school based remediation services for their child once they arrive to US.

In the absence of qualified speech pathologists attached to the orphanage or conclusive interviews with medical professionals, paraprofessionals, and teachers (lack of availability, language barrier, time constraints, etc) regarding the child’s speech and language development, it will be very helpful for parents to videotape the child during speaking tasks. Most parents who request pre-adoption consultations are well familiar with videotaping, requested by various pre-adoption professionals (pediatricians, psychologists, etc) in order to review the child’s presenting appearance, fine and gross motor skills, behavior and social skills as well as other areas of functioning. Language video samples should focus on child’s engagement in literacy tasks such as reading a book aloud (if sufficiently literate), and on speaking activities such as telling a story, recalling an episode from daily life or a conversation with familiar person. In the absence of all other data, these samples can later be analyzed and interpreted in order to determine if speech language deficits are present. (Glennen, 2009)

Parents need to understand that internationally adopted children can often be denied special education services in the absence of appropriate documentation. Such denials are often based on misinterpretation of the current IDEA 2004 law. Some denials may be based on the fact that once these children arrive to US, it is very difficult to find a qualified speech language pathologist who can assess the child in their birth language, especially if it’s a less commonly spoken language such as Amharic, Kazakh, or Ukrainian. Additionally, schools may refuse to test internationally adopted children for several years post arrival, on the grounds that these children have yet to attain “adequate language abilities in English” and as such, the testing results will be biased/inadequate, since testing was not standardized on children with similar linguistic abilities. Furthermore, even if the school administers appropriate testing protocols and finds the child’s abilities impaired, testing results may still be dismissed as inaccurate due to the child’s perceived limited English exposure.

Contrastingly, a speech and language report in the child’s birth language will outline the nature and severity of disorder, and state that given the extent of the child’s deficits in his/her birth language, similar pattern will be experienced in English unless intervention is provided. According to one of the leading speech-language researchers, Sharon Glennen, “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)

To continue, some options in locating a speech pathologist in the child’s birth country include consulting with the adoption agency or the local pediatrician, who is providing medical clearance for the child. However, it is very important that the speech language pathologist be licensed and reputable, as unqualified professionals will not be able to make appropriate diagnostic interpretations and suggestions, and may provide erroneous information to the parent.

If the parents are unable to obtain the relevant report in the child’s birth country, the next viable option is to obtain a comprehensive speech language assessment upon arrival to US, from a qualified professional who is well versed in both: the child’s native language as well as speech and language issues unique to assessment of internationally adopted children. Please note that the window of opportunity to assess the school age child in his/her native language is very narrow, as birth language attrition occurs within literally a matter of several months post adoption and is more rapid in children with delayed and disordered speech and language abilities (Gindis, 1999, 2005, 2008).

If the presence of a speech language delay has been confirmed (e.g., documented in adoption paperwork, interpreted through video samples, supported by a psycho-educational assessment, etc) the next step is to request the relevant speech language services for your child through the school system. Typically school administration will ask you to produce such a request in writing. One such letter template is available through the Post Adoption Learning Center (see link below). This template, complete with relevant references, can be modified to each child’s unique circumstances, and submitted along with supporting paperwork (e.g., speech-language, psycho-educational reports) and available video samples. In cases of services denials, an educational attorney specializing in educational policy relevant to international adoptions may need be consulted.

Once the child is qualified for appropriate speech language services in the school system it is also important to understand that language acquisition occurs in a progression, with social language (CLF) preceding cognitive language (CLM) (Gindis, 1999). Communicative Language Fluency (CLF) is language used in social situations for day-to-day social interactions. These skills are used to interact at home, on the playground, in the lunch room, on the school bus, at parties, playing sports and talking on the telephone. Social interactions are usually context embedded. Because they occur in meaningful social contexts they are typically not very demanding cognitively and the language required is not specialized. These language skills usually emerge in internationally adopted children as early as several months post adoption. Once these abilities emerge and solidify it is very important for speech language pathologists not to dismiss the child from services but to continue the treatment and focus it in the realm of cognitive/ academic language.

Cognitive Language Mastery (CLM) refers to language needed for formal academic learning. This includes listening, speaking, reading, and writing about subject area content material including analyzing, synthesizing, judging and evaluating presented information. This level of language learning is essential for a child to succeed in school. Language impaired children adopted at older ages need time and support to become develop cognitive language and become proficient in academic areas, an ability which usually takes a number of years to refine. Before discharging the child from therapy services it is very important that their cognitive/academic language abilities are assessed and are found within average limits.

Understanding the extent of speech language delay in internationally adopted older children AND factors pertaining to appropriate remediation are crucial for delivery of relevant (and meaningful to the child) speech language services as well as ensuring their continued academic success in school setting.

References:

• Gindis, B. (1999) Language-Related Issues for International Adoptees and Adoptive Families. In: T. Tepper, L. Hannon, D. Sandstrom, Eds. “International Adoption: Challenges and Opportunities.” PNPIC, Meadow Lands , PA. , pp. 98-108

• Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315.

• Gindis (2008) Abrupt Native Language Loss in International Adoptees Advance for Speech/Language Pathologists and Audiologists Dec 22.

• Glennen, S. & Masters, G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe. American Journal of Speech-LanguagePathology, 44, 417-433

• Glennen, S., & Bright, B. J. (2005). Five years later: Language in school-age internationally adopted children. Seminars in Speech and Language, 26, 86-101.

• .Glennen, S (2009) Speech and Language Guidelines for Children Adopted from Abroad at Older Ages. Topics in language Disorders 29, 50-64.

• Intercountry Adoption Bureau of Consular Affairs US Department of State Retrieved on Jul 29, 2011 from http://adoption.state.gov/about_us/statistics.php

• Krakow, R. A., & Roberts, J. (2003). Acquisitions of English vocabulary by young Chinese adoptees. Journal of Multilingual Communication Disorders, 1, 169-176.

• Muchnik, M. How to request speech/language services for your child. Retrieved on Aug 2, 2011 from http://www.bgcenterschool.org/FreePresentations/P8-Speech-language-support.shtml

• Roberts, et al, (2005). Language development in preschool-aged children adopted from China. Journal of Speech, Language and Hearing Research, 48, 93-107.

Bio: Tatyana Elleseff MA CCC-SLP is a bilingual speech language pathologist with a full-time affiliation with University of Medicine and Dentistry of New Jersey and a private practice in Somerset, NJ. She received her Master’s Degree from New York University and her Bilingual Extension Certification from Columbia University. Currently she is licensed by the states of New Jersey and New York and holds a Certificate of Clinical Competence from American Speech Language and Hearing Association. She specializes in working with bilingual, multicultural, internationally and domestically adopted at risk children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders. For more information about her services call 917-916-7487 or visit her website: www.smartspeechtherapy.com

Cite as: Elleseff, Tatyana (2011, October) Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention. Adoption Today.

 Posted by telleseff at 2:59 pm  Tagged with: , ,

Differential Diagnosis of AD/HD and Auditory Processing Disorders in Internationally Adopted School Age Children

 ADHD, assessment, Auditory Processing Disorders, Smart Speech Therapy Article  No Responses »
Jun 062011
 

Differential Diagnosis of AD/HD and Auditory Processing Disorders in Internationally Adopted School Age Children

Tatyana Elleseff MA CCC-SLP

Scenario:   Corinne is an adorable 8 year old girl with an infectious smile, who has been adopted from Russia at the age of 15 months. She sits quietly by the bookshelf; completely absorbed by the book in her lap, while her distraught mother is quietly telling me in the hallway why Corinne has come to visit me today. Corinne has numerous listening difficulties. She is very inattentive and frequently mishears verbal messages. She is very distractible and tends to act impulsively at home and in school. She has trouble organizing her verbal output when speaking and is constantly forgetting what has been told to her, even if it was only moments ago. Corinne has never had a speech and language assessment before, but she does have a documented diagnosis of ADHD, for which she is currently taking medication. The trouble is that this medication does not seem to be helping Corinne one bit. She is just as distractible, impulsive and inattentive as she was before. Not only that, but this is not the first medication or the lowest dosage that Corinne has been taking for her ADHD. According to Corinne’s mother, Corinne’s medications and dosages have been adjusted multiple times by several doctors, but so far it hasn’t really affected anything. Corinne’s parents’ are at their wit’s end! Corinne is desperately struggling with her studies despite working very hard and getting a lot of help at home, but she is doing so poorly – that her school has been hinting very strongly that Corinne ought to be held back in 3rd grade.

Fast forwarding several assessment sessions later, I am not so convinced that ADHD is Corinne’s primary deficit, or even if it’s an appropriate diagnosis for Corinne at all. Testing has revealed that Corinne has a severe language processing difficulty and requires a referral to an audiologist for a comprehensive auditory processing testing battery. Corinne’s mom is bewildered at the news: “But no one has suggested anything like this at all before!”

Sadly, Corinne’s case is far from unique. The incidence and prevalence of AD/HD (the slash is used to denote both subtypes with and without the hyperactivity component) in internationally adopted children is very high and continues to be on the rise.

What further complicates the situation is lack of valid statistical data. At this time there are no reliable statistics to cite! However, parents of internationally adopted children and those professionals who work with this unique population know just how frequently this label is used. AD/HD prevalence in internationally adopted children is so highly alarming that it begs a number of important questions:

      • “What criteria are currently used for diagnosing AD/HD in internationally adopted children?”
      • “Are other disorders with similar symptoms being ruled out before the diagnosis of AD/HD is made?”

Attention Deficit/Hyperactivity Disorder is one of the most commonly diagnosed disorders of childhood. As a speech language pathologist, who works in a pediatric psychiatric hospital setting, I see many children, including a large number of internationally adopted children, who have the diagnosis of AD/HD in conjunction with other comorbidities including psychiatric disorders as well as speech-language and learning deficits.

However, after the initial screening and assessment period when these children are seen by our multidisciplinary team (psychiatrist, psychologist, nurse, occupational and speech therapists, as well as a learning specialist) in a number of cases, the AD/HD diagnosis is ruled out.

It is very important to understand that the core symptoms of AD/HD: inattention, hyperactivity, and impulsivity are also the core symptoms in a variety of other disorders, which need to be ruled out in order for the diagnosis of AD/HD to be confirmed with reasonable accuracy.

The above “core symptoms” are observed in a number of disorders:

      • Sensory Processing Dysfunction
      • Auditory Processing Disorder
      • Mental Retardation
      • Hearing Deficits
      • Mood Disorders
      • Sleep Disorders
      • Seizure Disorders
      • Acquired Traumatic Brain Injury
      • Autistic Spectrum Disorders
      • Language Disorders
      • Nonverbal Learning Disorder
      • Yeast Overgrowth

And this list is by no means exhaustive.

Since I am a speech language pathologist, in this article I would like to focus on a diagnosis that is most frequently mistaken or may co-occur with AD/HD, which is auditory processing disorder (APD), also referred to as Central Auditory Processing Disorder (C/APD).

Auditory Processing Disorder (APD) is technically not one disorder but a number of disorders, which affect the processing and use of auditory information at the level of the Central Nervous System (CNS). A child with APD has normal hearing but has trouble recognizing, processing and/or interpreting auditory information.

The reason why it’s not just a name for one disorder is because according to the 2005 ASHA’s CAPD Technical Report, auditory processing difficulties may affect a number of abilities such as “sound localization and lateralization; auditory discrimination; [and/or] auditory pattern recognition.” Additionally, the difficulties could be with the “temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking; auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals” (ASHA, 2005, CAPD Technical Report).

These technical terms translate into some of the following auditory processing difficulties for the child:

1. Difficulty processing auditory information efficiently

      a. Child may require increased processing time to respond to questions
      b. Child may present like they are ignoring the speaker
      c. Child may request the speaker to repeat presented information several times
      d. Child may not be able to follow long sentences
      e. Child will have difficulty keeping up with class discussions in group settings
      f. Child’s poor listening abilities under noisy conditions may be interpreted as “distractibility”

2. Difficulty maintaining attention on presented tasks

      a. Frequent loss of focus
      b. Difficulty completing assignments on their own

3. Poor Short Term Memory – difficulty remembering instructions and directions or verbally presented information

4. Difficulty with phonemic awareness, reading and spelling

      a. Poor ability to recognize and produce rhyming words
      b. Poor segmentation abilities (separation of sentences, syllables and sounds)
      c. Poor sound manipulation abilities (isolation, deletion, substitution, blending, etc)
      d. Poor sound letter identification abilities
      e. Poor vowel recognition abilities

The combination of above factors may result in generalized deficits across the board, affecting the child’s social and academic performance:

      • Poor reading comprehension;
      • Poor oral and written expression
      • Disorganized thinking (e.g., disjointed narrative production)
      • Sequencing errors (recalling/retelling information in order, following recipes, etc)
      • Poor message interpretation
      • Difficulty making inferences
      • Misinterpreting the meaning of abstract information

Auditory processing difficulties frequently coexist along with AD/HD. So a child may have both diagnoses AD/HD and APD. However, the child may also be accidentally misdiagnosed with one, instead of the other, or may even have a different diagnosis entirely, which is why a differential diagnosis is absolutely crucial! 

How to initiate an appropriate referral process if you suspect that your school age child has auditory processing difficulties?

If your child is exhibiting any of the above mentioned symptoms, it is very important to address the cause of the problem. Even though AD/HD and APD may have similar core symptoms, the management of both disorders is quite different. Management of AD/HD may require a number of interventions including behavioral management, medication, and language therapy vs. APD which may require language intervention only, since behavior therapy and stimulant medications used to control AD/HD do not improve the symptoms of APD! (Tillary et al 2000)

The differential diagnosis of auditory processing disorder falls under the auspices of an audiologist. However, because many of AD/HD and APD symptoms overlap and manifest as language difficulties, before a referral to an audiologist is made, a speech language pathologist is often consulted first to determine the presence and/or extent of language difficulties that affect the child’s listening comprehension, short term memory, attention to verbal messages, and so on.

A speech language pathologist may also be consulted before the audiologist, if the symptoms in question pertain to a younger child (e.g., 4-5 years of age). Most auditory processing batteries can only be administered partially when a child is minimally 5 years of age (e.g., SCAN-3C; Pearson Publications) and comprehensively when a child reaches about 7 years of age, due to the differences in speed of brain maturation in children. In contrast, a speech language pathologist can determine much earlier if a child presents with difficulties which may later be diagnosed as APD. In fact one recent test that came out in 2010, the Auditory Skills Assessment (ASA), available from Pearson Publications, screens children as young as 3;6 years of age for early auditory and phonological skills.

As the result of the above guidelines, some parents have asked me in the past: “If an auditory processing disorder is suspected but only fully diagnosed at 7, does it mean that we have to wait until that age to confirm the diagnosis and only then initiate language therapy?” Absolutely not! 

If the assessment indicates that intervention is merited, the speech pathologist can begin addressing specific deficits (e.g., understanding verbal messages, following complex directives, etc), long before the diagnosis of auditory processing disorder can be made, since our aim is to treat the presenting symptoms and not a specific label!

Furthermore, even after an audiologist confirms the presence of an auditory processing disorder, in the vast majority of cases, the child will be sent back to the speech language pathologist for treatment since treatment of auditory processing deficits falls under the auspices of a speech language pathologist.

Thus, early detection (e.g., ages 4-5) frequently facilitates successful treatment, remediation, and/or mitigation of symptoms. Early treatment may also decrease symptom severity (e.g., mild-moderate auditory processing disorder vs. severe auditory processing disorder) by the time the child is tested by an audiologist at an older age (e.g., age 8).

After the initial referral is made, and depending on the nature of deficits (e.g., attention, processing, phonological awareness, memory, etc) a speech pathologist may chose to use a number of language testing instruments, sensitive to various auditory processing components.

Below are just several of the popular screening and testing instruments which may be used by a speech language pathologist in order to determine whether a referral for a comprehensive auditory processing assessment battery with an audiologist is merited.

      • The Listening Inventory (TLI) (2005) available from Academic Therapy Publications
      • Differential Screening Test for Processing (DSTP) (2006)*
      • Dynamic Screening for Phonological Awareness (DSPA) (2010)*
      • Test of Auditory Processing Skills-3 (2005)**
      • The Listening Comprehension Test-2 (LCT-2) (2006)*
      • The Listening Comprehension Test Adolescent (LCT-A) (2009)*
      • Phonological Awareness Test -2 (PAT-2) (2007)*
      • Comprehensive Test of Phonological Processing (CTOPP) (1999)**
      • Lindamood Auditory Conceptualization Test-3 (LAC-3) (2004)**

*Denotes instruments available from Linguisystems
** Denotes instruments available from multiple publishers such as Linguisystems, Pearson Publications, and/or Super Duper Publications

Please note that a speech language pathologist does not have to use the above tests in order to refer the child for an auditory processing assessment battery. He/she can select the testing subtests from a number of commonly used language testing instruments such as Clinical Evaluation of Language Fundamentals-4 or Test for Auditory Comprehension of Language-3 (Pearson Publications) in order to test the affected areas of difficulty (e.g., listening comprehension, following directions, etc).

So, the SLP will test the child’s language abilities in order to determine if their testing results are indicative of deeper auditory processing deficits. If they are, and the child’s age is appropriate, then the child will need to see an audiologist who will first perform a routine hearing test to rule out hearing impairment and then, if the hearing is normal, the audiologist will administer the auditory processing testing battery.

What is the role of audiologist in the assessment of auditory processing disorders?

      • An audiologist is the ONLY professional who diagnoses auditory processing disorders.
      • An audiologist is the ONLY professional who is responsible for describing auditory processing deficits diagnosed during the above assessment.
      • The audiologist is EXPECTED to suggest treatment and management strategies for school and home accommodations, which are specific to the child’s unique deficits.
      • An audiologist MAY provide auditory processing remediation to the child but TYPICALLY he/she will refer the child to a speech language pathologist for further treatment.
      • Subsequent to receiving auditory processing intervention, the child will go back to the audiologist (usually after 1 year) in order to receive an auditory processing reassessment battery.
      • The child may continue to receive yearly reassessments until the audiologist determines that further assessments/treatments are no longer necessary.

Audiological testing battery differs from speech language testing battery. Most audiological tests are administered in sound-proof booths and involve the attention and response to signals/tones in addition to attention and response to recorded words, word pairs, and sentences (in contrast to live voice) in the absence and presence of background noise. Based on presenting symptoms an audiologist will determine what combinations of tests need to be administered.

After testing is completed it is very important that parent request that the audiologist outline confirmed deficits, suggest treatment hierarchy with goals and objectives as well as make recommendations for school and home accommodations which will be specific to the child’s unique deficits.

This is especially important because much of the terminology used by audiologists may not be familiar to many school based speech language therapists much less parents who are attempting to interpret the report. Therefore, it is important that an audiologist clearly explain what the deficits are and what needs to be done.

This is necessary in order to avoid confusion regarding the meaning of terms as well as to avoid generalized and unnecessary interventions. For example, the deficits pertaining to term “tolerance fading memory” should be explained as difficulties with speech interpretation in the presence of background noise as well as difficulty with short term memory. Moreover, it is also important to caution parents that the generic recommendation of an FM system (frequency modulation system) is not applicable to all children with auditory processing deficits but only to those who have been accurately diagnosed with auditory sensitivity and/or auditory distractibility. Similarly, not all parents of children with auditory processing disorders need to rush out to purchase “Earobics” (www.earobics.com) or “Lindamood-Bell” (www.lindamoodbell.com) software programs especially because these phonological awareness programs and their levels of difficulty may not be necessarily applicable to many children with APD symptoms.

Parents should also be wary of recommendations heavily emphasizing specific costly software or remediation programs (to the exclusion of all other interventions), since not all recommendations are based on scientific research and evidence. Therefore it’s very important to research the efficacy and effectiveness of these products and programs on the ASHA (American Association of Speech Language and Hearing Science) website.

I also want to reemphasize again that even after the diagnosis of C/APD has been confirmed, it may be necessary to revisit the child’s remaining symptoms once more in order to reassess the continued applicability of AD/HD diagnosis and use of medications as well as to rule out the presence of additional comorbidities.

On such occasions, I have found that The Listening Inventory (TLI) screening instrument is a very helpful tool for making additional referrals. This questionnaire, which can be filled out by parents AND teachers in as little as 15 minutes, has the users rating the child’s difficulties in 6 areas: linguistic organization, decoding/language mechanics, attention/organization, sensory/motor, social/behavioral, and auditory processes. After all the statements are rated and the index scores are calculated, many parents are often surprised by the results. Oftentimes the difficulties they interpret as being social behavioral may actually be the result of sensory/motor impairments, which require an assessment by an occupational therapist.

This is why the multidisciplinary approach to identification, differential diagnosis, and management of disorders like AD/HD and/or C/APD is so important. Just one individual assessment, be it psychological, occupational, or audiological, CANNOT reliably determine accurate diagnosis to the exclusion of all others, especially when the diagnostic criteria is based on generalized symptomology (symptoms fit several diagnoses).

To learn more about auditory processing disorders please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find professionals specializing in assessment (audiologist) and treatment (speech language pathologist) of auditory processing disorders in your area please visit: http://asha.org/proserv/.

References

      • American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders [Technical Report]. Available from www.asha.org/policy.
      • Lucker, J.R. (2007). History of Auditory Processing Disorders in Children. In D. Geffner and D. Ross-Swain, Auditory Processing Disorders for Speech-Language Pathologists San Diego: Plural Publishers.
          • Tillery et al. (2000) Effects of Methylphenidate (Ritalin) on Auditory Performance in Children With Attention and Auditory Processing Disorders. Journal of Speech Language and Hearing Research 43, 893-901
 Posted by telleseff at 7:51 am  Tagged with: , , ,

What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

 assessment, internationally adopted children, Smart Speech Therapy Article, social pragmatic language, speech language pathology  No Responses »
Mar 142011
 

What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

Tatyana Elleseff MA CCC-SLP

Scenario:   John is a bright 11 year old boy who was adopted at the age of 3 from Russia by American parents. John’s favorite subject is math, he is good at sports but his most dreaded class is language arts. John has trouble understanding abstract information or summarizing what he has seen, heard or read. John’s grades are steadily slipping and his reading comprehension is below grade level. He has trouble retelling stories and his answers often raise more questions due to being very confusing and difficult to follow. John has trouble maintaining friendships with kids his age, who consider him too immature and feel like he frequently “misses the point” due to his inability to appropriately join play activities and discussions, understand non-verbal body language, maintain conversations on age-level topics, or engage in perspective taking (understand other people’s ideas, feelings, and thoughts). John had not received speech language services immediately post adoption despite exhibiting a severe speech and language delay at the time of adoption. The parents were told that “he’ll catch up quickly”, and he did, or so it seemed, at the time. John is undeniably bright yet with each day he struggles just a little bit more with understanding those around him and getting his point across. John’s scores were within normal limits on typical speech and language tests administered at his school, so he did not qualify for school based speech language therapy. Yet John clearly needs help.

John’s case is by no means unique. Numerous adopted children begin to experience similar difficulties; years post adoption, despite seemingly appropriate early social and academic development. What has many parents bewildered is that often times these difficulties are not glaringly pronounced in the early grades, which leads to delayed referral and lack of appropriate intervention for prolonged period of time.

The name for John’s difficulty is pragmatic language impairment, a diagnosis that has been the subject of numerous research debates since it was originally proposed in 1983 by Rapin and Allen. 

So what is pragmatic language impairment and how exactly does it impact the child’s social and academic language abilities? 

In 1983, Rapin and Allen proposed a classification of children with developmental language disorders. As part of this classification they described a syndrome of language impairment which they termed ‘semantic–pragmatic deficit syndrome’. Children with this disorder were described as being overly verbose, having poor turn–taking skills, poor discourse and narrative skills as well as having difficulty with topic initiation, maintenance and termination. Over the years the diagnostic label for this disorder has changed several times, until it received its current name “pragmatic language impairment” (Bishop, 2000).

Pragmatic language ability involves the ability to appropriately use language (e.g., persuade, request, inform, reject), change language (e.g., talk differently to different audiences, provide background information to unfamiliar listeners, speak differently in different settings, etc) as well as follow conversational rules (e.g., take turns, introduce topics, rephrase sentences, maintain appropriate physical distance during conversational exchanges, use facial expressions and eye contact, etc) all of which culminate into the child’s general ability to appropriately interact with others in a variety of settings.

For most typically developing children, the above comes naturally. However, for children with pragmatic language impairment appropriate social interactions are not easy. Children with pragmatic language impairment often misinterpret social cues, make inappropriate or off-topic comments during conversations, tell stories in a disorganized way, have trouble socially interacting with peers, have difficulty making and keeping friends, have difficulty understanding why they are being rejected by peers, and are at increased risk for bullying.

So why do adopted children experience social pragmatic language deficits many years post adoption? 

Well for one, many internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Children in institutional care often experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which has long lasting negative impact on their language development including the development of their pragmatic language skills (especially if they are over 3 years of age). Furthermore, other, often unknown, predisposing factors such as medical, genetic, and family history can also play a negative role in pragmatic language development, since at the time of adoption very little information is known about the child’s birth parents or maternal prenatal care.

Difficulty with detection as well as mistaken diagnoses of pragmatic language impairment 

Whereas detecting difficulties with language content and form is relatively straightforward, pragmatic language deficits are more difficult to detect, because pragmatics are dependent on specific contexts and implicit rules. While many children with pragmatic language impairment will present with poor reading comprehension, low vocabulary, and grammar errors (pronoun reversal, tense confusion) in addition to the already described deficits, not all the children with pragmatic language impairment will manifest the above signs. Moreover, while pragmatic language impairment is diagnosed as one of the primary difficulties in children on autistic spectrum, it can manifest on its own without the diagnosis of autism. Furthermore, due to its complicated constellation of symptoms as well as frequent coexistence with other disorders, pragmatic language impairment as a standalone diagnosis is often difficult to establish without the multidisciplinary team involvement (e.g., to rule out associated psychiatric and neurological impairment).

It is also not uncommon for pragmatic language deficits to manifest in children as challenging behaviors (and in severe cases be misdiagnosed due to the fact that internationally adopted children are at increased risk for psychiatric disorders in childhood, adolescence and adulthood). Parents and teachers often complain that these children tend to “ignore” presented directions, follow their own agenda, and frequently “act out inappropriately”. Unfortunately, since children with pragmatic language impairment rely on literal communication, they tend to understand and carry out concrete instructions and tasks versus understanding indirect requests which contain abstract information. Additionally, since perspective taking abilities are undeveloped in these children, they often fail to understand and as a result ignore or disregard other people’s feelings, ideas, and thoughts, which may further contribute to parents’ and teachers’ beliefs that they are deliberately misbehaving.

Due to difficulties with detection, pragmatic language deficits can persist undetected for several years until they are appropriately diagnosed. What may further complicate detection is that a certain number of children with pragmatic language deficits will perform within the normal range on typical speech and language testing. As a result, unless a specific battery of speech language tests is administered that explicitly targets the identification of pragmatic language deficits, some of these children may be denied speech and language services on the grounds that their total language testing score was too high to qualify them for intervention.

How to initiate an appropriate referral process if you suspect that your school age child has pragmatic language deficits? 

When a child is presenting with a number of above described symptoms, it is recommended that a medical professional such as a neurologist or a psychologist be consulted in order to rule out other more serious diagnoses. Then, the speech language pathologist can perform testing in order to confirm the presence of pragmatic language impairment as well as determine whether any other linguistically based deficits coexist with it. Furthermore, even in cases when the pragmatic language impairment is a secondary diagnosis (e.g. Autism) the speech language pathologist will still need to be involved in order to appropriately address the social linguistic component of this deficit.

To obtain appropriate speech and language testing in a school setting, the first step that parents can take is to consult with the classroom teacher. For the school age child (including preschool and kindergarten) the classroom teacher can be the best parental ally. After all both parents and teachers know the children quite well and can therefore take into account their behavior and functioning in a variety of social and academic contexts. Once the list of difficulties and inappropriate behaviors has been compiled, and both parties agree that the “red flags” merit further attention, the next step is to involve the school speech language pathologist (make a referral) to confirm the presence and/or severity of the impairment via speech language testing.

When attempting to confirm/rule out pragmatic language impairment, the speech language pathologist has the option of using a combination of formal and informal assessments including parental questionnaires, discourse and narrative analyses as well as observation checklists.

Below is the list of select formal and informal speech language assessment instruments which are sensitive to detection of pragmatic language impairment in children as young as 4-5 years of age.

1. Children’s Communication Checklist-2 (CCC–2) (Available: Pearson Publication)
2. Test of Narrative Development (TNL) (Available: Linguisystems Publication)
3. Test of Language Competence Expanded Edition (TLC-E) (Available: Pearson Publication)
4. Test of Pragmatic Language-2 (TOPL-2) (Available: Linguisystems Publication)
5. Social Emotional Evaluation (SEE) (Available: Super Duper Publication)
6. Dynamic Informal Social Thinking Assessment (www.socialthinking.com)
7. Social Language Development Test -Elementary (SLDT-E) (Available: Linguisystems Publication)
8. Social Language Development Test -Adolescent (SLDT-A) (Available: Linguisystems Publication)

It is also very important to note that several formal and informal instruments and analyses need to be administered/performed in order to create a complete diagnostic picture of the child’s deficits.

When to seek private pragmatic language evaluation and therapy services?

Unfortunately, the process of obtaining appropriate social pragmatic assessment in a school setting is often fraught with numerous difficulties. For one, due to financial constraints, not all school districts possess the appropriate, up to date pragmatic language testing instruments.

Another issue is the lack of time. To administer comprehensive assessment which involves 2-3 different assessment instruments, an adequate amount of time (e.g., 2+ hours) is needed in order to create the most comprehensive pragmatic profile for the child. School based speech language pathologists often lack this valuable commodity due to increased case load size (often seeing between 45 to 60 students per week), which leaves them with very limited time for testing.

Further complicating the issue are the special education qualification rules, which are different not just from state to state but in some cases from one school district to the next within the same state. Some school districts strictly stipulate that the child’s performance on testing must be 1.5-2 standard deviations below the normal limits in order to qualify for therapy services.
But what if the therapist is not in possession of any formal assessment instruments and can only do informal assessment?

And what happens to the child who is “not impaired enough” (e.g., 1 SD vs. 1.5 SD)?

Consequently, in recent years more and more parents are opting for private pragmatic language assessments and therapy for their children.

Certainly, there are numerous advantages for going via the private route. For one, parents are directly involved and directly influence the quality of care their children receive.

One advantage to private therapy is that parents can request to be present during the evaluation and therapy sessions. As such, not only do the parents get to understand the extent of the child’s impairment but they also learn valuable techniques and strategies they can utilize in home setting to facilitate carryover and skill generalization (how to ask questions, provide choices, etc).

Another advantage is the provision of individual therapy services in contrast to school based services which are generally attended by groups as large as 4-5 children per session. Here, some might disagree and state that isn’t the point of pragmatic therapy is for the child to practice his/her social skills with other children?

Absolutely! However, before a skill can be generalized it needs to be taught! Most children with pragmatic language impairment initially require individual sessions, in some of which it may be necessary to use drill work to teach a specific skill. Once the necessary skills are taught, only then can children be placed into social groups where they can practice generalizing their skills. Moreover, many of these children greatly benefit from being in group or play settings with typical peers and/or sibling tutors who may facilitate the generalization of the desired skill more naturally, all of which can be arranged within private therapy settings.

Yet another advantage to obtaining private therapy services is that there are some private clinics which are almost exclusively devoted to teaching social pragmatic communication and which offer a variety of therapeutic services including individual therapy, group therapy and even summer camps that target the improvement of pragmatic language and social communication skills.

The flexibility offered by private therapy is also important if a parent is seeking a specific social skills curriculum for their child (e.g., “Socially Speaking”) or if they are interested in social skill training that is based on the methods of specific researchers/authors (e.g., Michelle Garcia Winner MACCC-SLP; Dr. Jed Baker PhD, etc), which may not be offered by their child’s school.

There are many routes open for parents to pursue when it comes to their child’s pragmatic language assessment and intervention. However, the first step in that process is parental education!

To learn more about pragmatic language impairment please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find a professional specializing in assessment and treatment of pragmatic language disorders in your area please visit http://asha.org/proserv/.

References

Adams, C. (2001). “Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder.” International Journal of Language and Communication Disorders 36(3): 289-305.

Bishop, D. V. (1989). “Autism, Asperger’s syndrome and semantic-pragmatic disorder: Where are the boundaries?” British Journal of Disorders of Communication 24(2): 107-121.

Bishop, D. V. M. and G. Baird (2001). “Parent and teacher report of pragmatic aspects of communication: Use of the Children’s Communication Checklist in a clinical setting.” Developmental Medicine and Child Neurology 43(12): 809-818.

Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autism, 3, 371–396.[

Brackenbury, T., & Pye, C. (2005). Semantic deficits in children with language impairments: Issues for clinical assessment. Language, Speech, and Hearing Services in Schools, 36, 5–16.

Burgess, S., & Turkstra, L. S. (2006). Social skills intervention for adolescents with autism spectrum disorders: A review of the experimental evidence. EBP Briefs, 1(4), 1–21.

Camarata, S., M., and T. Gibson (1999). “Pragmatic Language Deficits in Attention-Deficit Hyperactivity Disorder (ADHD).” Mental Retardation and Developmental Disabilities 5: 207-214.

Ketelaars, M. P., Cuperus, J. M., Jansonius, K., & Verhoeven, L. (2009). Pragmatic language impairment and associated behavioural problems. International Journal of Language and Communication Disorders, 45, 204–214.

Ketelaars, M. P., Cuperus, J. M., Van Daal, J., Jansonius, K., & Verhoeven, L. (2009). Screening for pragmatic language impairment: The potential of the Children’s Communication Checklist. Research in Developmental Disabilities, 30, 952–960.

Miniscalco, C., Hagberg, B., Kadesjö, B., Westerlund, M., & Gillberg, C. (2007). Narrative skills, cognitive profiles and neuropsychiatric disorders in 7-8-year-old children with late developing language. International Journal of Language and Communication Disorders, 42, 665–681.
Rapin I, Allen D (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). : Academic Press.

 Posted by telleseff at 1:00 am  Tagged with: , , , , ,

A case for early speech-language assessments of adopted children in the child’s birth language.

 assessment, internationally adopted children, Smart Speech Therapy Article  No Responses »
Feb 232011
 

A case for early speech-language assessments of adopted children in the child’s birth language.

Tatyana Elleseff MA CCC-SLP

As more and more research is being published on communication, linguistic abilities, as well as speech and language delay of adopted children, a debate has arisen with regard to the necessity of early assessment of speech and language abilities of newly adopted children. Many medical and related professionals have posed a relevant question: “What is the purpose of performing a speech-language evaluation immediately after arriving in the U.S.?” After all how can you perform an evaluation in English when the child has minimal knowledge of English at the time of arrival? And what about speech and language evaluation conducted in the birth language post arrival? Will it yield any definitive or predictive results given that within a relatively short period (2-6 months depending on which study you look at) the child would have lost the birth language and rapidly gained English? And honestly, can one really translate or adapt a test standardized on English speaking children to the child’s birth language (e.g., Russian) with any hope of reliable results?

The truth is that one definitive answer simply does not exist. It would be erroneous to state that ‘yes’ all newly adopted children need to be assessed within the first week of US arrival or “no” you can wait until the child has been in the country for several months before a reliable assessment can be performed. Here, I think that an individualized and educated approach is necessary in order to determine whether an early speech–language assessment may be appropriate for your newly adopted child.

In order to better explain my position on this issue, I must mention something of my own background and how it affects my approach to speech and language assessments. I am a bilingual, Russian-English, speaking speech language therapist, and I specialize in assessing children adopted from Eastern Europe (vs. South America or China, etc).

I am also in a rather unique position because all internationally adopted children that I’ve evaluated to date have traditionally been referred to me by a medical or a related professional (pediatrician or psychologist vs. a parent who’s contacted me without a specific referral) who felt that the child needed to be seen because of a specific speech or language deficit that was manifesting rather overtly (e.g., significant speech or language delay in birth language).

Since such referrals are frequently made within the child’s first 2 weeks of being in US (e.g., immediately following a visit to the pediatrician), I typically perform the initial speech and language assessment in Russian, using recently published Russian speech language pathology materials, which though are non-standardized (in Russia standardized speech and language protocols haven’t been developed yet) are still more reliable than the standardized tests translated from English. Here, my window of opportunity to assess the child in his/her native language is very narrow, as birth language attrition occurs very rapidly post adoption.

So what do these early speech and language assessments in the child’s birth language reveal to me?

Well, quite a lot actually!

Let’s start by age range:

First let’s talk about children ages 0-3.

Depending on a country, the youngest age children become available for adoption is 7-9 months and depending on length and complexity of the adoption process, may become legally adopted by 12 months of age or older. My first concern with this group (+/-1 – 3 years) is the child’s feeding and swallowing abilities. Difficulties may range from immature feeding skills (e.g., immature chewing abilities) to a more severe failure to thrive, to even structural or functional deviations of the swallow mechanism, which may require detailed imaging tests and subsequent dysphagia therapy. In some rare instances, more serious discoveries were made during those initial speech and language assessments such as presence of vocal webs and submucous clefts, conditions which actually required surgical intervention.

Another concern with this age range are the child’s speech and language abilities or I should say lack of thereof. In the case of younger children (15-18 months), the “red flag” is a complete absence of words, jargon, babbling or general lack of any sound production during both – their early development and the parent bonding pre-adoption period during which the parents intensively interact and communicate with the child. In older children (2.5-3 years of age) the “red flag” is the general absence of phrases and/or words in their birth language, which is a strong indication that assessment is merited.

Finally, with this age group, any form of abnormal social interaction should be thoroughly investigated. Many children who have resided in very deprived institutional environments may present with a pattern of autistic-type behaviors. In reaction to emotional trauma, loss of primary caregiver, isolation in hospital cribs, and lack of stimulation, some children may develop symptoms often found in autistic children and may exhibit limited communicative intent in the absence of speech (make limited gestures, vocalizations, eye contact, etc). As a result, an early speech and language assessment in conjunction with other testing (neurological, psychological, etc) may shed light on whether the child presents with a form of institutional autism or true autistic spectrum behavior.

Unfortunately, internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Knowing the above, oftentimes it is important to determine a degree of delay (severe vs. mild), and if it’s not that clear (especially if the child is under 3 years of age and the parents don’t speak the child’s birth language or are not familiar with typical developmental milestones) than a safer choice would be an initial speech and language assessment in the child’s birth language which can determine the type and degree of delay and make recommendations regarding the necessity of further services.

It is also important to highlight that a child’s mastery of the birth language is a good predictor of the rate of learning the new language. Many professionals make an error of assuming that internationally adopted infants and toddlers will not be affected by cross-linguistic interference because the children have just begun to learn the birth language at the time of adoption, before the attrition of birth language occurred. However, due to a complex constellation of factors, language delays in birth language transfer and become language delays in a new language. These delays will typically persist unless appropriate intervention is provided. For older children (3 years +), the delays will be very recognizable and will likely be part of the child’s adoption record but for younger children an early speech and language assessment may be the first step on the way to appropriate language remediation.

Now let’s talk about older children. In our second group, the age range at the time of adoption will range from 3-16 years (although it is important to note that most adopted older children will be in the range of 3-12 years, while adoption of children 12+ is somewhat less common).

Here, most speech and language delays will be more acutely pronounced and as a result far more recognizable. As mentioned above they will also probably be clearly documented in the child’s adoption records. With this age-range there are a number of concerns ranging from poor articulation to language delay to social pragmatic communication impairments.

So how do professionals and parents decide which child merits early assessment?
With regard to articulation, it’s important to keep in mind that if the child is limitedly intelligible in their birth language, they will continue making similar error patterns in English unless they receive appropriate intervention. So assessment is definitely merited.

Similarly, if at the time of adoption, a preschool or school age child presents with delayed language abilities in their birth tongue (e.g., inability to answer “wh” questions, speaking in phrases vs. sentences, etc) then no matter how quickly they will gain basic English proficiency, it is reasonable to expect that similar difficulty will be encountered in English with respect to academically based tasks. In other words they may gain basic skills fairly appropriately but then present with significant deficits acquiring higher level listening and speaking abilities required for long-term academic success.

Another reason why it’s important to assess a child in the birth language in the first few weeks post arrival has to do with their pragmatic language skills or the appropriate use of language. Pragmatic language ability is the ability to appropriately initiate conversations, maintain and terminate topics, appropriately narrate stories, understand jokes and sarcasm, interpret non-verbal body cues, all of which culminate into the child’s general ability to appropriately interact with others in a variety of social settings.

As mentioned above, many children who have resided in deprived institutional environments may present with a pattern of unusual social behaviors, be socially withdrawn, or present with poor ability to socialize with others. Thus, the longer is the period of time the child spends in the institutional environment the greater is the risk of social pragmatic deficits. Unfortunately, this important area of language often receives merely cursory attention.

To illustrate, in recent years I have assessed a number of adopted children, who were 5-7 years post adoption, and had never previously received any speech and language services. Once brought to US they quickly gained English language proficiency and did not seemingly present with any of the “red flags” described above.

The reason these children were referred for intervention so many years later was because “seemingly overnight” they developed numerous difficulties. Oh, they were still getting good grades and presented with adequate vocabulary skills. But both parents and educators were getting concerned that these children were acting very immature for their age, had problems socializing with other children, presented with difficulty understanding figurative language, could not understand non-verbal conversational and social cues, couldn’t coherently express their thoughts, and presented with significant difficulty understanding and retelling stories.

Interestingly, when questioned further, all interviewed parents revealed that the above difficulties had existed from the get-go albeit in a milder form in their child but in the presence of appropriate receptive and expressive skills these difficulties were not deemed worthy of assessment/ intervention. Had these children received early assessment when these problems were first noticed, the outcome (degree of impairment; duration of therapy) might have been entirely different.

Up until now we have discussed the ‘red flags’ which indicate the necessity for early speech and language assessment and intervention of adopted children in their birth language. However, once these children are in therapy, many parents would also like to know if there are any specific predictors for successful language remediation and decreased duration of services?

Unfortunately, it is impossible to answer this question definitively due to the variability of each child’s progress as well as the type and degree of their impairment. Having said that, from my personal clinical experience, what I have found is that if the child has good problem solving abilities (as per non-verbal IQ testing and certain language reasoning tasks) and grossly appropriate social pragmatic language skills, even if the child presents with a moderate-severe speech and language impairment, he/she will generally fare better in treatment with respect to duration of service as well as therapy gains, versus the less severely impaired peers with poorer problem solving and social pragmatic skills.

So, do all newly adopted children require early speech language assessments? Not, at all. However, understanding the “red flags” for each age group will be helpful for both parents and professionals when they make their decision to refer a newly adopted child for a an early speech-language assessment.

As always, if parents or related professionals would like to find more information on this topic, they should visit the ASHA website at www.asha.org and type in their query in the search window located in the upper right corner of the website.

 Posted by telleseff at 2:46 pm  Tagged with: ,

How to improve the feeding abilities of young adopted picky eaters.

 picky eaters, Smart Speech Therapy Article  No Responses »
Jun 302009
 

How to improve the feeding abilities of young adopted picky eaters.

Tatyana Elleseff MA CCC-SLP

It is an unfortunate fact that so many parents of adopted children are too familiar with the problem of food selectivity. Food selectivity, better known as “picky eating” is common in many formerly institutionalized children. It often develops due to numerous physical and sensory constraints associated with institutialization (e.g. an orphanage may feed their wards a highly limited diet lacking a variety of tastes and textures).

It is important to make a clear distinction between children who are picky eaters due to serious impairment (e.g., autism, neurological disorders, swallowing difficulties, etc) and children who were fed highly limited diets before their adoption took place. In the case of neurological impairment, picky eating will most likely not abate without intensive feeding intervention (typically performed by speech language pathologists who specialize in feeding and swallowing). However, in the case of picky eating due to institutionalization there are a few strategies that parents can try to work on improving their adopted child’s food selectivity. These strategies are intended to help parents figure out whether their child is just unused to new tastes and textures or whether it’s a more serious issue that merits professional consultation with a relevant provider (see above).

Picky eating can take so many forms. It may take form of a highly limited diet with exclusion of entire food groups (grains, vegetables etc) or it may involve the exclusion of foods with certain textures or tastes (e.g., crunchy, smooth, sour, bitter).

So why should we be concerned with picky eating habits? Children will grow out of that on their own, right? Well, it’s really not that simple. Limited nutritional intake for prolonged periods of time can stunt growth, cause acute/chronic illness and even limit the child’s social interactions.

“But what can we do?” ask frustrated parents. “We try to give them different foods but they don’t even want to look at them, much less eat them”…

The truth is that a simple (usually pleasurable) act of feeding designed to bond the child with his/her caretaker from the earliest age, can turn into a nightmare for both child and parent when food selectivity comes into play. It may also be further exacerbated by the following erroneous beliefs that some parents hold regarding feeding:

      1. Children will eat the food presented to them because there is nothing else to eat
    2. You can verbally cajole or bribe children into eating the foods that they need to eat

However, if the child’s food selectivity is extremely severe, chances are that he will choose to go hungry rather than eat foods that he considers repellent. In extreme circumstances, we may have a situation where a frustrated parent is trying to feed the child via any means possible (bribing, cajoling, threatening, force feeding), and the child is desperate to escape the same activity by any means possible (e.g., screaming, crying, spitting, vomiting).

The key here is to: “GO SLOW!” For example, never introduce a brand new dish to a child if you know it will elicit a strong reaction. Introduce new foods in little bits and pieces very gradually. It may also help placing bits of new foods and mixing them into existing foods the child is currently eating (e.g. placing bits of fruit [that the child refuses to eat on its own] into the child’s oatmeal). You will also have a much better chance in getting the child to try the new food if it has a similar look and texture of the food that they are already eating. For example, if the child only likes to eat “buckwheat kasha”, present the child with a similar “kasha” (e.g., oatmeal) to see if he is willing to try a small amount of the dish. It is equally important for a parent or a sibling to demonstrate how “yummy” the new food is so that your child is more receptive to intake.

One very important consideration that often comes into play with picky eaters is “sensory integration deficits”. Very briefly, sensory integration has to do with the child’s overall ability to self-regulate. Deficits in sensory integration may involve the child being hyper or hyposensitive to their immediate environment (e.g. inability to focus, impulsivity, high arousal or withdrawing from input, high tolerance of pain etc). They can also manifest in poor postural control (e.g. clumsy, constantly in motion) or in regards to feeding they may cause sensory defensiveness (hyper vigilance and intense avoidance of certain food textures and tastes).

Mild sensorimotor difficulties can be frequently observed in young adopted children during mealtimes. They can manifest in a variety of following ways: low tone of cheeks and lips (muscle feels mushy, soft, and lose), deficient chewing movements, poor tongue control during eating and drinking, poor discrimination and awareness of food in mouth [food stuffing, having bits of food in mouth for hours after a meal], open mouth posture and visible drooling during mealtimes, as well as poor attention (e.g., running around the table while eating) during feeding which may often result in episodes of coughing, mild choking, and drooling/loss of food from mouth.

Keeping the above in mind, the major goal of feeding is to decrease sensory defensiveness and increase the child’s acceptance of new foods via a hierarchy of sensory textures and tastes.

As stated above the first step to a varied diet is to start building upon the foods that the child already accepts. Consequently it is important for parents to create an inventory of foods that their child is willing to tolerate and foods that they refuse to eat.

      1. Make a list of the foods and drinks the child will accept and organize by sensory properties (e.g. crunchy, soft, etc)
      2. Make a list of other foods (that your child does not accept yet) in the same categories

During that time it is also helpful to rule out certain conditions that may make certain foods unpalatable to children. For example, food allergies and gastroesopageal reflux may not evidence as dramatically with some children as they evidence with others. Therefore, it is very important to rule them out before the initiation of new food trials.

So how do we begin?

For starters, structure all meals and snacks. The routine is intended to reduce mealtime anxiety and improve the child’s appetite. In order for the latter to occur it is very important to eliminate nibbling of non-scheduled snacks or filling juices between meals. It is also important to serve food in one specific designated area (e.g. dining room or kitchen) as opposed to any room in the house (e.g., bedroom, living room). Finally, try to limit meal presentation to 30 minutes. This is important for two reasons:

      1. Meals that take more than 30 minutes begin to increase the child’s fatigue and often cause loss of calories due to increased effort involved in food consumption
      2. Mealtime should not become “a never ending buffet” from which a child may partake whenever it strikes their fancy.

After the implementation of structure during meals, begin the introduction of new foods in tiny amounts to the child’s existing diet. Here you may work based on the following premise:

      1. Introduce foods with similar taste, color, and texture
      2. Once the child is somewhat accepting of new foods, gradually fade old foods so that the child is primarily eating the new foods (e.g., start with a few kernels of corn in mashed potatoes and as you continue working gradually replace all mashed potatoes with corn)
      3. Use a reward system for trying new foods (keep a plate of preferred food next to the plate with small amounts of new food; reward the child with preferred food after he has taken a small bite of the new food)
      4. If a child refuses to taste the new food compromise and negotiate for the child to touch (with lips/mouth) the new food without swallowing it (earn double rewards for swallowing food instead of just holding it in mouth and then spitting out)
      5. Always feed a child from dishes and cups and never from the original containers (e.g., juice boxes)
      6. Make sure that you go though a variety of utensils and dishes so the child does not become “stuck” on a set of feeding utensils (only wants to eat from specific set)
      7. Sand timers may be helpful for setting specific short term meal time limits for younger children
      8. Encourage your child to observe you prepare and serve food
      9. USE PRAISE FOR EVERY LITTLE EFFORT YOUR CHILD EXHIBITS IN REGARDS TO NEW FOOD TRIALS

Some important DONTS:

      1. Don’t ask a child what he wants or you will become a short-order cook (the goal is for the child to eat what the parents eat and not for the parent to eat what the child eats or make several meals per each mealtime)
      2. Don’t fight about food or have power struggles
      3. Don’t let the children watch TV during mealtimes or snacks
      4. Don’t let children play with food as it is messy, costly and is generally a waste of time (to date there’s no evidence that playing with food leads to food consumption as opposed to touching (to lips), smelling, and tasting food)

Chewing Development in children:

Jaw movement Age Appears

Phasic bite release 5-9 months

Munching pattern 9-12 months

Diagonal rotary chewing pattern 15 months +

Sustained bite (Chewing with lips closed.

May still lose food or saliva) 18-24months

Chews with closed lips (no loss of food/saliva) 24 months +

Food consumption guidelines for adopted infants and toddlers by age:

Foods Types Eaten Age Appears:

Liquids bottle 1 month

Liquids bottle & introduction of baby cereals/purees
(rice cereal, oatmeal) fruits and vegetables
(very ripe, mashed banana, apple sauce, pureed pear,
acorn or butternut squash, sweet potato) 4-8 months

Liquids, pureed foods, ground foods, and mashed
table foods (grains, fruits, vegetables, meats
such as turkey and chicken etc) 8-12 months

Liquids and coarsely chopped table foods 12-18 months

Liquids and all table foods 18 months +

While it is unusual to end an article with a disclaimer, it is important to mention again that this article was not written to discuss the feeding strategies for adopted children diagnosed with autism or any other serious neurological or genetic based disorders. It is also not intended for parents who are concerned with the swallowing abilities of their young adopted children. For above concerns, parents are strongly encouraged to schedule face to face consultations with speech language therapists in their area.

To find more information on this topic or to find a speech language pathologist in your area, visit the ASHA website and click on the ‘Public’ tab located at the top of the screen.

Best of luck and happy feeding!

References:
Feeding and Swallowing Disorders, American Speech-Language-Hearing Association, www.asha.org
Feeding and Nutrition for the Child with Special Needs, by Marsha Dunn Klein and Tracey A. Delaney, Therapy Skill Builders, 1994
Feeding and Swallowing Disorders in Infancy: Assessment and Management, by Lynn S. Wolf and Robin P. Glass, Therapy Skill Builders, 1992
Morris, Suzanne Evans and Marsha Dunn Klein; Pre-Feeding Skills, Second Edition; Therapy Skill Builders; 2000
Select Online Resources (pertaining to feeding milestones):

http://www.childrensmemorial.org/documents/TypicalDevelFeeding.pdf

http://www.cedwvu.org/programs/feeding/development.doc

http://www.latrobe.edu.au/hcs/projects/paed_feeding/Biting-Chewing.htm

 Posted by telleseff at 9:55 am  Tagged with: ,

Speech Language Services and Insurance Coverage: What Parents Need to Know

 insurance coverage, resource websites, Smart Speech Therapy Article, speech language pathology  No Responses »
May 272009
 

Speech Language Services and Insurance Coverage: What Parents Need to Know.

Tatyana Elleseff MA CCC-SLP

Introduction

When a child presents with speech and language deficits there are often several options that are available to parents when seeking services. Both, early intervention agencies (services at reduced cost) and school systems (services free of charge) provide speech language therapy services to children who qualify under a set of federal regulations and state education laws. Many hospitals also provide outpatient speech language services to children, though each facility has its own regulations regarding service provision, which may be significantly restricted.

To qualify for early intervention services, a child must be from 0-3 years of age. They must also present with a 33% delay (as per standardized testing) in one developmental area of functioning (e.g., speech and language) or a 25% delay in two or more developmental areas of functioning (e.g., cognitive and social emotional) in order to be picked up for therapy by an early intervention agency in your area. Even if children do qualify for speech services they may be placed on a waiting list if the agency is a very busy one or if they experience a shortage of speech language pathologists at that particular time.

In the school setting in order for the child (pre-K and up) to receive speech and language services they must be classified. This involves creating a “label” which translates into an “explanation” for the child’s speech and language difficulty. The severity of speech and language delay as well as overall functioning of the child will typically determine the “type of classification” the child will receive (e.g., in NJ if the child has a speech and language deficit only they may be classified as “Communication Impaired”). Unfortunately the vast majority of school districts require for the child to have a specific classification in order to be eligible for speech language therapy or any other special education services. Of course, during the course of therapy the child can be reclassified or even declassified depending on their progress and gains. However, some parents may not be happy with their child receiving a negative academic label due to a concern on how that label will affect their child’s future academic opportunities. As a result they may seek private therapy in order to keep their options open.

There are also many instances when the child may not be eligible for therapy services despite the display of an obvious speech and language deficits on their part. For example, their deficit may not be “great enough” to qualify them for services. In other instances, the child might qualify for services but the frequency may not be satisfactory to the parent (the child might get only one group therapy session and the parent feels they need 2 or 3 individual sessions).

As a result of the above, many parents often choose to pursue the services of a private speech and language therapist in order to either set up treatment or to supplement their child’s existing therapy sessions. Many of them choose to do it because supplemental therapy can often reduce the time children spend in treatment.

However, when families seek supplemental services from their health plan, they often discover that the majority of private health plans will not pay for the exact same services that are provided in early intervention or school settings. That is because unlike other therapies (e.g. physical therapy), whose sessions may be completely covered by your insurance, speech therapy is a whole other ball game. Consequently, below are some explanations of what speech therapy services your insurance may actually cover.

Assessment Coverage
Typically, parents don’t usually seek out speech language pathologists before consulting with other relevant professionals such as pediatricians and child psychologists. In the majority of cases it is usually the pediatrician who gives a referral for speech therapy services or at least for a speech language assessment.

It is important to note that most insurance policies will cover (partially or completely) initial speech and language evaluations even if the speech therapist is out of network. The first step is to call your insurance company and ask them what documentation is required to get assessment coverage. Here, depending on your insurance company, responses might vary. Some insurance companies require a written prescription from the doctor coupled with the precertification interview with the treating speech therapist. Typically the utilization management section of the insurance company deals with the precertification interview. After precertification takes place, make sure to ask your insurance representative regarding the coverage for the out of network therapists. Please note that many private practitioners don’t accept insurance. They will instead provide you with a letter for your insurance company, containing the necessary diagnosis and treatment codes, incurred fees as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Note: Parents should not assume that if assessment is provided in an outpatient hospital setting their health insurance will pay the bill. In many cases insurance denials result in the parents having to pay the full cost of the services provided. Hospital services can be very expensive. Assessments at hospitals vary from $260 to $1200 depending on the type and comprehensiveness of an assessment provided. Consequently, even if you do decide to seek assessment services from an outpatient hospital setting, you still need to check with your insurance company to make sure that this service will be covered.

The first step to insurance coverage for assessment is to speak to the insurance representative directly, even if your service provider had already done so for you. Parents are encouraged to do the above in order to avoid any misunderstanding and confusion, which may lead to costly errors. Just asking if you are covered for “speech” therapy is not enough to determine if you are covered for the specific treatment you need. Therefore, when asking about coverage, you want to ask which diagnostic and procedure codes your speech therapist should use to help assure the codes used accurately reflect the coverage you have. It is always better to learn and clearly understand information firsthand rather than from a third party, especially because the same coverage that pays for assessment may not cover therapy services: a fact that baffles and outrages many of the parents.

To reduce confusion, take detailed notes during all conversations with the insurance company. You may get conflicting information from different people at the insurance company and it will be important for you to write everything down as you move through this process. Always write down the date and time of your phone calls, as well as the name, phone number and department of the person you’re speaking with and their exact response to your question.

Therapy coverage
The truth is that most commercial health insurance speech therapy coverage is very limited for pediatric speech-language pathology services. Many policies exclude children by age (e.g., all children under 6) from coverage. Others refuse to cover school age children because they specify that the child is expected to receive speech language services in school settings. Some policies exclude children with congenital conditions, regardless of the nature or severity. Other policies state that they will pay for treatment of problems related to medical conditions, but will not pay for autism or developmental delays (e.g. late talkers, articulation deficits). MOST POLICIES DO NOT COVER DEVELOPMENTAL SPEECH THERAPY SERVICES.

A research of a few selected major insurance companies (e.g., Cigna, Aetna, Blue Cross, United Healthcare etc) yielded the following results in regards to coverage for speech therapy services:

Aetna US Healthcare Covers: Speech therapy for non-chronic conditions, illnesses, and injuries. Limits: treatment for a 60-day period per incident of illness or injury. Requires referral of PCP and prior approval by Aetna.

Blue Cross Blue Shield Covers: Outpatient short-term rehabilitation services for conditions which are expected to show significant improvement through short-term therapy, as determined by the PCP. Limits: Limited to a maximum of 30 visits per calendar year.

CIGNA / Healthsource Covers: Conditions that are expected to show significant improvement within a 60-day period, as determined by CHCNC. Covered for correcting speech disorders that are the result of diagnosed medical illness, surgery, or accidents only.

United HealthCare Covers: Short-term speech therapy provided under the direction of a participating provider. Limits: Limited to 20 visits per member per calendar year. Requires prior approval. Inpatient services are covered under the medical inpatient benefits. Excludes: Speech therapy for children of school age as these services must be provided through the school system.

Some insurance companies tend to explicitly specify exclusions to services. For example, here is an excerpt taken directly from the Blue Cross Blue Shield of Rhode Island website regarding speech therapy services: “Treatment of the following conditions is a contract exclusion: psychosocial speech delay, expressive language delay, behavioral problems (including impulsive behavior and impulsivity syndrome), attention disorders, conceptual handicap, mental retardation, autism, developmental delay (excluding BlueCHiP for RIte Care), stammering, or stuttering as treatment for these services are provided by the school department.”

However others do not explicitly state what kind of conditions will be excluded from coverage. For instance, your benefit’s handbook may state that speech therapy is a covered service; however, your plan may deny reimbursement for services based on your child’s diagnosis. Diagnoses that may be excluded from coverage include:• Apraxia

  •  • Autism
  •  • Central Auditory Processing
  •  • Congenital Disorder (i.e. Cleft Lip & Palate)
  •  • Developmental Delay
  •  • Mental Retardation
  •  • Language Disorder
  •  • Stuttering (Fluency)

When parents call the insurance company regarding coverage of therapy services, there are several important questions they need to ask:

      1. My child is ____old. Does our policy cover his speech services?
      2. What conditions will insurance specifically cover?
      3. What ICD-9 (diagnosis) codes and CPT (treatment) codes are covered for reimbursement?
      4. Do I need to obtain a prescription for therapy services?
      5. Do I need to obtain precertification for therapy services?
      6. Which conditions are specifically excluded from treatment?
      7. How many sessions will insurance cover? Is there a time limit?
      8. Do I have a deductible or co-pay?
      9. Do I need to schedule all of the visits by a certain date?
      10. Does insurance cover out of network therapy services?
                  11.  How do I get reimbursed for out of pocket therapy expenses? What do I need to provide the insurance company with?

Speech Language Services and diagnosis of Autism
It is important to note that when seeking speech language services for children diagnosed with Autism Spectrum Disorders (e.g., PDD, Asperger’s etc) there are 17 states that provide insurance coverage (California, Connecticut, Georgia, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Montana, New Hampshire, New Jersey, New York, Tennessee, and Virginia). Of these, 10 provide coverage for autism through their laws mandating coverage for mental illness (California, Illinois, Iowa, Kansas, Louisiana, Maine, Montana, New Hampshire, New Jersey, and Virginia). The other six states have specific laws regarding insurance coverage for autism (Georgia, Indiana, Kentucky, Maryland, New York, and Tennessee), which you can find directly in the policy.

Denials and Appeals
If you have the speech therapy benefits and the coverage for your child’s speech and language therapy is denied, always ask for the denial in writing and try to appeal the decision using the proper appeal procedure within your insurance company. Insurance companies count on consumers not appealing decisions. And the fact is that most people don’t do it because it’s a time consuming hassle. Along the way, document all conversations with insurance representatives. Documentation can be very helpful for an appeal. In some states, even if you have exhausted appeal procedures within your insurance company, you can appeal to your state’s insurance commission, some of which allow for the filing of complaints online.

Now that we have gone over the insurance process in some detail, please keep in mind that you can always learn more information on this and any other speech pathology related topic by visiting the ASHA website and clicking on the ‘Public’ tab located on the left side of the screen.

Selected References
1.http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0177_coveragepositioncriteria_speech_therapy.pdf
2. http://www.cga.ct.gov/2006/rpt/2006-R-0793.htm
3. http://www.insurancehelpforautism.com/insuranceletter.html
4. http://www.aetna.com/cpb/medical/data/200_299/0243.html
5. http://www.stutteringhelp.org/Default.aspx?tabid=71
6. http://www.asha.org/public/outreach/take-action/sample-apraxia.htm
7. https://www.oxhp.com/secure/policy/outpatient_speech_therapy_1208.html
8. https://www.bcbsri.com/BCBSRIWeb/plansandservices/services/medical_policies/SpeechTherapy.jsp
9. http://www.ican-online.org/advocacy/filing-insurance-complaint
10. http://www.asha.org/default.htm

 Posted by telleseff at 12:58 pm  Tagged with: ,

How to select the right speech language pathologist for your adopted child?

 internationally adopted children, Smart Speech Therapy Article, speech language pathology  No Responses »
May 112009
 

How to select the right speech language pathologist for your adopted child?

You have decided to consult a private speech language pathologist because of concerns over your adopted child’s developing speech and language. But how do you choose the right one? There are many speech therapists out there and not all of them are alike in experience and skills. On top of it all, you are also looking for a bilingual therapist, one who is not only proficient in your child’s native language but is also knowledgeable regarding the speech and language issues of international adoptees. That is not an easy decision to make, especially for many parents who until now have not had any direct contact with a speech language pathologist.
Not to worry, below is a list of simple guidelines designed to assist you in the right therapist selection.

Let’s begin with something basic: educational and professional credentials. A speech language pathologist must possess a Master’s Degree (or its equivalent) from a reputable academic institution of higher learning. They must also have a Certificate of Clinical Competence from the American Speech Language Hearing Association as well as an appropriate licensure from the state in which they maintain their practice. Additionally, it is highly recommended that they have Bilingual Certification as it indicates that they have completed the necessary academic coursework and are proficient in the issues surrounding normal and disordered speech-language acquisition of bilingual children in dual languages.

Now we are ready to proceed to experience. Here its gets a little tricky. The traditional approach: “I want the therapist with a gazillion years of experience” is just not going to be all that useful. It can’t be just any experience; it has to be the right experience! After all do you really want a therapist with 30 years of experience in exclusively treating articulation deficits when your child needs help with feeding and swallowing or with developing augmentative/alternative communication?

It is important to choose a therapist who has a rich and varied experience from multiple settings, total years of experience may not be as important as the qualitative value of that experience. A good therapist has probably spent a considerable portion of his/her time in a variety of settings from schools and early intervention agencies to hospitals and rehabilitation clinics. As the result of working in these diverse environments that therapist is much more likely to come up with innovative ideas and solutions to your child’s problems as opposed to just using the same old remediation strategies that they have learned way back then. It is also a good idea to inquire regarding the areas of specialization of the therapist in order to find out whether he/she has successfully treated children with similar problems to your child’s.

Typically, private speech language pathologists who maintain some type of pediatric hospital affiliation (e.g. per diem or part-time employees) are up to date regarding the current methodologies, which they apply to practice on daily basis. The reasons for that are twofold:

Speech departments in hospitals deal with diverse caseloads, with patients ranging in ages, diagnoses (some of which can be quite unusual), and levels of severity. In an average inpatient department staff SLP’s are expected to carry caseloads of 12-16 patients per day.
In order to keep up with the caseload diversity and with the latest treatment trends, hospitals require these SLP’s to actively take professional development courses in order to provide their patients with the best quality of care.
This brings us to another important consideration: professional development. To maintain their state licensure and national certification all therapists are required to take professional education courses in order to stay up to date with all the relevant research and new treatments developed in our field. The minimum requirement is to accumulate 30 professional education hours every 3 years whether by attending courses in person, taking them online through qualified providers, or by conducting workshops and presenting at conferences. Professional development provides the speech therapists with an opportunity to use evidence based techniques supported and tested by research to treat a variety of communication disorders. Consequently, when selecting your therapist it is important to find out just how up to date are they on the current treatment methods and methodologies pertaining to your child speech and language deficits. You can always find out this information by politely questioning the therapist regarding their background and “resume highlights.”

It is also important to find out whether you understand and agree with the therapist’s methods and approaches. For example, if your child is a toddler, it probably does not make sense for him/her to spend most sessions doing worksheets and drills when he/she needs to be engaged in play based, child centered therapy. Don’t be intimidated by the therapist’s credentials and your lack of knowledge, if something they said doesn’t make sense, ask follow up questions and/or look up pertinent information online. While you should not use the internet to diagnose your child’s problems, it can be used as a valuable learning tool to look up information and to share ideas with other parents who experience similar difficulties.

Now that we have specified general selection criteria, let’s talk about how to initiate your search for the right SLP. The best way is again to go online. Start your search by going to the ASHA website and clicking on the ‘Find Professional Button’ located in the top of the page and then follow the instructions on the screen. Fill out your search criteria carefully but don’t be too specific. For example, don’t look for a Russian speaking SLP in Blue Creek, California as you will probably not find one. Instead try typing in the first 3 digits of your zipcode or your state of residence (if it’s small enough) and don’t forget to specify the language of the practitioner. That will get you the optimum results.

Once you have located several candidates, you can narrow down the search by trying to learn something about them online. Google the clinician’s name (or the name of their practice) to see whether they have their own website, have written any articles or have been profiled by any organizations. To make sure that your practitioner’s licensure is up to date, visit your state’s speech language accreditation website and type in the last name of the professional. Typically, a window will pop up listing the therapists’ names alphabetically, find the one you are looking for and check if their license is active. Finally, armed with your research, create a list of questions that you might have for the practitioners and start making phone calls. Find out all the pertinent information and don’t forget to ask about rates which may differ depending on what services the practitioner is providing.

Please note that many private practitioners refuse to deal with insurance companies directly due to the hassle of multiclient billing as well as extended wait for reimbursement. They will instead provide you with a letter for your insurance company, containing the necessary diagnosis and treatment codes, incurred fees as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Now that we have gone over the selection process in some detail, please keep in mind that you can always learn more information on this and any other speech pathology related topic by visiting the ASHA website and clicking on the ‘Public’ tab located at the top of the screen.

Best of luck in your search and happy hunting!

Useful websites:
Find a Professional SLP on the ASHA website: http://www.asha.org/proserv/
State Contacts & Licensure Requirements: http://www.asha.org/about/legislation-advocacy/state/

 Posted by telleseff at 11:56 am  Tagged with: ,
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