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Test Review: Clinical Assessment of Pragmatics (CAPs)

Today due to popular demand I am reviewing the Clinical Assessment of Pragmatics (CAPs) for children and young adults ages 7 – 18, developed by the Lavi Institute. Readers of this blog are familiar with the fact that I specialize in working with children diagnosed with psychiatric impairments and behavioral and emotional difficulties. They are also aware that I am constantly on the lookout for good quality social communication assessments due to a notorious dearth of good quality instruments in this area of language.

I must admit when I first learned about the existence of CAPs in May 2018, I was definitely interested but quite cautious. Many standardized tests assessing pragmatics and social language contain notable psychometric limitations due to the inclusion of children with social and pragmatic difficulties into the normative sample. This, in turn, tends to overinflate test scores and produce false negatives (a belief that the child does not possess a social communication impairment due to receiving average scores on the test).  Furthermore, tests of pragmatics such as Test of Pragmatic Language -2 (TOPL-2) tend to primarily assess the child’s knowledge of rules of politeness and knowing the right thing to say under a particular set of circumstances and as such are of limited value when it comes to gauging the child’s ability to truly assume perspectives and adequately showcase social cognitive abilities.

The CAPs is a unique test as compared to others with a similar purpose, due to the fact that the testing administration (which can take between 45-60 mins) is conducted exclusively via videos. The CAPs consists of 6 subtests and 3 indices.

Subtests (You can read up more on the comparison of the CAPs subtests HERE ):

Instrumental Performance Appraisal (IPA) subtest (Awareness of Basic Social Routines) is a relatively straightforward subtest which examines the student’s ability to be polite in basic social contexts. The student is asked to first identify “if anything went wrong in the presented scenario?” After that, the student is asked to explain, what went wrong and how s/he knows? Targeted structures include greeting and closure, making requests, responding to gratitude, requesting help, answering phone calls, asking for directions, asking permission, etc.  Goals: can the student discern between appropriate and inappropriate language and then provide a verbal rationale in a coherent and cohesive manner.

Score types: (2) correct identification of problem or lack of thereof + correct justification; (1) correct identification but incorrect rationale; (0) incorrect identification.

Social Context Appraisal (SCA) subtest (Reading Context Cues) requires the student to engage in effective perspective taking (assume mutual vs. individual perspectives) by identifying sarcasm, irony, and figurative language in the presented video scenarios. The student is then asked to provide a coherent and cohesive verbal explanation and effectively justify own response.

Score types: (3) correct identification of the problem or lack of thereof + identification of idiom or sarcasm + reference to both characters actions; (2) correct identification of the problem or lack of thereof + identification of idiom or sarcasm + reference to one character’s actions; (1) correct identification of the problem or lack of thereof but an inability to verbalize the problem in the situation; (0) for incorrect identification.

Paralinguistic Decoding (PD) subtest (Reading Nonverbal Cues) assesses the students’ ability to notice and interpret micro-expressions and nonverbal language.  The aim of this subtest is to have the students grasp what went wrong vs. well in the presented videos, assume mutual perspectives,  as well as verbally justify their responses providing adequate and relevant details.

Score types: (3) correct identification of the problem or lack of thereof + explanation of situation + reference to both characters facial expressions and tone of voices; (2) correct identification of the problem or lack of thereof + explanation of situation  + reference to one character’s facial expression and tone of voice  (1) correct identification of the problem or lack of thereof but an inability to explain actions and/or nonverbal body language; (0) for incorrect identification.

Instrumental Performance (IP) subtest (Use of Social Routine Language) assesses the student’s ability to use rules of politeness (e.g., make requests, respond to gratitude, answer phone calls, etc.) by providing adequately supportive responses using first-person perspectives relevant to various social situations.

Score types: (2) appropriate introduction + use of supportive statements; (1) appropriate introduction without the use of supportive statements; (0) inappropriate intent of message or use of impolite language 

Affective Expression (AE) subtest (Expressing Emotions) assesses the student’s ability to effectively display empathy, gratitude, praise, apology, etc., towards affected peers in the video scenario. It requires the usage of relevant facial expressions, tone of voice, as well as stating appropriately supportive comments.

Score types: (2) expresses empathy, praise, apology, gratitude, etc. along with supportive statements +appropriate facial and prosodic affect; (1) expresses empathy, praise, apology, gratitude, etc. + appropriate facial and prosodic affect without relevant supportive statements;   (0) provides an approrpiate response but lacks adequate prosody and affect, or message contains inappropriate intent 

Paralinguistic Signals (PS) subtest (Using Nonverbal Cues)assesses the student’s ability to appropriately use facial expressions, gestures, and prosody (act out vs. recognize and interpret facial expression and gestures). This includes showing appropriate expression of empathy, frustration, alarm, excitement, gratitude, etc., exhibiting relevant inflection in prosody as well as showing appropriate to the situation facial expression (vs. having inappropriate message intent, be monotone, have flat affect, etc.)

Score types: (2) appropriately expresses urgency, empathy apology, etc. +exhibits inflections in prosody and shows relevant facial expressions; (1) appropriately expresses urgency, empathy apology, etc. +exhibits inflections in prosody without showing relevant facial expressions  (0)   inappropriate intent of message or monotone prosody. 

Indices (information regarding the student’s pragmatic proficiency):

  1. Pragmatic Judgement (Sum of IPA, SCA & PD scaled scores)
  2. Pragmatic Performance (Sum of IP, AE & PS scaled scores)
  3. Paralinguistic (Sum of PD, AE & PS scaled scores)

Based on the administration of this test the following goals can be formulated for remediation purposes:

Long Term Goal: Student will improve pragmatic abilities for social and academic purposes

Short-Term Objectives: 

  1. The student will verbally identify instances of politeness or impoliteness in presented social routines
  2. The student will provide relevant justifications explaining which aspects of the presented scenarios were appropriate vs. inappropriate
  3. The student will verbally identify sarcasm, irony, and figurative language in presented social scenarios
  4. The student will effectively explain sarcasm, irony, and figurative language in presented social scenarios
  5. The student will verbally interpret micro-expressions and nonverbal body language  (e.g., they feel disgusted; the girl is smirking, the man’s hands are crossed, etc.)
  6. The student will effectively use rules of politeness and provide adequately supportive responses using first-person perspectives pertaining to various aspects of social scenarios
  7. The student will display a range of emotional expressions via the use of relevant facial expressions, tone of voice when providing supporting responses
  8. The student will state appropriately supportive comments regarding relevant social scenarios
  9. The student will use a range of facial expressions, gestures, and relevant prosody pertinent to the provided social scenarios

Furthermore, this test comes with a Contextualized Assessment of Pragmatics Checklist as well as a downloadable  Free Report Template.

Multiple videos posted by the Lavi Institute showcasing individual subtest administration can be accessed by clicking on the above-highlighted links as well as on YouTube.

Psychometrics: the normative sample consisted of 914 individuals out of which 137 (or 15%)  included individuals with atypical language development: ASD: N-18; SLI: N-27; Other (Learning Disabilities): N-92.

Excellent Sensitivity and Specificity Cut Scores (at 1, 1.5 & 2 SD) for clients with ASD ONLY:

Impressions:  To date, I have used this assessment with only 3 students. As such, expect multiple updates of this post as I continue to document how well it suited to identify children with social communication difficulties. Below are my preliminary impressions on how well this test is suited for children with varying pragmatic profiles.

A. Initial Assessment: 8-3-year-old male diagnosed with Autism

The CAPs had captured the student’s display of pragmatic deficits extremely well.  It was able to highlight the student’s relative strengths as well as pervasive pragmatic needs.  Based on the results of the CAPs, I was able to generate relevant pragmatic goals to target with this student in therapy.

B.  Yearly Reassessment: 8-11-year-old diagnosed with Anxiety:

I definitely had some trepidation about how well the CAPs will be able to capture this student’s pragmatic difficulties. This student was initially assessed via the Social Language Development Test-Elementary (SLDTE), which did show deficits in the areas of making inferences, interpersonal negotiation, as well as multiple interpretations of social situations. However, subsequent to his assessment that student did exceptionally well in treatment and had improved exponentially. While I knew that the student was not done with the treatment quite yet, I wasn’t certain if the CAPs was capable of picking up his subtle social pragmatic difficulties. Much to my surprise, the CAPs was effective in highlighting my student’s difficulties on a number of subtests including those pertaining to the effective reading and use of context and nonverbal cues, comprehension  and interpretation of irony and sarcasm, effective support of peers via a variety of statements relevant to social situations (coherent and cohesive sentence formulation given relevant details), as well as use of relevant prosody, facial expressions, tone of voice, and nonverbal cues.

C. Initial Assessment: 11-year-old student with suspected language and literacy deficits 

This was definitely the trickiest assessment subject from my small sample. Based on the collected data I suspected the student had social communication deficits, however, given his relative strengths in a variety of areas and that the fact that no one had previously brought it up, I truly did not anticipate that CAPs will effectively and accurately identify his pragmatic needs. As expected, the student did quite well on that “easier” subtests of the CAPs: (IPA, IP, and AE). However, I was very pleasantly surprised that the CAPs had accurately picked up on the fact that the student presented with difficulty reading both context and nonverbal cues as well as using nonverbal cues to effectively answer the presented questions.

Summary: While my sample of subjects has been quite small to date, I fully intend to continue using the CAPs with students of varying ages with varying diagnoses in order to continue refining profile of students who will significantly benefit from CAPs administration for assessment and reassessment purposes.

MISC:

Current Cost $149

Where to purchase: Effective 1/7/19 on the WPS Publishing website

There you have it! These are my impressions of using the CAPs in my settings. How about you? Have you used this test with any of your students to date? If yes, what are some strengths and limitations you are noticing?

 

 

 

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Dear SLPs, Try Asking This Instead

Image result for functionalI frequently see numerous posts on Facebook that ask group members, “What are your activities/goals for a particular age group (e.g., preschool, middle school, high school, etc.) or a particular disorder (e.g., Down Syndrome)? After seeing these posts appear over and over again in a variety of groups, I decided to write my own post on this topic, explaining why asking such broad questions will not result in optimal therapeutic interventions for the clients in question.

Firstly, while it’s highly desirable to select a thematic activity to address a variety of treatment objectives, it’s important to make sure that the goal selection takes primacy in this process and the choice of the activity does not inform goal selection. To illustrate, one recommendation seen frequently around this time of year is to download “Thanksgiving ‘Following Directions’ Activity” from TPT and utilize it with students of various ages. The problem with this recommendation is that ‘following directions’ activities possess very significant limitations and do not functionally transfer/generalize towards academic or social gains. In contrast, keeping the particular students’ goals in mind, the clinicians can ask for Thanksgiving book recommendations with a particular emphasis (e.g., social themes, character education, verbal reasoning, speech sounds, etc.) to functionally address the students’ goals during the treatment sessions in a fun, evidenced-based and thematic way.

Furthermore, it is very important to understand that there is a significant heterogeneity of symptoms as pertaining to the manifestations of language and literacy deficits in children of various ages.  As such, while many children with language and literacy impairments will have some broad common difficulties (e.g., poor comprehension of metalinguistic and metacognitive language, abstract text, etc.), most of them will require a great deal of fine-tuning with respect to goal selection in order to optimize intervention outcomes.

Image result for preschoolLet’s address one common response on social media as pertaining to goal formulation for preschool children.  One common response is, “I recommend phonological/phonemic awareness goals” for that age group.  However, let’s analyze this response in-depth in order to determine its suitability for the children in question.  Phonological awareness is a broad skill, or an umbrella term, which involves identification and manipulation of words, syllables, as well as onsets (initial consonants/consonant blends) and rimes (vowels and final consonants). Examples of the above activities include recognition and production of rhymes, clapping/tapping/counting syllables in words, recognizing words which start with similar sounds, etc. Phonological awareness at times confused with: phonemic awareness a subset of skills which involve manipulation (isolation, segmentation, blending, replacing, etc.) of phonemes (sounds) in syllables and words.

Image result for phonemic awarenessIn other words, neither phonological nor phonemic awareness are isolated skills. Both involve a hierarchy of complexity, from simple to a more difficult progression of tasks.  As such, a general recommendation to address either one does not take into consideration the fact that while preschool children may have deficits in both areas, without a comprehensive assessment of both areas, the treating clinician does not know where in a hierarchy the children are developmentally and which skills need to be addressed. For example, the treating clinician may begin with addressing the production of rhyming words, without knowing that the children may have already mastered that stage. Conversely, without additional information, the clinician may not know that the children are not even at a rhyme recognition stage yet, and as a result are unable to master the rhyme production stage, due to skill deficits.

Image result for middle schoolNow let us move on to another broad recommendation as the response to, “What goals do you address in middle school?” Again, numerous responders will produce suggestions to address social communication. However, social communication is also a broad umbrella term which encompasses numerous goals pertaining to pragmatics, social cognition, social awareness, etc. Furthermore, a number of researchers in this area had explicitly pointed out that interventions should focus on a specific skill deficit rather than prescribing a general social skills program for all students, which may not address their individual areas of difficulty (Gresham et al., 2000). So yes, the simple answer is that certain types of goals will definitely be beneficial for a certain type of students. However, without thorough assessments of deficit areas, the clinicians will not know for certain whether the goals they are addressing are truly appropriate for particular students in question.

On this note, let me switch gears and make some recommendations which may be helpful for the purpose of creating more efficient and effective treatment practices.  As mentioned previously, the first step to goal determination is some form of an assessment.  Now, remember, the assessment doesn’t have to be standardized or even complete. If you feel that your students can benefit significantly in a particular area of functioning be it phonemic awareness, decoding, morphological awareness, interpretation of ambiguous language, etc., the first step is to probe deeper their abilities in that particular area. It can be done on an informal basis in the context of therapy sessions. Furthermore, it could also be administered informally to the students in a small group setting in order to determine the starting point of therapy.

Image result for assessmentSuch an assessment should yield an extensive amount of information regarding the student’s strengths and needs as well as determine the starting point of therapy or even if therapy in a certain area of functioning is even warranted.  Let’s illustrate via the following example.  You are working with a group of 5-grade students and you are noticing that their reading abilities are significantly below grade level. You wish to implement a literacy intervention in your therapy sessions (which is greatly commendable) and you decide to provide phonemic awareness intervention to these kids because they reading abilities appear to be really quite low.  You begin your intervention and administer it for a period of six weeks. They do incredibly well during that time period with their tasks and you feel incredibly hopeful that what you did will significantly improve their reading abilities. However, at the end of that six-week period, you are dismayed to find out that none of their teachers have noticed any tangible difference in the reading abilities.  You are confused. You did everything by the book. Or did you?

Actually, had you administered to them some basic measures of phonemic awareness as well as decoding prior to the initiation of your intervention you would have found out the following:

  1. Your students’ phonemic awareness abilities were intact in the targeted areas
  2. You didn’t actually target a subset of phonemic abilities which strongly correlate with decoding (phonemic blending and manipulation) (Kilpatrick, 2012)
  3. Your students were actually reading above the second grade level as a result of which you didn’t have to target their phonemic abilities (Hogan, Catts, & Little, 2005) and instead targeting their decoding abilities would have been far more beneficial with respect to goal functionality.

So here are a few takeaway messages. Targeting broad short-term goals with students in certain age groups or diagnosed with particular disorders, lacks functionality without fine-tuning those broad goals specifically to address subareas of difficulty. It is very important to implement periodic informal clinical assessment measures to ensure that the clinician is on the right track and is targeting areas that actually require treatment and that the treatment targets are commensurate with the student’s abilities and level of functioning (not too complex). Asking specific questions vs. generalized/nonspecific ones will better assist with optimizing treatment options:

  • “What informal measures are sensitive to determining _____?”
  • “I am working on ___ with my students to improve their _____. I would like to locate ____ for extra opportunities to address my treatment targets.”
  • “Is there evidence that working on ___ will generalize to ____?”
  • “What steps can I take to determine that the goals I am targeting ______are functional for the students in question given the following _______?

Finally, incorporating relevant literacy tasks into language-based treatment sessions for all students is one way to maximize the impact of intervention targets, decrease time spent in therapy, as well as optimize treatment outcomes.

For more information regarding FREE EBP assessment and treatment materials pertaining to speech language pathology, visit SLPs for Evidence-Based Practice group on Facebook.

References:

  1. Gresham, F. M., MacMillan, D., Beebe-Frankenberger, M. E. & Bocian, K. M. (2000). Treatment integrity in learning disabilities intervention research: Do we really know how treatments are implemented? Learning Disabilities Research and Practice, 15, 198-205.
  2. Hogan, T.P., Catts, H., & Little, T. (2005). The relationship between phonological awareness and reading: Implications for the assessment of phonological awareness. Language, Speech, and Hearing Services in the Schools, 36, 285-293.
  3. Kilpatrick, D. A. (2012). Phonological segmentation assessment is not enough: A comparison of three phonological awareness tests with first and second graders. Canadian Journal of School Psychology, 27(2), 150-165.
  4. Kilpatrick, D. A. (2012). Not all phonological awareness tests are created equal: Considering the practical validity of phonological manipulation vs. segmentation. Communiqué: Newspaper of the National Association of School Psychologists, 40(6), 31-33.
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Why “good grades” do not automatically rule out “adverse educational impact”

Image result for good grades?As a speech-language pathologist (SLP) working with school-age children, I frequently assess students whose language and literacy abilities adversely impact their academic functioning.   For the parents of school-aged children with suspected language and literacy deficits as well as for the SLPs tasked with screening and evaluating them, the concept of ‘academic impact’ comes up on daily basis. In fact, not a day goes by when I do not see a variation of the following question: “Is there evidence of academic impact?”, being discussed in a variety of Facebook groups dedicated to speech pathology issues.

At first glance, the issue of academic impact appears to be rather straightforward. For example, many SLPs will readily assert that if a child is receiving good grades (A’s and B’s) in the school setting and is not exhibiting any “significant” maladaptive and challenging behaviors, then there is no evidence of adverse academic impact, and screening/evaluation/intervention services are unnecessary.

Unfortunately, things are not as “crystal clear” as they appear. That is because of the relative subjectivity pertaining to the grading practices of the students’ work in the school setting. Now, before you accuse me of inventing a problem where there is none, please hear me out.

In this post, I would like to illustrate how the subjectivity of grading practices can obfuscate the issue of academic impact to such an extent that students with significant language and learning needs may not be identified as being in need of help until it’s far too late – if identified at all.

Related imageLet’s begin with reading, an incredibly complex and deeply misunderstood process, especially in settings which do not utilize scientifically informed practices (e.g., synthetic phonics) when teaching young children to read.  When it comes to the teaching and assessment of reading, it is an absolute Wild West out there! And no one is more familiar with it, than parents of reading impaired children.

One of the first things these parents notice about their children in the early grades is that their reading abilities are highly inconsistent and are not commensurate with those of their peers.  These parents will notice that it takes their kids an extraordinary amount of time to master the alphabetic principle (remember the letters of the alphabet, match letters to sounds, etc.). They will notice that their children have an extraordinarily difficult time blending simple three letter words involving initial and final consonants with a medial vowel (e.g., “nob”). They will complain that their children display inconsistent knowledge of “sight words” from day to day, as well as misread and skip words when reading.

Here is the problem though, unless objective measures are used to test their children’s phonemic awareness and phonics abilities, there is a very strong possibility that these issues will persist well into upper elementary years, completely unnoticed in the school system, given the subjectivity involved in assessing reading mastery.

Indeed, numerous studies highlight the lack of efficacy of build-in assessments in programs such as Fountas and Pinnell, Reading Recovery, as well as the utility of utilizing Running Records, for reading assessment purposes.  My clinical observations of struggling readers in a variety of school settings, as part of the independent evaluation process, certainly support and corroborate available research on the subject. Namely, in many educational disputes, there’s a significant mismatch between teacher claims “S/he is reading at grade level as per (insert subjective method here)”  and observed student’s abilities (child is functionally illiterate) during reading tasks in the classroom. 

Related imageNow, let’s move on to discuss the subjectivity of the weekly spelling test. A number of scientific studies on this subject have shown that spelling instruction needs to be direct, explicit and systematic in order to be effective for struggling learners. When teaching spelling, best instruction practices involve consistently addressing and grouping words according to specific spelling patterns rather than teaching random “grade level” or topically related words. However, in the vast majority of instances, the weekly spelling test continues to consist of random words which are expected to be memorized by students. As a result of these memorization practices, numerous students will attain high marks on spelling tests but will be absolutely unable to correctly spell these words in a variety of writing assignments even a week later.

Image result for children taking a testThe practice of teaching to the test is certainly not restricted to spelling.  I have also seen similar practices pertaining to the subjects of science and social studies, whereas children are provided with specific handouts pertaining to a particular topic to memorize for the test. While this allows these children to perform well on such tests, unfortunately, their topic knowledge remains minimal to nonexistent given the fact that the memorized information will be long forgotten in a period of just a few weeks, if not sooner.

Similarly, science projects and social studies book reports may not even be necessarily completed by the children themselves. Many parents of struggling learners will readily acknowledge the mammoth work they had contributed to such projects just so their children could attain good marks which were worth a significant percentage of the overall class grade.

Many parents of struggling learners will also readily admit their significant involvement in the homework process and how stressful and frustrating it is on the students. They report spending numerous hours each day explaining information, their children’s tears of frustration and rage, significant tantrum behavior, and in some extreme cases even visits to a hospital, subsequent to accidental injuries stemming from challenging behaviors.

Finally, the subjectivity of grading written assignments is another important factor that needs to be explicitly acknowledged. Many parents and professionals tasked with the evaluation of the students’ spontaneous written work will readily confirm that oftentimes the grades some struggling learners receive on written assignments appear to be almost ridiculously overinflated.  Despite seemingly clear rubrics provided to the students explaining the breakdown of points for a particular written composition, many students end up receiving much higher marks than they deserve.  I myself have observed this phenomenon firsthand by reviewing the written work of my clients in private practice following parental complaints of grade inflation.

Related imageWe’re talking essays, blatantly lacking in coherence and cohesion, peppered with run-on and fragmented sentences, lacking subject-verb agreement, and full of grammatical errors, given A- and B+ grades, when the grading rubrics which came with the assignment, clearly indicate that the work is at the best deserving of a C- or a D+ grade.

These are just some of the many reasons why students of all ages with very noticeable language and learning needs, may end up being denied much-needed language and literacy assessments to determine the extent of their difficulties in order to receive targeted assistance.

Further complicating this issue is the fact that even when these students are finally tested in the school setting, due to the relative “mildness”  of their deficits,  coupled with the use of general (vs. targeted), often psychometrically weak tests, a lack of or under-identification of their deficit areas often occurs.

So what can parents and professionals do with this information? For starters, all are encouraged to examine the available information through a critical lens, albeit in different ways. Parents are encouraged to collect the samples of the child’s work (independent writing and spelling, audio samples of their reading, etc.) highlighting the discrepancies between the grades they receive and their actual abilities. They should absolutely request child study team assessments and if they are unsatisfied with the results of those tests they can seek out independent evaluations pertaining to the child’s areas of concern.

Image result for high sensitivity high specificitySimilarly, SLPs are encouraged to review their testing practices to ensure that they accurately reflect the students’ deficit areas. They are also strongly encouraged to review the psychometric properties of the tests they are using to better understand the sensitivity and specificity of these instruments with respect to the appropriate identification of language disorders. Finally, SLPs are strongly encouraged to familiarize themselves with the language and literacy expectations of older students and utilize clinical assessment procedures which reflect more sensitive assessment practices.

Image result for falling dominoesSo the next time someone has concerns regarding the language and literacy abilities of students with seemingly good grades, do not be so hasty in dismissing their worries due to a “lack of academic impact”. Depending on the setting and testing in question,  that impact may be far greater than we know!

Helpful Related Posts: 

  1. Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know
  2. What Makes an Independent Speech-Language-Literacy Evaluation a GOOD Evaluation?
  3. What Research Shows About the Functional Relevance of Standardized Language Tests
  4. Part II: Components of Comprehensive Dyslexia Testing – Phonological Awareness and Word Fluency Assessment
  5. On the Limitations of Using Vocabulary Tests with School-Aged Students
  6. It’s All Due to …Language: How Subtle Symptoms Can Cause Serious Academic Deficits
  7. Dear Reading Specialist, May I Ask You a Few Questions?
  8. Help, My Student has a Huge Score Discrepancy Between Tests and I Don’t Know Why?
  9.  The Reign of the Problematic PLS-5 and the Rise of the Hyperintelligent Potato
  10. Components of Qualitative Writing Assessments: What Exactly are We Trying to Measure?

 

 

 

 

 

 

 

 

 

 

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Updated: How Early can “Dyslexia” be Diagnosed in Children?

Image result for dyslexiaIn recent years there has been a substantial rise in awareness pertaining to reading disorders in young school-aged children. Consequently, more and more parents and professionals are asking questions regarding how early can “dyslexia” be diagnosed in children.

In order to adequately answer this question it is important to understand the trajectory of development of literacy disorders in children.

Image result for ida dyslexiaAccording to the definition set forth by the International Dyslexia Association“Dyslexia is a specific learning disability that is neurobiological in origin. It is characterized by difficulties with accurate and/or fluent word recognition and by poor spelling and decoding abilities. These difficulties typically result from a deficit in the phonological component of language that is often unexpected in relation to other cognitive abilities and the provision of effective classroom instruction. Secondary consequences may include problems in reading comprehension and reduced reading experience that can impede growth of vocabulary and background knowledge.”

Thus, despite the significant controversy over the use of the label “dyslexia”, as being ‘unscientific and conceptually problematic’, the above definition affirms the fact that it is undisputedly a linguistically based disability.   While it is true that merely using the term “dyslexia” does not automatically evoke our understanding of what type of specific reading-related deficits the child is experiencing, which prevents him/her from reading effectively, it does alert us right away to the fact that a reading disability exists.

In this post, rather than utilizing the term “dyslexia”, I will use a more broad term “literacy deficits” to refer to children who develop trouble reading, writing, and spelling.

Image result for genetic inheritanceSo who exactly are those children? Well, with respect to genetic inheritance, children with immediate and/or extended family members who have in the past received diagnoses such as “dyslexia”, “reading disability”, “learning disability” or who had experienced special education placements during school years are significantly more at risk of developing literacy based deficits than children with no history of above problems in the family.

Unfortunately, the situation is further complicated by the fact that some children with no recognizable family history of learning disabilities, may be at risk for future literacy deficits if they display a pattern of linguistic difficulties during early development (e.g., delayed developmental milestones).

Below is the approximate hierarchy of language development in young children:

  • Exploration of the environment (early socio-emotional development)
  • Play (continuation of socio-emotional development)
  • Receptive Language
    • Comprehension of  words, phrases, sentences, stories
  • Expressive Language
    • Speaking single words, phrases, sentences, engaging in conversations, producing stories
  • Social Emotional Development (Pragmatics) continues to be refined and becomes more sophisticated
  • Reading
    • Words, sentences, short stories, chapter books, etc.
    • General topics
    • Domain specific topics (science, social studies, etc)
  • Spelling
  •  Writing
    • Words, sentences, short stories, essays

The fact is that if the child experiences any deficits in the foundational language areas such as listening and speaking, s/he will most certainly experience difficulties in more complex areas of language: reading, writing, and spelling.

So now that we know that children with a history of language delay/disorder are at a significant risk of having the disorder turn into a learning disability when they’re older, let’s talk about how early can these children be assessed in order to better plan their future literacy based interventions for optimal functional outcomes.

The first scenario is a more obvious one.  If a child has a documented history of language impairments and is receiving services from a very early age (e.g., early intervention, preschool, etc.) then given what we know about the connection between language disorders and learning disabilities, professionals can begin administering phonological awareness/emergent reading interventions during the early preschool years in order to optimally facilitate the child’s literacy outcomes.

Image result for detective clipartNow our second scenario is not so clear-cut. In our second scenario, the child may have never been identified as having language difficulties during toddlerhood or even early preschool years. However, as the child grows older (e.g., 4-5 years of age) his/her parents may be noticing some subtle difficulties such as difficulty remembering nursery rhymes and songs, trouble remembering the letters of the alphabet, trouble recognizing simple rhyming words, etc.  A such, even without a pertinent family history of literacy disabilities it may be important for a child to undergo an early literacy assessment in order to determine whether intervention is warranted.

Now let’s talk about various assessment options available for preschool children with suspected literacy deficits.  Firstly, if the child has never received a language assessment it is paramount that the child’s language abilities in the areas of listening comprehension, verbal expression, problem-solving and social communication be assessed prior to assessment of literacy  to ensure that the child does not present with any unrecognized/previously undetected deficits in any of the above areas.  This is done in order to ensure optimal intervention outcomes as failure to address gaps/deficits in foundational language areas may significantly impede any potential literacy gains even when the child is provided with optimal literacy based interventions (click HERE to view my post discussing select speech-language tests for preschool children 2-6 years of age).

Now that we’ve covered some basics let us move on to discuss how early can select literacy tests be administered.  Luckily, there are a number of tests pertaining to literacy which can be administered to children as young as 3:6 years of age.

Image result for asa pearsonTo illustrate: The Auditory Skills Assessment (ASA) can be administered to children 3:6—6:11 years of age. Present controversy over CAPD notwithstanding, it does assess important areas related to early phonological awareness development including nonsense word repetition, phonemic blending, as well as rhyming.

Image result for ctoppThe Comprehensive Test of Phonological Processing-2 —(CTOPP-2), starts at 4 years of age and assesses such areas as:

  • Phonological Segmentation
  • Blending Words
  • Sound Matching
  • Initial, Medial and Final Phoneme Isolation
  • Blending Nonwords*
  • Segmenting Nonwords*
  • Memory for Digits
  • Nonword Repetition*
  • Rapid Digit Naming 
  • Rapid Letter Naming 
  • Rapid Color Naming 
  • Rapid Object Naming 

(—Assesses the ability to manipulate real and *nonsense words)

(—Assesses word fluency skills via a host of rapid naming tasks)

Image result for Emerging Literacy & Language Assessment®For children 4:6 years of age and older the  Emerging Literacy & Language Assessment (ELLA) deserves a mention. It assesses the following literacy related abilities:

  • Section 1 – Phonological Awareness and Flexibility assesses rhyming (awareness and production), initial sound identification, blending and segmenting sounds, words, and syllables, and deleting and substituting sounds in the initial and final positions of words.
  • Section 2 – Sign and Symbol Recognition and Interpretation assesses environmental symbol identification, letter-symbol identification, word reference association, and reading comprehension for one to three sentences.
  • Section 3 – Memory, Retrieval, and Automaticity assesses rapid naming, word associations (name items that start with the “S” sound), and story retell (includes three story levels based on the child’s age).

For children between 5:0-9:11 years of age, —The Phonological Awareness Test-: NU (PAT 2: NU assesses the following areas:

  • —Rhyming:  Discrimination and Production—identify rhyming pairs and provide a rhyming word
  • —Segmentation:  Sentences, Syllables, and Phonemes—dividing by words, syllables and phonemes
  • —Isolation:  Initial, Final, Medial—identify sound position in words
  • —Deletion:  Compound Words, Syllables, and Phonemes—manipulate root words, syllables, and phonemes in words
  • —Substitution With Manipulatives—isolate a phoneme in a word, then change it to another phoneme to form a new word
  • —Blending:  Syllables and Phonemes—blend units of sound together to form words
  • —Graphemes—assess knowledge of sound/symbol correspondence for consonants, vowels, consonant blends, consonant digraphs, r-controlled vowels, vowel digraphs, and diphthongs
  • —Decoding—assess  general knowledge of sound/symbol correspondence to blend sounds into nonsense words
  • —Invented Spelling (optional)—write words to dictation to show encoding ability

The new Test of Auditory Processing Skills-4 (TAPS-4) begins at 5 years of age and covers several areas pertaining to phonological awareness including word discrimination of words, phonological deletion and blending segmentation, as well as supplemental syllabic blending abilities.

Furthermore, starting from 5 years of age the —Rapid Automatized Naming and Rapid Alternating Stimulus Test RAN/RAS  tests can be administered in order to assess the child’s word fluency skills.  Decreased word fluency is a significant indicator of reading deficits, which is why this ability is very important to test.

—In addition to the above assessments, there are several tests of early reading and writing abilities which are available for younger children with suspected literacy deficitsThe  Test of Early Reading Ability–Fourth Edition (TERA-4assesses  the emergent reading abilities of children starting from 4-0 years of age. Similarly, the Test of Early Written Language, Third Edition (TEWL-3) assesses  the emergent writing abilities of children also starting from 4:0 years of age.

So there you have it! Now you know that if needed children as young 3:6 years of age can undergo early literacy assessments in order to determine their potential risk of developing literacy deficits when older.

Of course, due to the precociously young age of the children, it is important for examiners to exercise significant caution when it comes to interpretation of standardized testing results. It is a well-documented fact that standardized tests present with numerous limitations when it comes to identification of children with language and literacy disorders.

As such, due to the children’s young age there will be a number of instances when testing may reveal “false negative results” (show that there are no deficits when deficits still exist).  Consequently, in such cases, it is important to carefully monitor the child’s school performance in order to perform a literacy reassessment (if needed) when the child is older and his/her difficulties may be more apparent (click HERE to view my 4-part post discussing Components of Comprehensive Dyslexia Testing for further details).

Finally, it is very important to reiterate that children presenting with language and literacy deficits will not outgrow these deficits on their own. While there may be periods of “illusory recovery” when it looks like children with early language disorders have caught up with their peers, such “spurts” are typically followed by a “post-spurt plateau” (Sun & Wallach, 2014). This is because due to the ongoing challenges and an increase in academic demands “many children with early language disorders fail to “outgrow” these difficulties or catch up with their typically developing peers” (Sun & Wallach, 2014).  That is why it is crucial that we identify language and literacy deficits in children at a very early age in order to ensure their optimal educational outcomes.

Related Posts:

Helpful Smart Speech Therapy Resources Pertaining to Preschoolers: 

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Editable Report Template and Tutorial for the Test of Integrated Language and Literacy

Today I am introducing my newest report template for the Test of Integrated Language and Literacy.

This 16-page fully editable report template discusses the testing results and includes the following components:

  • Table of testing results
  • Recommendations for using severity ratings of percentile ranks
  • Recommendations of which information to include in the background history section of the report
  • Teacher Interview Samples for Adolescent and Elementary Aged Students
  • Classroom Observations Sample
  • Adaptive behavior section sample
  • Assessment findings
    • All subtests descriptions
    • Extensive descriptions of how to analyze error patterns on all subtests
    • Descriptions of how to analyze scenarios when a student obtains average performance but it contradicts academic functioning.
    • Elaborations regarding specific subtests, weaknesses on which are not as apparent or straightforward (e.g., Nonword Repetition, Following Directions, etc.)
    • Recommendations for supplemental testing when the performance on select subtests (e.g., Social Communication) is within the average range despite glaring weaknesses
    • Extensive error descriptions that can be found on the Reading Fluency subtest
    • Extensive footnotes with clarifying information
    • Links to a variety of TILLS FREE tutorials created by the authors
    • Impressions section formulation
    • Possible ICD-10 diagnoses that can result based on TILLS assessment
    • Accommodations Section
    • Adaptive Recommendations Section
    • Maintaining Factors Section
    • Suggested Therapy Long and Short Term Goals Sampler for
      • Listening Comprehension
      • Oral Communication
      • Social Communication
      • Phonological Awareness
      • Phonics
      • Reading Fluency
      • Reading Comprehension
      • Spelling
      • Writing Conventions
      • Writing Composition
      • Reward System and Rationale
      • Expected duration of treatment
      • Prognosis
      • Therapy Discharge Recommendations

You can access it HERE in my online store.  My review of the TILLS is available HERE 

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New Additions to My Comprehensive Report Tutorials and Templates

I have previously written regarding my line of products on the topic of: “Comprehensive Report Tutorials“.  I had already added a number of editable comprehensive report templates to my online store.

These templates summarize popular speech-language pathology tests with meticulous detail. Each editable template will contain:

  • Formal testing results breakdown in the form of a table
  • A detailed overview of each subtest including a variety of hypotheses behind the student errors
  • Summary of the students perceived deficits on the test and their correlation with language/literacy based deficits
  • Long-term goals and detailed short-term’s objectives

Image result for Speech language Test manualsBelow is a select list of templates which are already available:

Related imageAvailable templates to date:

Continue reading New Additions to My Comprehensive Report Tutorials and Templates

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What Makes an Independent Speech-Language-Literacy Evaluation a GOOD Evaluation?

Image result for Independent Educational EvaluationThree years ago I wrote a blog post entitled: “Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know“. In it, I used  4 very different scenarios to illustrate the importance of comprehensive language evaluations for children with subtle language and learning needs.  Today I would like to expound more on that post in order to explain, what actually constitutes a good independent comprehensive assessment.

Independent evaluations, whether educational, psychological, speech and language, etc., are typically performed with a particular purpose in mind. That purpose is not to simply document the student’s strengths and needs but also to explicitly advise on solid goals and objectives or a strong treatment plan so the child could improve abilities in the affected areas of functioning.

Image result for all children can learnFor example, psychological evaluations do not simply determine the child’s full-scale IQ. Depending on the breakdown of the child’s scores, they help educators with planning for the child’s educational needs. To illustrate, let’s say that an IQ testing determined that the child is functioning in the below average range with significantly lower scores in the areas of working memory and processing speed.  Given this information professionals working with the child in the classroom and in the therapy room can plan accordingly in terms of designing an appropriate intervention which takes into the consideration the child’s cognitive challenges.

Image result for functionalSimilarly, let’s say an educational/learning testing had determined that the child exhibits difficulties in the areas of phonics, word reading, reading fluency, etc.   Such information is hugely helpful in assisting the child to receive additional reading intervention services with a focus on improving the affected areas of difficulty.

In other words, it is not nearly enough to state in the body of the report, what is wrong with the child, rather it is important to make functional recommendations on what can be done with a child in order to make the child better.

Now here it is very important to understand that accommodations and modifications, while extremely helpful for all children with learning needs, are simply not going to be as functional as actual targeted intervention goals in the affected areas, be it reading, writing, listening comprehension, etc.

Independent evaluations need to make concrete recommendation suggestions regarding best remediation practices for the child. They need to contain goals that other professionals can follow. Without this component, independent evaluations have highly limited value. Here is an example which illustrates a limited value of one such report.

Several years ago I was asked to do a comprehensive language and literacy evaluation on a fifth-grade student who was functionally illiterate. The student had already underway and a comprehensive neuropsychological evaluation, which surprisingly enough did not draw any conclusion regarding the student’s abilities.

The neuropsychologist found that the student had an average IQ and learning difficulties across the board in numerous tested areas. Because of these findings, the neuropsychologist chose to ‘blame’ the student’s deficits on ADHD and stated that he is unable to diagnose a student with a learning disability because there were no score discrepancies on educational testing (not a scientifically backed argument).

Image result for valueNow, what is the value of such an assessment? This child’s parents have spent thousands of dollars on this assessment but in the end, they had absolutely nothing to show for it! The assessment had literally found nothing useful because the submission of such an assessment to the school setting would not have resulted in an altered and beneficial program placement for this child.

So what are the components of a good comprehensive independent evaluation? For the purpose of this particular question, I’ll stick to the subject of language and literacy evaluations, which are in my purview.

Here are the sections I include in a typical independent comprehensive language and literacy report for school-age clients. Make sure to click on the multicolored/highlighted words to learn more details via relevant past posts pertaining to this topic.

Formal Testing Results

  • This section includes the tables of all the standardized testing administered to the child

Background Information

  • This section comprehensively discusses the child’s history to date. It summarizes in meticulous detail prenatal perinatal and postnatal histories, developmental milestones acquisition, relevant medical and psychiatric histories, as well as a compilation of information regarding all previous assessments and interventions to date. This is particularly important for cases involving a change in school placement. After all, if the child had received extensive interventions in a particular school setting which were found to be ineffective to date, it is a strong indication that a different school placement may be warranted.

School Visit

  • This section is hugely important for the determination of the child’s functioning in school setting. It documents an observation one hour in length, preformed to determine whether the child is receiving free and appropriate education in school setting (whether the child is appropriately receiving relevant therapies/schooling).
    • School Visit Impressions
      • All school visits need to include a report section which discusses the observers impressions of the program, as well as their suitability to the child’s educational needs.

Adaptive Behavior

  • This section documents the child’s social communication abilities as displayed throughout testing. Was the child calm or distractible, but did the child display any socially awkward behaviors, did the child display any refusal behaviors, was there any odd conversational exchanges, did it take the child too long to answer questions, with the child displaying any word finding difficulties when speaking? All of these observations are documented in that section as a precursor to both formal as well as clinical social communication testing (see below)

Peripheral Oral Motor Exam

  • Here any orofacial anomalies get documented if needed

Voice, Fluency, Resonance and Prosody

  • This section discusses any deviations in the above, and/or documents the presence of typical functioning as commensurate with age.

Articulation and Phonology

  • Here I document the presence of typical or atypical speech patterns

Auditory Function

  • This is a section which discusses previous audiological findings, history of hearing deficits (if present), as well as overall impressions of child’s hearing throughout the assessment.

Methods of Assessment

Testing Protocols 

  • A list of all the formal tests used during the assessment

Language Processing and Listening Comprehension:

  • Detailed findings of both formal and clinical testing pertaining to the child’s ability to process and comprehend language

Expressive Language and Metalinguistic Abilities:

  • Detailed findings of both formal and clinical testing pertaining to the child’s ability to verbally express self via the effective/ineffective ability to manipulate words and sentences

Discourse Analysis

  • Detailed findings of clinical testing pertaining to the child’s ability to produce age level narratives

Problem Solving, Critical Thinking, and Verbal Reasoning:

  • This section documents formal testing results of problem-solving testing

Social Communication Abilities

Reading Assessment

  • This extensive section includes the details of both formal as well as clinical reading testing including information on the child’s phonemic awareness abilities, decoding abilities, reading fluency and reading comprehension, summarization of read information, etc.

Written Assessment

  • This section contains results of formal and clinical writing assessments including spelling as well as writing composition

IMPRESSIONS

  • At this juncture I am ready to summarize the results of my assessment findings in detail. Here I discuss the severity of the impairment as well as list the areas in which deficits have been noted.

ICD-10 Diagnoses

  • Here I list relevant to the assessment diagnoses which were revealed by the conclusion of testing

CLASSROOM PLACEMENT RECOMMENDATIONS:

  • If necessary, this section discusses recommendations for alternative classroom placement. Here I include information regarding the class size, what additional therapies the child may need to receive, the need for additional classification/services, etc.

Instructional Accommodations to Improve Information Processing

  • Here I discuss my observations pertaining to accommodations which may be beneficial to the child in the school setting

ACCOMMODATIONS VS. REMEDIATION:

  • Here, I discuss the importance of providing direct remediation services versus mere accommodations and modifications alone

Knowledge Retention Recommendations:

  • This section may also be merited at times especially with severely impaired children who may not be able to process information presented to them in longer sentences

Adaptive Recommendations:

  • This section requires what adaptive modifications with respect to the child’s physical space, session materials, etc. may be needed in order for the child to succeed

Maintaining Factors (factors contributing to the maintenance of linguistic deficits)Image result for worse

  • Cognitive
  • Sensorimotor
  • Psychosocial
  • Linguistic

SUGGESTED THERAPY GOALS

  • As mentioned before this is a hugely important section which details the students long term as well as short-term goals which were derived based on the presence of deficit areas as documented throughout the assessment report

Reward system and rationale:

  • This may be a particularly important section for students with the greater degree of impairment as here we may be able to document what type of reward/reinforcements (intrinsic/extrinsic) work to for the student to motivate him/her to complete the assessment
  • If possible, an internal and social system of reward for targeted skill achievement (fostering, intrinsic motivation to take pride in own accomplishments) is strongly recommended

Goal Termination

  • Here I discuss the expectations for goal termination. I typically recommend a contingency of 90% or above accuracy marker over a period of 3 consecutive sessions

Expected duration of treatment

  • While it is often impossible to predict the duration of treatment, certain educated guesses may be taken to determine therapy length. This is frequently determined based on how rapidly the student progresses in therapy, the extent of parental involvement as evidenced or homework as well as carryover activities and exercises at home, any additional private therapy services as well as any additional school therapy services and support (e.g., reading instruction)

Image result for prognosisPrognosis

  • Here, once again depending on the extent of severity of the students deficits, a statement of prognosis may be made (e.g., “Good but cautious due to the above maintaining factors”)

Therapy Discharge:

  • Contingent on a successful reassessment of target deficit areas.

Appendices

  • This is a section where I provide any pertinent to the assessment documents such as the results of the prescriptive spelling test (e.g., SPELL-2) or a synopsis of a particular narrative (e.g., Dr. De Soto by William Steig) so that assessment readers could compare the student’s narrative production with expected production

So now that you know, what sections I include in my independent comprehensive language and literacy evaluations, I’d love to know if there are other sections/areas that you including yours? Post your thoughts and suggestions in the comments section below

Related Posts:

  1. Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know
  2. On the Limitations of Using Vocabulary Tests with School-Aged Students
  3. Updated: What Does “Their Social Skills Are Just Fine” Really Means When it Comes to Children with Language Impairment
  4. Why Developmental History Matters: On the Importance of Background Information in Speech-Language Assessments
  5. The Importance of Narrative Assessments in Speech-Language Pathology (Revised)
  6. Analyzing Discourse Abilities of Adolescents via Peer Conflict Resolution (PCR) tasks
  7. What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?
  8. Analyzing Narratives of School-Aged Children
  9. Adolescent Assessments in Action: Informal Reading Evaluation
  10. Dear Reading Specialist, May I Ask You a Few Questions? 
  11. Test Review of CELF-5 Metalinguistics: What SLPs Need to Know
  12. Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets
  13. Social Communication and Describing Skills: What is the Connection? 
  14. Recommendations for Assessing Language Abilities of Verbal Children with Down Syndrome (DS)
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On the Limitations of Using Vocabulary Tests with School-Aged Students

Those of you who read my blog on a semi-regular basis, know that I spend a considerable amount of time in both of my work settings (an outpatient school located in a psychiatric hospital as well as private practice), conducting language and literacy evaluations of preschool and school-aged children 3-18 years of age. During that process, I spend a significant amount of time reviewing outside speech and language evaluations. Interestingly, what I have been seeing is that no matter what the child’s age is (7 or 17), invariably some form of receptive and/or expressive vocabulary testing is always mentioned in their language report.

Many of you may be wondering, “What’s wrong with having a vocabulary test as part of an assessment battery? Isn’t vocabulary hugely correlated with both language and literacy outcomes?”  The answer is, “It is more complicated than that.” Here’s why.

Children with robust lexicons formulate longer sentences and more interesting stories, better comprehend complex texts, and even compensate to some degree for reading deficits (Colozzo et al, 2011Law and Edwards, 2015; Rvachew and Grawburg, 2006).

In contrast, studies have found that children with Developmental Language Disorder (DLD) (formerly known as Specific Language Impairment or SLI) have limited expressive vocabularies (Leonard, 2014), have trouble learning new words (Alt & Spaulding, 2011; Storkel et al, 2016), and have clinically significant word retrieval deficits (Dockrell, Messer, George, & Wilson, 1998).

Due to these deficits, one-word vocabulary tests are often used in the assessment process to qualify children for speech and language services (Betz, Eickhoff, & Sullivan, 2013). However, studies have found that single word vocabulary tests have poor psychometric properties and/or are not representative of linguistic competence embedded in life-activities (Gray et al., 1999; Ukrainetz & Blomquist, 2002; Bogue, DeThorne, Schaefer, 2014).

Furthermore, because of this, single word vocabulary tests can overinflate testing scores and not represent the child’s true expressive language competence. Finally, even when a student truly has solid or even superior vocabulary knowledge and naming skills, doesn’t mean that s/he can effectively utilize these abilities during the narrative production as well as reading and writing tasks.

Image result for test resultsDon’t believe me?  Consider reviewing language evaluations of current or former students who received outstanding scores on one-word vocabulary tests, yet who were unable to utilize these words to perform semantic flexibility tasks (e.g., name antonyms, synonyms, provide clear definitions as well as define multiple meaning words), produce coherent and cohesive narratives, comprehend these words in the context of read texts, or utilize them during writing composition tasks.

The problem is that numerous SLPs overuse these tests and rely on them for qualification purposes when diagnosing language impairment (Betz, Eickhoff, & Sullivan, 2013). However, the practice of qualifying students based on single-word vocabulary testing in conjunction with psychometrically weak comprehensive testing (visit HERE for a compilation of psychometric data on major SLP testing), can often result in many language-impaired students not being qualified for language therapy services despite desperately needing them.

Image result for informed decisionNow it’s important to understand that I am not recommending elimination of vocabulary tests from SLP assessment batteries.  I am merely suggesting that SLPs use these tests wisely during the assessment process, and utilize them with children who truly benefit from their administration. Such populations include toddlers and preschoolers (under 5 years of age) as well as any children presenting with severe language deficits regardless of age, secondary to intellectual and neuro/developmental impairments such as ASD, DS, FXS, FASD, etc.  They are especially relevant for children with limited vocabularies who are unable to effectively participate in semantic flexibility tasks or produce narratives. As such, we want to learn more about the types of words they know and use on a daily basis to express their wants/needs, so we can increase their lexicon for functional communication purposes and prepare them for effective engagement in both semantic flexibility as well as narrative tasks, in order to further improve their language abilities.

In contrast, for children age 5-6 and older, it is far more practical for SLPs to functionally determine their linguistic flexibility skills as pertaining to the use of language.  This can be accomplished via standardized as well as informal measures. As mentioned above, broadly speaking, linguistic flexibility tasks focus on the manipulation of language.  Tasks such as generation of attributes, production of synonyms and antonyms, formulation of clear and precise definitions of words as well as explanations of multiple meaning, figurative, and ambiguous words and sentences are all examples of language manipulation tasks.

As such, these tasks are far more representative of the student’s language ability in an academic setting versus selecting a picture out of a visual field of four items (receptive identification) or naming a word in the presented picture (expressive generation).

Now there are numerous tests which possess subtests relevant to this purpose.  I, personally, often use select subtests from the below tests:

  • The WORD Tests (Elementary and Adolescent)
    • Associations
    • Antonyms
    • Synonyms
    • Definitions
    • Flexible Meanings
  • Language Processing Test – 3 (LPT-3)
    • Similarities and Differences
    • Multiple Meaning Words
    • Attributes
  • Expressive Language Test – 2 (ELT-2)
    • Metalinguistics
    • Defining Categories
  • Test of Integrated Language and Literacy 
    • Vocabulary Awareness
  • Clinical Evaluation of Language Fundamentals – 5 Metalinguistics (CELF-5M)
    • Multiple Meanings
    • Figurative Language

There are a number of other tests which contain subtests suitable for this purpose. SLPs can also easily create their own informal assessment procedures, similar to the above, for clinical assessment purposes.

However, even these tasks, though a huge improvement over one-word vocabulary tests are not sufficient. In addition to these, research strongly recommends the inclusion of narrative assessment (which is highly correlated with social, reading, as well as academic outcomes), as part of SLP assessment battery.

Related imageNarrative language skills have routinely been identified as one of the single best predictors of future academic success (Bishop & Edmundson, 1987; Feegans & Appelbaum 1986; Dickinson and McCabe, 2001). Language produced during story retelling is positively related to monolingual and bilingual reading achievement (Reese et al, 2010; Miller et al, 2006) Narratives provide insights into child’s verbal expression by tapping into multiple language features and organizational abilities simultaneously (Hoffman, 2009; Ukrainetz, 2006;Bliss & McCabe, 2012). They encompass a number of higher-level language and cognitive skills (Paul et al, 1996) such as event sequencing, text cohesiveness, use of precise vocabulary to convey ideas without visual support, comprehension of cause-effect relationships, etc. Narratives bridge the gap between oral and written language and are needed for solid reading and writing development (Snow et al, 1998).

Contrastingly, poor discourse and narrative abilities place children at risk for learning and literacy-related difficulties including reading problems (McCabe & Rosenthal-Rollins, 1994), while narrative weaknesses significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014). As a result, narrative analyses help SLPs with distinguishing children with DLD from their typically developing (TD) peers (Allen et al 2012).

So the next time you are tasked with selecting appropriate language testing to determine whether a student presents with language and literacy deficits, don’t be so hasty in picking up that single-word vocabulary test.  Take a moment to carefully consider its utility for the student in question. After all, it may very well be a determining factor in deciding whether the student will qualify for language therapy services.

References: 

  1. Allen, M,  Ukrainetz, T & Carswell, A (2012) The narrative language performance of three types of at-risk first-grade readersLanguage, Speech, and Hearing Services in Schools, 43(2), 205-221.
  2. Alt, M., & Spaulding, T. (2011). The effect of time on word learning: An examination of decay of the memory trace and vocal rehearsal in children with and without specific language impairmentJournal of Communication Disorders44(6), 640–654
  3. Betz, Eickhoff, & Sullivan,( 2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment. Language, Speech, and Hearing Services in Schools, 44, 133-146.
  4. Bishop, D. V. M., & Edmundson, A. (1987). Language-impaired 4-year-olds: Distinguishing transient from persistent impairment. Journal of Speech and Hearing Disorders, 52, 156–173.
  5. Bliss, L. & McCabe, A (2012, Oct) Personal Narratives: Assessment and InterventionPerspectives on Language Learning and Education. 19:130-138.
  6. Bogue, E. L., DeThorne, L. S., & Schaefer, B. A. (2014). A psychometric analysis of childhood vocabulary tests. Contemporary Issues in Communication Science and Disorders, 41, 55-69.
  7. Colozzo, P., Gillam, R. B., Wood, M., Schnell, R. D., & Johnston, J. R. (2011). Content and form in the narratives of children with specific language impairment. Journal of Speech, Language, and Hearing Research, 54(6), 1609-1627.
  8. Dickinson D. K., McCabe A. (2001). Bringing it all together: the multiple origins, skills and environmental supports of early literacy. Learning Disabilities Research and Practice. 16, 186–202.
  9. Dockrell, J. E., Messer, D., George, R., & Wilson, G. (1998). Children with word-finding difficulties: Prevalence, presentation and naming problems. International Journal of Language & Communication Disorders, 33, 445–454.
  10. Feegans, L.,& Appelbaum, M (1986). Validation of language subtypes in learning disabled childrenJournal of Educational Psychology78, 358–364.
  11. Gray, S., Plante, E., Vance, R., & Henrichsen, M. (1999). The diagnostic accuracy of four vocabulary tests administered to preschool-age children. Language, Speech, and Hearing Services in Schools30(2), 196–206.
  12. Hoffman, L. M. (2009). Narrative language intervention intensity and dosage: Telling the whole story. Topics in Language Disorders29, 329–343.
  13. Law, F., II, & Edwards, J.R. (2015). Effects of vocabulary size on online lexical processing by preschoolers. Language Learning and Development11, 331–355.
  14. Leonard, L. B. (2014). Children with specific language impairment. Cambridge, MA: MIT Press.
  15. McCabe, A., & Rollins, P. R. (1994). Assessment of preschool narrative skills. American Journal of Speech-Language Pathology, 3(1), 45–56
  16. Miller, J et al (2006). Oral language and reading in bilingual childrenLearning Disabilities Research and Practice, 21, 30–43
  17. Norbury, C. F., Gemmell, T., & Paul, R. (2014). Pragmatics abilities in narrative production: a cross-disorder comparison. Journal of child language, 41(03), 485-510.
  18. Paul R, Hernandez R, Taylor L, Johnson K. (1996) Narrative development in late talkers: early school age. Journal of Speech and Hearing Research, 39(6):1295–1303
  19. Reese E., Suggate S., Long J., Schaughency E. (2010). Children’s oral narrative and reading skills in the first three years of reading instruction. Reading & Writing: An Interdisciplinary Journal, 23, 627–644.
  20. Rvachew S., Grawburg M. (2006). Correlates of phonological awareness in preschoolers with speech sound disorders. Journal of Speech, Language, and Hearing Research, 49: 74–87.
  21. Snow, C.E., Burns, M.S., & Griffin, P. (eds.) (1998). Preventing reading difficulties in young children. Washington, DC: National Academy Press
  22. Ukrainetz, T. A. (2006). Teaching narrative structure: Coherence, cohesion, and captivation. In T. A. Ukrainetz (Ed.), Contextualized language intervention: Scaffolding PreK–12 literacy achievement (pp. 195–246). Austin, TX: Pro-Ed.
  23. Ukrainetz, T. A., & Blomquist, C. (2002). The criterion validity of four vocabulary tests compared with a language
    sample. Child Language Teaching and Therapy, 18, 59–78.

 

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Updated: What Does “Their Social Skills Are Just Fine” Really Means When it Comes to Children with Language Impairment

As a frequent participant in a variety of speech pathology forums I’ve read through countless “mini scenarios” of SLPs asking for advice regarding various aspects of therapy service provision for children with average IQ and language impairment (characterized by weaknesses in the area of listening comprehension, language processing, vocabulary acquisition, sentence formulation, as well as conversational development.)

When I ask the following question: “What about their social skills difficulties?” I invariably receive the following answer: “Their social skills are just fine!” When I ask: “How was their social competence assessed?” I am invariably told: “The teachers don’t have any complaints, their eye contact is good, and they can keep up with conversations.”

As a result of seeing these and similar statements over and over again from a number of professionals, I decided to write a blog post on this topic due to a certain degree of frustration on my part.

The first concept taught in typical language development classes in undergrad is the fact that language is composed of three areas: Content, Form, and Use. Basically speaking Content refers to conveying coherent and cohesive messages to others, Form refers to grammatically and syntactically correct expression of language, while Use refers to appropriate social pragmatic interactions with the public at large (Bloom & Lahey, 1978). In other words these three areas are interconnected and difficulties will not be exclusively relegated to one area only.

This is further supported by research which indicates that children with language impairment (what many clinicians know as Developmental Language Disorders or DLD, formerly known as Specific Language Impairment or SLI) are actually impaired in numerous aspects of language including phonology, morphology, syntax, etc.

Furthermore, research into language development and disorders has revealed that there is no such category as expressive language disorder alone. In other words, if there are expressive language deficits, you will most certainly find receptive language deficits if you look carefully enough.  In his seminal article entitled: “Is Expressive Language Disorder an Accurate Diagnostic Category?” Laurence Leondard (2009) concluded that “deficits in language expression are typically accompanied by limitations in language knowledge or difficulties processing language input“.

So now that we know that language deficits are diffused and not isolated (e.g., impaired vocabulary/grammar only), let us discuss how social skills/social competence deficits fit into this picture.

One set of researchers who has been studying the construct of social skills in children with DLD for the past several decades are Bonnie Brinton and Martin Fujiki.  In some of their earlier articles in the 90s they found evidence that children with DLD manifested pragmatic difficulties in conversational contexts with partners and were unable to adequately adjust to the needs of others in social interactions (Brinton, & Fujiki, 1993: Brinton & Fujiki,  1995; Brinton, Fujiki,  & Powell, 1997; Fujiki & Brinton, 1994: Fujiki, Brinton  & Todd 1996).

Later, Brinton’s and Fujiki’s work expanded beyond the pragmatic interactions to focus on the concept of social competence of children with language impairments. For those unfamiliar with this term, social competence is a complex, multidimensional concept composed of successful co-interaction of social, emotional, cognitive as well as behavioral factors, resulting in successful social adaptation (Semrud-Clikeman, 2007).

Brinton and Fujiki’s later studies found that children with language impairments were less accepted by peers, had poorer friendships, were perceived by teachers as being more withdrawn (as compared to peers) as well as presented with poor emotional competence and emotional intelligence (Brinton & Fujiki, 2012; Fujiki, Spackman, Brinton, & Illig, 2008; Spackman, Fujiki, Brinton, Nelson, & Allen, 2005).

Studies by other authors found that children with language impairments also present with impaired abstract emotion comprehension (Ford & Milosky, 2003).

In addition, researchers also found that the social competence of language impaired children is affected from a very early age. To illustrate, Longobardi, Spataro, Frigerio & Rescorla, 2015, found that young children (2+ years of age) with delayed language development (who produced fewer than 50 words) exhibited lower social abilities, compared to age-matched peers.

What does this mean? 

Research unequivocally indicates that children with language impairment or DLD, also present with concomitant social communication difficulties, which if left untreated will significantly adversely affect their academic outcomes as well as future life success. It is important to note that due to the varying the nature of social communication deficits (internalizing versus externalizing manifestations) many social communication deficits will be missed without the administration of appropriate social pragmatic language assessments.  It is also important to note that presently social pragmatic assessments ARE NOT routinely administered in numerous school settings as part of comprehensive language assessments.

Consequently, if a student presents with language impairment and the prevailing teacher/parental belief is that his/her social skills are “just fine”, it is important to support this with relevant data based on comprehensive formal and informal battery of social communication assessments in order to justify the above statement with all due veracity.

References:

  • Bloom, L & Lahey, M. (1978) Language development and language disorders.New York, Wiley.
  • Brinton, B., & Fujiki, M. (1993).  Language, social skills, and socioemotional behavior.  Language, Speech, and Hearing Services in Schools, 24, 194-198.
  • Brinton, B. & Fujiki, M. (1995). Intervention with conversational skills.  In M. E. Fey, J. Windsor, & S. Warren, (Eds.) Communication intervention for school-age children (pp. 183-212).  Baltimore: Paul H. Brookes.
  • Brinton, B., Fujiki, M., & Powell, J. M. (1997).  The ability of children with language impairment to manipulate topic in a structured task.  Language, Speech, and Hearing Services in Schools, 28, 3-11.
  • Brinton B., & Fujiki, M. (2012). Social and affective factors in children with language impairment. Implications for literacy learning. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy: Development and disorders (2nd Ed.). New York, NY: Guilford.
  • Ford, J., & Milosky, L. (2003). Inferring emotional reactions in social situations: Differences in children with language impairment. Journal of Speech, Language, and Hearing Research, 46(1), 21-30.
  • Fujiki, M. & Brinton, B. (1994).  The social competence of children with specific language impairment.  In M. L. Rice & R. Watkins (Eds.) Language intervention with children with specific language impairment (pp. 123-143). Baltimore: Paul H. Brookes.
  • Fujiki, M., Brinton, B., & Todd, C.M. (1996).  Social skills of children with specific language impairment.  Language, Speech, and Hearing Services in Schools, 27, 195-202.
  • Fujiki, M., Spackman, M. P., Brinton, B., & Illig, T. (2008). Ability of children with language impairment to understand emotion conveyed by prosody in a narrative passage. International Journal of Language & Communication Disorders, 43(3), 330-345
  • Longobardi, E, Spataro, P, Frigerio A & Rescorla, L (2015) Language and social competence in typically developing children and late talkers between 18 and 35 months of age. Early Child Development and Care.
  • Semrud-Clikeman, M. (2007). Social competence in children. New York, NY: Springer.

Helpful Smart Speech Resources Related to Assessment and Treatment of Social Pragmatic Disorders 

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Speech, Language, and Literacy Fun with Helen Lester’s Picture Books

Picture books are absolutely wonderful for both assessment and treatment purposes! They are terrific as narrative elicitation aids for children of various ages, ranging from pre-K through fourth grade.  They are amazing treatment aids for addressing a variety of speech, language, and literacy goals that extend far beyond narrative production.

There are numerous children books authors whom I absolutely adore (e.g., Karma Wilson, Keiko Kasza, Jez Alborough, M. Christina Butler, etc.). Today I wanted to describe how I implement books by Helen Lester into my treatment sessions with elementary aged children. (For information on how I use her books: “Pookins Gets Her Way” and “A Porcupine Named Fluffy” for narrative elicitation purposes click HERE.)

It is important to note that while Ms. Lester’s books are intended for younger children (4-7 years; pre-K-3rd grade), older children (~10 years of age) with significant language and learning difficulties and/or intellectual disabilities have enjoyed working with them and have significantly benefited from reading/listening to them.

Two reasons why I love using Ms. Lester’s books are versatility and wealth of social themes. To illustrate, “Hooway for Wodney Wat” and “Wodney Wat’s Wobot” are two books about a shy rat who cannot pronounce his ‘r’ sounds. Wodney is hugely embarrassed by that fact, and since there are no speech-language pathologists in Rodentia-land, Wodney spends his recess, hiding inside his jacket, trying to be as inconspicuous as possible. The arrival of a bullying, Miss-know-it-all, Camilla Capybara, brings some unexpected changes into the school’s dynamic, as well as provides Wodney with a very welcome opportunity to shine socially.

Image result for wodney wobotSpeech Production: Not only is there a phenomenal opportunity to use this book with children struggling with /r/ sound production, but it’s also heavily laden with a plethora of /r/ words in a variety of word positions (e.g., rodeo, robot, contraption, barrel, terrific, fur, prickled, bigger, fear, classroom, smarter, sure, etc.).

Language: There are numerous language goals that could be formulated based on Helen Lester’s books including answering concrete and abstract listening comprehension questions, defining story-embedded vocabulary words, producing word associations, synonyms, antonyms, and multiple meaning words (semantic awareness), formulating compound and complex sentences (syntax), answering predicting and inferencing questions (critical thinking), gauging moods and identifying emotional reactions of characters (social communication), assuming characters’ perspectives and frame of reference (social cognition, theory of mind, etc.), identifying main ideas in text (Gestalt processing) and much, much more.

  • Select Highlights:
    • VocabularyFor the ages/grades that there’ve written for (4-7 years; pre-K-3rd grade), Ms. Lester’s books are laden with a wealth of sophisticated vocabulary words such a: curtsy, contraption, trembled, dreary, shudder, varmint, fashionable, rodent, rattled, shenanigans, chanting, surgical, plunked, occasion, exception, etc.
    • Word Play:  Ms. Lester infuses a great deal of humor and wit in her books. Just look at the names of her characters in “A Sheep in Wolf’s Clothing”, which are: Ewetopia, Ewecalyptus, Ewetensil, Heyewe, Rambunctious, Ramshackle, and Ramplestiltskin.  Her ovine characters live in Pastureland and attend Woolyones’ Costume Balls while her porcine characters eat in a trough-a-teria.  
    • Social Communication: Many of Ms. Lester’s book themes focus on the celebration of neurodiversity (e.g., “Tacky the Penguin”), learning valuable life lessons (e.g., “Me First”), addressing one’s fears (e.g., “Something Might Happen”) and feeling uncomfortable in own skin (e.g., “A Sheep in Wolf’s Clothing”), etc.

Literacy: Similar to the above, numerous literacy goals can be formulated based on these books. These include but are not limited to, goals targeting phonological (e.g., rhyming words, counting syllables in words, etc.) and phonemic awareness, phonics, reading fluency and comprehension, spelling, as well as the composition of written responses to story questions.

  • Image result for princess penelope's parrotSelect Highlights:
    • Phonics: Students can practice reading words containing a variety of syllable shapes as well as decode low-frequency words containing a variety of consonantal clusters (Examples from “Princess Penelope’s Parrot” are:  hissed, parrot, buzzard, horribly, flicked, plucked, field,  flapped, silence, Percival, velvet, cloak, caviar, clippy-clopped, poofiest, impressed, expensive, galloping, gulped, bouquet, squawked, etc.)
    • Morphology: There’s a terrific opportunity to introduce a discussion on roots and affixes when using Ms. Lester’s books to discuss how select prefixes and suffixes (e.g., ante-, -able, -ive, -ion, etc.) can significantly increase word sophistication of numerous root words (e.g., impressive, exception, etc.)
    • Spelling: There is a terrific opportunity for children to practice spelling numerous spelling patterns to solidify their spelling abilities, including -ee-, -ea-, -ou-,-oo-, -oa-, -ui-, -ck, -tt-, -rr-, -ss-, -cc-, etc.

When working with picture books, I typically spend numerous sessions working with the same book. That is because research indicates that language disordered children require 36 exposures  (as compared with 12 exposures for typically developing children) to learn new words via interactive book reading (Storkel et al, 2016). As such, I discuss vocabulary words before, during, and after the book reading, by asking the children to both repeatedly define and then use selected words in sentences so the students can solidify their knowledge of these words.

I also spent quite a bit of time on macrostructure, particularly on the identification and definitions of story grammar elements as well as having the student match the story grammar picture cards to various portions of the book.

When working with picture books, here are some verbal prompts that I provide to the students with a focus on story Characters and Setting

  • Who are the characters in this story?
  • Where is the setting in this story?
  • Are there multiple settings in this story?
  • What are some emotions the characters experience throughout this story?
  • When did they experience these emotions in the story?
  • How do you think this character is feeling when ____?
    • Why?
    • How do you know?
  • What do you think this character is thinking?
    • Why?
    • How do you know?
  • What are some actions the characters performed throughout the story?
  • What were the results of some of those actions?

Here is a sampling of verbal prompts I provide to the students with a focus on story Sequencing 

  • What happened at the beginning of the story?
    • What words can we use to start a story?
  • What happened next?
  • What happened after that?
  • What happened last?
  • How do we end a story?
  • What was the problem in the story?
  • Was there more than one problem?
    • What happened?
    • Who solved it?
    • How did s/he solve it?
  • Was there adventure in the story?
    • If yes, how did it start and end?

Here is a sampling of verbal prompts I provide to the students with a focus on Critical Thinking 

  • How are these two characters alike/different? (compare/contrast)
  • What do you think will happen next? (predicting)
  •  Why/How do you think ___ happened (inferencing)
  • Why shouldn’t you, couldn’t s/he ____ ? (answering negative questions)
  • What do you thing s/he must do to ______? (problem-solving)
  • How would you solve his problem? (determining solutions)
  • Why is your solution ______ a good solution? (providing justifications)

Image result for tacky penguinHere is a small sampling of verbal prompts I provide to the students with a focus on Social Communication and Social Cognition 

  • How would you feel if ____?
  • What is his/her mood at ____ point in the story?
    • How do you know?
  • What is his/her reaction to the ____?
    • How do you know?
  • How does it make you feel that s/he are _____?
  • Can you tell me two completely different results of this character’s actions?
  • What could you say to this character to make him/her feel better?
    • Why?
  • What would you think if?

At times, I also use Ms. Lester’s guide for the following books: ‘It Wasn’t My Fault’, ‘Listen, Buddy’, ‘Me First’, and ‘A Porcupine Named Fluffy‘ to supplement my therapy sessions goals. It provides additional helpful ideas and suggestions on how her books can be further used in both therapy room as well as the classroom.

Finally, one of the major reasons why I really like Ms. Lester’s books is because some of them are ‘art imitating life’ and do not necessarily end up in a ‘traditional’ happily ever after. To, illustrate, “Princess Penelope’s Parrot” is a book about a spoiled princess who cannot get her new parrot to talk, even after threatening it and calling it insulting names. When Prince Percival comes courting, the parrot takes his hilarious revenge on Princess Penelope, and the parrot and Prince Percival do end up living happily ever after. However, Princess Penelope quickly gets over her embarrassment and goes back to her unrepentantly spoiled way of acting.

There you have it! Just a few of my many reasons why I adore using Helen Lester’s books for language and literacy treatment purposes. How about you? Do you use any of her books for assessment and treatment purposes? If yes, comment below which ones you use and why do you use them?

References:

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