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AAP: Council on Foster Care, Adoption and Kinship Care Presentation

Boston MA- First conference of the Fall 2011 season:

October 17, 2011: Got to co-present with my favorite pediatrician (Alla Gordina, MD, FAAP) an interesting clinical case in front of American Academy Of Pediatrics: Council on Foster Care, Adoption and Kinship Care. Granted my part was via phone and connection wasn’t great but it so nice to see medical professionals being interested in ancillary professionals’ perspective on issues of internationally adopted children.

Presentation Title: A Case of Isolated Social Pragmatic Language Deficits in an Internationally Adopted Child

Presentation Highlights:

Language based deficits may affect internationally adopted children many years post adoption

Even children adopted at very young ages can present with subtle BUT significant delays in select areas of functioning (see below)

One such delay may be in the area of social pragmatic functioning  or the use of language

Select examples of social pragmatic deficits include:

  • Impaired ability to appropriately interpret social situations, events and contexts
  • Impaired ability to create and convey messages to different audiences (adults vs. children)
  • Impaired ability to interpret facial expressions, body language and gestures
  • Difficulty labeling and identifying basic emotions of self and others
  • Poor or absent perspective taking (understanding thoughts and feelings of others)
  • Inappropriate initiation of social interactions (e.g., not knowing how to start a conversation or appropriately interrupt a game)
  • Comprehension of age-level abstract and inferential information (stories, sarcasm, figurative language, etc)
  • Missing “the big picture” (integrating ideas into a whole, synthesizing and summarizing information)
  • Poor connection and relatedness to peers

Implications for Professionals:

Very easy to misdiagnose a child with social pragmatic deficits as someone with psychiatric disturbances (e.g., ADHD or Autism) without multidisciplinary differential diagnosis

“Low risk referrals” do carry a significant risk of deprivation-related issues, which can surface years after adoption

Internationally adopted children with behavioral, listening, sensory, and any unusual deficits need a differential  diagnosis (including assessment of language abilities before a conclusive diagnosis is made)

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

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)

 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 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.


• 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

• 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

• 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:

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.

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

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 (
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 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


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.

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

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 and type in their query in the search window located in the upper right corner of the website.

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

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:
State Contacts & Licensure Requirements:

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Functional Strategies for Improving the Language Abilities of Your Adopted School-Age Child

Functional Strategies for Improving the Language Abilities of Your Adopted School-Age Child.

While most internationally adopted children catch up to their peers in language development somewhat quickly, not all internationally adopted children demonstrate equal progress by the time they reach school age. Below are some suggestions on how parents can facilitate their school age child’s language skills and improve their language abilities via fun interactive games that the whole family can enjoy and benefit from.

There are several language functions important for academic success. Typically this hierarchy develops from the most basic to the most complex, with the earliest stages beginning long before the child reaches school age. These functions include the ability to: seek information, inform, compare, order, classify, analyze, infer, justify/persuade, solve problems, synthesize, and evaluate. For some children those abilities come naturally while for others – a creative push in the right direction might just do the trick. Luckily, there are plenty of children’s games on the market that address the above skills in a fun and functional way, oftentimes without the child even realizing that they are doing work.

One of the earliest and important areas of language development is vocabulary knowledge. Good vocabulary skills are essential for communication of thoughts and ideas, interaction with peers, as well as meeting the demands of the classroom. As academic demands increase the importance of good vocabulary comes prominently into play. Vocabulary hierarchy ranges from a simple ability of labeling (providing a name for people, actions and objects) to the advanced descriptions (using attributes, functions, and learned concepts to depict an object/item in a cohesive manner). As children’s vocabulary increases from basic labeling to using sophisticated descriptions it goes through several other important stages outlined below:

• Concept Knowledge – the ability to comprehend and identify qualitative (e.g., same–different, big– little, hot-cold), quantitative (e.g., few-many, more-less), temporal (e.g., before-after, next, first, last), or spatial (e.g., in-on, under-over) concepts
• Associations – knowledge of how words are semantically related/linked (e.g., knowing why a spoon and a knife go together)
• Categorization/Classification – the ability to identify items within a category (divergent naming) and provide labels for groups/classes of objects (convergent naming)

The following are just a few selected examples of available games (a more complete list will be provided at the end of this article) that should help facilitate the development of vocabulary language skills:
A to Z Jr- a game of early categorizations is recommended for players 5 – 10 years of age, but can be used with older children depending on their knowledge base. The object of the game is to cover all letters on your letter board by calling out words in specific categories before the timer runs out. This game can be used to increase word finding abilities in children with weak language skills as the categories range from simple (e.g., colors) to more complicated (e.,. animals with stripes). This game is great for several players of different age groups (e.g., older siblings), since children with weaker knowledge and language skills can answer simpler questions and learn the answers to the harder questions as other players get their turn.

Tribond Jr – is another great game which purpose is to determine how 3 seemingly random items are related to one another. Good for older children 7-12 years of age it’s also great for problem solving and reasoning as some of the answers are not so straight forward (e.g., what do the clock, orange and circle have in common? Psst…they are all round)

Password Jr-is a great game to develop the skills of description. In the game you guess passwords based on the one word clues. This game is designed to play with children ages 7 years and older as long as the parents help the non readers with the cards. It’s great for encouraging children to become both better at describing and at listening. Parents are encouraged to allow their kids to select the word they want to describe in order to boost their confidence in own abilities. Parents are also encouraged to provide visual cheat sheets (listing ways we can describe something such as: what does it do, where does it go, how can we use it etc) to the child as they will be much more likely to provide more complete descriptions of the target words given visual cues.

Blurt – a game for children 10 and up is a game that works on a simple premise. Blurt out as many answers as you can in order to guess what the word is. Blurt provides ready-made definitions that you read off to players so they could start guessing what the word is. Players and teams use squares on the board strategically to advance by competing in various definition challenges that increase language opportunities.

However, vocabulary knowledge alone does not determine academic success. There are other equally valuable language skills which are important as well. One of them is asking and answering questions. Being able to ask and answer questions is an integral part of academic success.

Asking questions is one of the main ways that children obtain knowledge about the world beyond their immediate experience. Children who are unable to ask questions are at a disadvantage when it comes to following directions or understanding difficult concepts since they are unable to request repetition and clarification from speakers. Moreover, the inability to answer questions effectively is an indication that the child will not be understood well by others. Being able to answer concrete and abstract questions is another necessary requirement for success in school. Games such as Guess Who (age 6+), Guess Where (age 6+), and Mystery Garden (age 4+) are great for encouraging students to ask relevant questions in order to be the first to win the game. They are also terrific for encouraging reasoning skills. Questions have to be thought through carefully in order to be the first one to win the game.

Another important ability in the language learning hierarchy is story telling. Being able to tell good stories is a difficult task for many children, even those without language impairment. Consequently, one way of learning to become a good story teller is through the usage of visual cues such as picture cards, or games. When children are very young speech therapists often work on improving their story telling abilities using props such as a variety of toys or puppets. As they get older they transition to picture cards or wordless story books with the final step being spontaneously produced stories with no visual support. One of such games is Fib or Not (ages 10+). The game encourages the players to fool other players by either telling an outlandish true story or a truly believable made up story. For the players who are listening to the story, the objective is to correctly guess if the story teller is fibbing or being truthful. Players advance by fooling the other players or by guessing correctly.

As children grow older, they are required to do more and more tasks that focus on their verbal reasoning and problem solving abilities. If your child’s problem solving skills are on the weaker side consider using events from storybooks that illustrate problems. Talk aloud about the problem and offer a list of choices if your child is having difficulties figuring out the answers. Have your child talk through the process of how they arrived to their conclusions and offer suggestions and guidance along the way. The two popular games that work on improving verbal reasoning and problem solving abilities are: 30 Second Mysteries (ages 8-12) and 20 Questions for Kids (ages 7+).

In 30 Second Mysteries kids need to use critical thinking and deductive reasoning in order to solve mysteriously sounding cases of everyday events. Each clue read aloud reveals more about the mystery and the trick is to solve it given the fewest number of clues in order to gain the most points. In 20 Questions for Kids, a classic guessing game of people, places, and things, children need to generate original questions in order to obtain information. Here again, each clue read aloud reveals more about the secret identity and the trick is to solve it given the fewest number of clues.

A good way of implementing the above games in action is during family fun night. Select a game that focuses on one or more elements that you feel your child needs to work on and then involve your entire family in a game playing activity so the child does not feel that they are being isolated for “work”. For children who are younger or with weaker vocabularies, modify the rules to help to simplify the demands of the game, or play in a team so that the child doesn’t feel overwhelmed. Feel free to provide your own cues and prompts in order to achieve maximum success with all gaming activities.

Now that we have gone over the game description and selection process in some detail, please keep in mind that you can always learn more about children’s games by simply going to a popular internet websites such as Amazon and reading product descriptions in order to figure out whether specific game is right fit for your child.

As always, parents are advised to consult with related professionals (speech and language therapists, psychologists, etc) if they have any serious concerns regarding their child’s communication skills. Early detection and treatment are critical to the process of successful speech and language development not just in early childhood but also during school age, adolescence, and even early adulthood.

Best of luck and have fun playing!

List of Selected Games:
• 20 Questions for Kids
• 30 Second Mysteries
• A to Z Jr.
• Blurt
• Fib or Not
• Guess Where?
• Guess Who?
• Last Word
• Loaded Questions
• Mystery Garden
• Outburst
• Password Junior
• Tribond Junior