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Spotlight on Syndromes: An SLPs Perspective on CHARGE Syndrome

Today’s guest post on genetic syndromes comes from Rebecca Freeh Thornburg, who is contributing on CHARGE Syndrome.

Overview:

CHARGE Syndrome is an extremely complex genetic condition encompassing anomalies of multiple systems. CHARGE affects approximately 1 in every 9 to 10,000 live births, worldwide. Respiratory issues and complex cardiac defects often require early and frequent hospitalization and surgical intervention. Characteristic hearing and vision impairments also contribute to delays in development.  Early and ongoing intervention by speech-language pathologists and other members of a multi-disciplinary care team is critical in achieving best outcomes for children affected by CHARGE. Continue reading Spotlight on Syndromes: An SLPs Perspective on CHARGE Syndrome

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Test Review: (OPUS) Oral Passage Understanding Scale

Today I am reviewing a listening comprehension assessment for students 5-21 years of age, entitled the Oral Passage Understanding Scale (OPUS) created by Elizabeth Carrow-Woolfolk, PhD, and Amber M. Klein, PhD, which is available via WPS.

The OPUS is a test of listening comprehension which assesses the following forms of knowledge: lexical/semantic (knowledge and use of words and word combinations), syntactic (knowledge and use of grammar, as well as supralinguistic (knowledge and use of indirect/complex language). Continue reading Test Review: (OPUS) Oral Passage Understanding Scale

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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Spotlight on Syndromes: An SLPs Perspective on 22q Deletion Syndrome

Today’s guest post on genetic syndromes comes from Lauren Laur, who is contributing a post on the 22q11.2 Deletion Syndrome.

22q11.2 Deletion Syndrome is a syndrome of many names. Also known as Velocardiofacial Syndrome, Shprintzen syndrome as well as DiGeorge Syndrome, 22q11.2 Deletion Syndromeis is caused by a microdeletion on the long arm of chromosome 22 (at location marker q11.2).  This syndrome follows an autosomal dominant inheritance pattern (a child only needs to get the abnormal gene from one parent in order to inherit the disease), however, only around 10% of cases are inherited; the majority of cases are due to a random mutation. Continue reading Spotlight on Syndromes: An SLPs Perspective on 22q Deletion Syndrome

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Improving Executive Function Skills of Language Impaired Students with Hedbanz

Those of you who have previously read my blog know that I rarely use children’s games to address language goals.  However, over the summer I have been working on improving executive function abilities (EFs) of some of the language impaired students on my caseload. As such, I found select children’s games to be highly beneficial for improving language-based executive function abilities.

For those of you who are only vaguely familiar with this concept, executive functions are higher level cognitive processes involved in the inhibition of thought, action, and emotion, which located in the prefrontal cortex of the frontal lobe of the brain. The development of executive functions begins in early infancy; but it can be easily disrupted by a number of adverse environmental and organic experiences (e.g., psychosocial deprivation, trauma).  Furthermore, research in this area indicates that the children with language impairments present with executive function weaknesses which require remediation.

EF components include working memory, inhibitory control, planning, and set-shifting.

  • Working memory
    • Ability to store and manipulate information in mind over brief periods of time
  • Inhibitory control
    • Suppressing responses that are not relevant to the task
  • Set-shifting
    • Ability to shift behavior in response to changes in tasks or environment

Simply put, EFs contribute to the child’s ability to sustain attention, ignore distractions, and succeed in academic settings. By now some of you must be wondering: “So what does Hedbanz have to do with any of it?”

Well, Hedbanz is a quick-paced multiplayer  (2-6 people) game of “What Am I?” for children ages 7 and up.  Players get 3 chips and wear a “picture card” in their headband. They need to ask questions in rapid succession to figure out what they are. “Am I fruit?” “Am I a dessert?” “Am I sports equipment?” When they figure it out, they get rid of a chip. The first player to get rid of all three chips wins.

The game sounds deceptively simple. Yet if any SLPs or parents have ever played that game with their language impaired students/children as they would be quick to note how extraordinarily difficult it is for the children to figure out what their card is. Interestingly, in my clinical experience, I’ve noticed that it’s not just moderately language impaired children who present with difficulty playing this game. Even my bright, average intelligence teens, who have passed vocabulary and semantic flexibility testing (such as the WORD Test 2-Adolescent or the  Vocabulary Awareness subtest of the Test of Integrated Language and Literacy ) significantly struggle with their language organization when playing this game.

So what makes Hedbanz so challenging for language impaired students? Primarily, it’s the involvement and coordination of the multiple executive functions during the game. In order to play Hedbanz effectively and effortlessly, the following EF involvement is needed:

  • Task Initiation
    • Students with executive function impairments will often “freeze up” and as a result may have difficulty initiating the asking of questions in the game because many will not know what kind of questions to ask, even after extensive explanations and elaborations by the therapist.
  • Organization
    • Students with executive function impairments will present with difficulty organizing their questions by meaningful categories and as a result will frequently lose their track of thought in the game.
  • Working Memory
    • This executive function requires the student to keep key information in mind as well as keep track of whatever questions they have already asked.
  • Flexible Thinking
    • This executive function requires the student to consider a situation from multiple angles in order to figure out the quickest and most effective way of arriving at a solution. During the game, students may present with difficulty flexibly generating enough organizational categories in order to be effective participants.
  • Impulse Control
    • Many students with difficulties in this area may blurt out an inappropriate category or in an appropriate question without thinking it through first.
      • They may also present with difficulty set-shifting. To illustrate, one of my 13-year-old students with ASD, kept repeating the same question when it was his turn, despite the fact that he was informed by myself as well as other players of the answer previously.
  • Emotional Control
    • This executive function will help students with keeping their emotions in check when the game becomes too frustrating. Many students of difficulties in this area will begin reacting behaviorally when things don’t go their way and they are unable to figure out what their card is quickly enough. As a result, they may have difficulty mentally regrouping and reorganizing their questions when something goes wrong in the game.
  • Self-Monitoring
    • This executive function allows the students to figure out how well or how poorly they are doing in the game. Students with poor insight into own abilities may present with difficulty understanding that they are doing poorly and may require explicit instruction in order to change their question types.
  • Planning and Prioritizing
    • Students with poor abilities in this area will present with difficulty prioritizing their questions during the game.

Consequently, all of the above executive functions can be addressed via language-based goals.  However, before I cover that, I’d like to review some of my session procedures first.

Typically, long before game initiation, I use the cards from the game to prep the students by teaching them how to categorize and classify presented information so they effectively and efficiently play the game.

Rather than using the “tip cards”, I explain to the students how to categorize information effectively.

This, in turn, becomes a great opportunity for teaching students relevant vocabulary words, which can be extended far beyond playing the game.

I begin the session by explaining to the students that pretty much everything can be roughly divided into two categories animate (living) or inanimate (nonliving) things. I explain that humans, animals, as well as plants belong to the category of living things, while everything else belongs to the category of inanimate objects. I further divide the category of inanimate things into naturally existing and man-made items. I explain to the students that the naturally existing category includes bodies of water, landmarks, as well as things in space (moon, stars, sky, sun, etc.). In contrast, things constructed in factories or made by people would be example of man-made objects (e.g., building, aircraft, etc.)

When I’m confident that the students understand my general explanations, we move on to discuss further refinement of these broad categories. If a student determines that their card belongs to the category of living things, we discuss how from there the student can further determine whether they are an animal, a plant, or a human. If a student determined that their card belongs to the animal category, we discuss how we can narrow down the options of figuring out what animal is depicted on their card by asking questions regarding their habitat (“Am I a jungle animal?”), and classification (“Am I a reptile?”). From there, discussion of attributes prominently comes into play. We discuss shapes, sizes, colors, accessories, etc., until the student is able to confidently figure out which animal is depicted on their card.

In contrast, if the student’s card belongs to the inanimate category of man-made objects, we further subcategorize the information by the object’s location (“Am I found outside or inside?”; “Am I found in ___ room of the house?”, etc.), utility (“Can I be used for ___?”), as well as attributes (e.g., size, shape, color, etc.)

Thus, in addition to improving the students’ semantic flexibility skills (production of definitions, synonyms, attributes, etc.) the game teaches the students to organize and compartmentalize information in order to effectively and efficiently arrive at a conclusion in the most time expedient fashion.

Now, we are ready to discuss what type of EF language-based goals, SLPs can target by simply playing this game.

1. Initiation: Student will initiate questioning during an activity in __ number of instances per 30-minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

2. Planning: Given a specific routine, student will verbally state the order of steps needed to complete it with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

3. Working Memory: Student will repeat clinician provided verbal instructions pertaining to the presented activity, prior to its initiation, with 80% accuracy  given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

4. Flexible Thinking: Following a training by the clinician, student will generate at least __ questions needed for task completion (e.g., winning the game) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

5. Organization: Student will use predetermined written/visual cues during an activity to assist self with organization of information (e.g., questions to ask) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

6. Impulse Control: During the presented activity the student will curb blurting out inappropriate responses (by silently counting to 3 prior to providing his response) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

7. Emotional Control: When upset, student will verbalize his/her frustration (vs. behavioral activing out) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

8. Self-Monitoring:  Following the completion of an activity (e.g., game) student will provide insight into own strengths and weaknesses during the activity (recap) by verbally naming the instances in which s/he did well, and instances in which s/he struggled with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

There you have it. This one simple game doesn’t just target a plethora of typical expressive language goals. It can effectively target and improve language-based executive function goals as well. Considering the fact that it sells for approximately $12 on Amazon.com, that’s a pretty useful therapy material to have in one’s clinical tool repertoire. For fancier versions, clinicians can use “Jeepers Peepers” photo card sets sold by Super Duper Inc. Strapped for cash, due to highly limited budget? You can find plenty of free materials online if you simply input “Hedbanz cards” in your search query on Google. So have a little fun in therapy, while your students learn something valuable in the process and play Hedbanz today!

Related Smart Speech Therapy Resources:

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What do Narratives and Pediatric Psychiatric Impairments Have in Common?

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

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Quality Assessments for Students with Suspected/Confirmed “APD”

Recently I wrote a blog post offering a free handout for parents and professionals entitled, “Deconstructing Auditory Processing Disorder (APD) for Parents and Professionals: Informational Handout“. While it was incredibly well-received, it resulted in numerous professionals asking the same questions:

  1. How do we help students with “APD?
  2. What constitutes a good quality assessment for a student with “APD”?

Today I would like to answer the above questions by providing further helpful information and links for parents and professionals seeking evidence-based assistance for students with suspected/confirmed “APD”.

Continue reading Quality Assessments for Students with Suspected/Confirmed “APD”
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Making Our Interventions Count or What’s Research Got To Do With It?

Image result for effective interventionTwo years ago I wrote a blog post entitled: “What’s Memes Got To Do With It?” which summarized key points of Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“. It delved into answering the following question: “Why do some terms, labels, ideas, and constructs [in our field] prevail whereas others fail to gain acceptance?”.

Today I would like to reference another article by Dr. Kamhi written in 2014, entitled “Improving Clinical Practices for Children With Language and Learning Disorders“.

This article was written to address the gaps between research and clinical practice with respect to the implementation of EBP for intervention purposes.

Dr. Kamhi begins the article by posing 10 True or False questions for his readers:

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

Guess what? Only statement 8 of the above quiz is True! Every other statement from the above is FALSE!

Now, let’s talk about why that is!

First up is the concept of learning vs. generalization. Here Dr. Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful. He explains that when we are talking about generalization – what children truly have a difficulty with is “transferring narrow limited rules to new situations“. “Children with language and learning problems will have difficulty acquiring broad-based rules and modifying these rules once acquired, and they also will be more vulnerable to performance demands on speech production and comprehension (Kamhi, 1988)” (93). After all, it is not “reasonable to expect children to use language targets consistently after a brief period of intervention” and while we hope that “language intervention [is] designed to lead children with language disorders to acquire broad-based language rules” it is a hugely difficult task to undertake and execute.

Next, Dr. Kamhi addresses the issue of instructional factors, specifically the importance of “varying conditions of instruction and practice“.  Here, he addresses the fact that while contextualized instruction is highly beneficial to learners unless we inject variability and modify various aspects of instruction including context, composition, duration, etc., we ran the risk of limiting our students’ long-term outcomes.

After that, Dr. Kamhi addresses the concept of distributed practice (spacing of intervention) and how important it is for teaching children with language disorders. He points out that a number of recent studies have found that “spacing and distribution of teaching episodes have more of an impact on treatment outcomes than treatment intensity” (94).

He also advocates reducing evaluative feedback to learners to “enhance long-term retention and generalization of motor skills“. While he cites research from studies pertaining to speech production, he adds that language learning could also benefit from this practice as it would reduce conversational disruptions and tunning out on the part of the student.

From there he addresses the limitations of repetition for specific tasks (e.g., text rereading). He emphasizes how important it is for students to recall and retrieve text rather than repeatedly reread it (even without correction), as the latter results in a lack of comprehension/retention of read information.

After that, he discusses treatment intensity. Here he emphasizes the fact that higher dose of instruction will not necessarily result in better therapy outcomes due to the research on the effects of “learning plateaus and threshold effects in language and literacy” (95). We have seen research on this with respect to joint book reading, vocabulary words exposure, etc. As such, at a certain point in time increased intensity may actually result in decreased treatment benefits.

His next point against processing interventions is very near and dear to my heart. Those of you familiar with my blog know that I have devoted a substantial number of posts pertaining to the lack of validity of CAPD diagnosis (as a standalone entity) and urged clinicians to provide language based vs. specific auditory interventions which lack treatment utility. Here, Dr. Kamhi makes a great point that: “Interventions that target processing skills are particularly appealing because they offer the promise of improving language and learning deficits without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (95) The problem is that we have numerous studies on the topic of improvement of isolated skills (e.g., auditory skills, working memory, slow processing, etc.) which clearly indicate lack of effectiveness of these interventions.  As such, “practitioners should be highly skeptical of interventions that promise quick fixes for language and learning disabilities” (96).

Now let us move on to language and particularly the models we provide to our clients to encourage greater verbal output. Research indicates that when clinicians are attempting to expand children’s utterances, they need to provide well-formed language models. Studies show that children select strong input when its surrounded by weaker input (the surrounding weaker syllables make stronger syllables stand out).  As such, clinicians should expand upon/comment on what clients are saying with grammatically complete models vs. telegraphic productions.

From there lets us take a look at Dr. Kamhi’s recommendations for grammar and syntax. Grammatical development goes much further than addressing Brown’s morphemes in therapy and calling it a day. As such, it is important to understand that children with developmental language disorders (DLD) (#DevLang) do not have difficulty acquiring all morphemes. Rather studies have shown that they have difficulty learning grammatical morphemes that reflect tense and agreement  (e.g., third-person singular, past tense, auxiliaries, copulas, etc.). As such, use of measures developed by ; (e.g., Tense Marker Total & Productivity Score) can yield helpful information regarding which grammatical structures to target in therapy.

With respect to syntax, Dr. Kamhi notes that many clinicians erroneously believe that complex syntax should be targeted when children are much older. The Common Core State Standards do not help this cause further, since according to the CCSS complex syntax should be targeted 2-3 grades, which is far too late. Typically developing children begin developing complex syntax around 2 years of age and begin readily producing it around 3 years of age. As such, clinicians should begin targeting complex syntax in preschool years and not wait until the children have mastered all morphemes and clauses (97)

Finally, Dr. Kamhi wraps up his article by offering suggestions regarding prioritizing intervention goals. Here, he explains that goal prioritization is affected by

  • clinician experience and competencies
  • the degree of collaboration with other professionals
  • type of service delivery model
  • client/student factors

He provides a hypothetical case scenario in which the teaching responsibilities are divvied up between three professionals, with SLP in charge of targeting narrative discourse. Here, he explains that targeting narratives does not involve targeting sequencing abilities. “The ability to understand and recall events in a story or script depends on conceptual understanding of the topic and attentional/memory abilities, not sequencing ability.”  He emphasizes that sequencing is not a distinct cognitive process that requires isolated treatment. Yet many SLPs “continue to believe that  sequencing is a distinct processing skill that needs to be assessed and treated.” (99)

Dr. Kamhi supports the above point by providing an example of two passages. One, which describes a random order of events, and another which follows a logical order of events. He then points out that the randomly ordered story relies exclusively on attention and memory in terms of “sequencing”, while the second story reduces demands on memory due to its logical flow of events. As such, he points out that retelling deficits seemingly related to sequencing, tend to be actually due to “limitations in attention, working memory, and/or conceptual knowledge“. Hence, instead of targeting sequencing abilities in therapy, SLPs should instead use contextualized language intervention to target aspects of narrative development (macro and microstructural elements).

Furthermore, here it is also important to note that the “sequencing fallacy” affects more than just narratives. It is very prevalent in the intervention process in the form of the ubiquitous “following directions” goal/s. Many clinicians readily create this goal for their clients due to their belief that it will result in functional therapeutic language gains. However, when one really begins to deconstruct this goal, one will realize that it involves a number of discrete abilities including: memory, attention, concept knowledge, inferencing, etc.  Consequently, targeting the above goal will not result in any functional gains for the students (their memory abilities will not magically improve as a result of it). Instead, targeting specific language and conceptual goals  (e.g., answering questions, producing complex sentences, etc.) and increasing the students’ overall listening comprehension and verbal expression will result in improvements in the areas of attention, memory, and processing, including their ability to follow complex directions.

There you have it! Ten practical suggestions from Dr. Kamhi ready for immediate implementation! And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation. They include:

References:

Kamhi, A. (2014). Improving clinical practices for children with language and learning disorders.  Language, Speech, and Hearing Services in Schools, 45(2), 92-103

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

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The Art of Asking for Help

Richie is an engaging 9 year old boy, who attends therapy to improve his language skills. He is compliant and cooperative in sessions and is eager to learn new information. There’s only one problem, Richie is unable to spontaneously ask questions and request clarification when he doesn’t understand the presented information. Oh, he’ll sit there quietly, intently looking at the therapist and making perfect eye contact. His entire body posture will scream at you “I am listening to you and I value what you have to say!” But when it comes to answering questions about what he’s just learned, Richie clearly doesn’t get it and has no clue on how to obtain it! He might attempt to answer the questions and stumble half way through before giving up. He might also provide a response completely unrelated to the presented question. But most of the time, much to your frustration, Richie will simply shrug his shoulders and reply “I don’t know”. This is typically when many graduate speech interns and CFs alike will ask him with barely disguised frustration: “Why didn’t tell me before you didn’t understand?” Richie will shrug his shoulders again. Oh, he is not trying to be oppositional, he really doesn’t know! Continue reading The Art of Asking for Help

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Why Do I Have to Tell You What’s Wrong with My Child? Or On the Importance of Targeted Assessments

A few days ago I received a phone call from a parent who was seeking a language evaluation for her child. As it is my policy with all assessments, I asked her to fill out an intake and a checklist to identify her child’s specific areas of difficulty in order to compile a comprehensive and targeted testing battery.  Her response to me was: “I’ve never heard of this before? Why do I have to tell you what’s wrong with my child? Why can’t you figure it out?” Similarly, last week, another parent has questioned: “So you can’t do the assessment without this form?” Given the above questions, and especially because May is a Better Hearing and Speech Month #BHSM, during which it is important to raise awareness about communication disorders, I want to take this time to explain to parents why performing targeted speech language assessments is SO CRUCIAL.

To begin with it is very important to understand that speech and language can be analyzed in many different ways beyond looking at pronunciation, vocabulary or listening and speaking skills.

Targeted areas within the scope of practice of pediatric school based speech language pathologists include the assessment of:

  • SPEECH
    • The child may have difficulties with pronunciation of sounds in words, stutter, clutter, have a lisp or have difficulties in the areas of voice, prosody, or resonance. For the majority of  the above difficulties completely different tests and testing procedures may be needed in order to appropriately assess the child.
  • LANGUAGE
    • Receptive Language
      • Ability to follow directions, answer questions, recall sentences, understand verbal messages, as well as comprehend orally presented text
    • Memory and Attention 
      • Also see executive function skills
    • Expressive Language
      • Vocabulary knowledge and use, formulation of words and sentences as well as production of narratives or stories
    • Problem Solving
      • Verbal reasoning and critical thinking skills are very important for successful independent decision making as well as for interpretation of academically based texts and complete assignments
    • Pragmatic Language 
      • Successful use of language for a variety of communicative purposes
        • Initiate and maintain topics, maintain conversational exchanges, request help, etc
    • Social Emotional Competence
      • Effective interpersonal negotiation skills, compromise and negotiation abilities, as well as perspective taking are integral to academic and social success. These abilities are often compromised in children with language disorders and require a thorough assessment
    • Executive Functions (EFs) 
      • These are higher level cognitive processes involved in inhibition of thought, action and emotion, which are located in the prefrontal cortex of the frontal lobe of the brain.  
      • Major EF components include working memory, inhibitory control, planning, and set-shifting. EFs contribute to child’s ability to sustain attention, ignore distractions, and succeed in academic settings. 
  • READING DISABILITIES AND DYSLEXIA
    • Phonological Awareness
    • Reading Ability
    • Writing
    • Spelling 

One General Language Test Does Not Fit All! 

Children with speech and language disorders do not necessarily display weaknesses in all affected areas but may only display difficulties in selected few.

To illustrate, high functioning students on the autistic spectrum may have very strong academic skills related to comprehension and expression of language but may display significant social pragmatic language weaknesses, which will not be apparent on general language testing (e.g., administration of Clinical Evaluation of Language Fundamentals -5). Thus, the administration of a general language test will be contraindicated for these students as it will only show typical performance on these tests and will not qualify them for targeted language based services that they need.  However, by administering to them a testing battery composed of tests sensitive to social pragmatic language competence will highlight their areas of difficulty and result in a creation of a targeted intervention plan to improve their abilities in the affected areas. 

Similarly, children at risk for reading disabilities will not benefit from the administration of general language testing either, since their deficits may lie in the areas of sound discrimination, isolation, or blending as well as as impaired decoding ability.  So the administration of tests sensitive to phonological awareness and emergent reading ability would be much more relevant. 

This is exactly why taking an extra step and filling out a simple form will result in a much more targeted and beneficial speech language assessment for the child.  The goal of any competent professional assessment is to eliminate the administration of unnecessary and irrelevant tests and focus only on the administration of instruments directly targeting the areas of difficulty that the child presents with.  Given the fact that assessment of language covers so many broad areas, it makes perfect sense to ask parents to fill out relevant checklists/intakes as a routine part of a pre-assessment procedure.  Otherwise, even after observations in school setting, I would still just be blindly ‘fishing’ for deficits without really knowing whether I will  ‘accidentally stumble upon them’ using a general test at hand.

Of course, even checklists need to be targeted by age and areas of functioning. Here’s how I use mine. When performing comprehensive fist time assessments I ask the parent to fill out the comprehensive checklists based on the child’s age.    These are broken down as follows:

However, oftentimes when I perform reassessments or second opinion evaluations, I may ask the parent to fill out checklists pertaining to specific, known, areas of difficulty. These currently include:

After the parent fills the checklist out, the child’s areas of difficulty literally jump out from the pages. Now, all I need to do is to choose the appropriate testing instruments, which will BEST help me determine the exact nature and cause of the child’s deficits and I am all set. I administer the testing, interpret the results and write a comprehensive report detailing which therapy goals will be targeted. And this is why pre-assessment checklist administration is so important.

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