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Clinical Fellow (and Setting-Switching SLPs) Survival Guide in the Schools

Related image It’s early August, and that means that the start of a new school year is just around the corner.  It also means that many newly graduated clinical fellows (as well as SLPs switching their settings) will begin their exciting yet slightly terrifying new jobs working for various school systems around the country.  Since I was recently interviewing clinical fellows myself in my setting (an outpatient school located in a psychiatric hospital, run by a university), I decided to write this post in order to assist new graduates, and setting-switching professionals by describing what knowledge and skills are desirable to possess when working in the schools. Continue reading Clinical Fellow (and Setting-Switching SLPs) Survival Guide in the Schools

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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. Continue reading Dear SLPs, Try Asking This Instead

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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. Continue reading On the Limitations of Using Vocabulary Tests with School-Aged Students

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FREE Resources for Working with Russian Speaking Clients: Part II

A few years ago I wrote a blog post entitled “Working with Russian-speaking clients: implications for speech-language assessment” the aim of which was to provide some suggestions regarding assessment of bilingual Russian-American birth-school age population in order to assist SLPs with determining whether the assessed child presents with a language difference, insufficient language exposure, or a true language disorder.

Today I wanted to provide Russian speaking clinicians with a few FREE resources pertaining to the typical speech and language development of Russian speaking children 0-7 years of age.

Below materials include several FREE questionnaires regarding Russian language development (words and sentences) of children 0-3 years of age, a parent intake forms for Russian speaking clients, as well as a few relevant charts pertaining to the development  of phonology, word formation, lexicon, morphology, syntax, and metalinguistics of children 0-7 years of age.

It is, however, important to note that due to the absence of research and standardized studies on this subject much of the below information still needs to be interpreted with significant caution.

Select Speech and Language Norms:

Image result for развитие речи детей

Select Parent Questionnaires (McArthur Bates Adapted in Russian):

  • Тест речевого и коммуникативного развития детей раннего возраста: слова и жесты (Words and Gestures)
  • Тест речевого и коммуникативного развития детей раннего возраста:  слова и предложения (Sentences)
  • Анкета для родителей (Child Development Questionnaire for Parents)

Материал Для Родителей И Специалистов По  Речевым
Нарушениям contains detailed information (27 pages) on Russian child development as well as common communication disrupting disorders

Stay tuned for more resources for Russian speaking SLPs coming shortly.

Related Resources:

 

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Back to School SLP Efficiency Bundles™

September is practically here and many speech language pathologists (SLPs) are looking to efficiently prepare for assessing and treating a variety of clients on their caseloads.

With that in mind, a few years ago I created SLP Efficiency Bundles™, which are materials highly useful for SLPs working with pediatric clients. These materials are organized by areas of focus for efficient and effective screening, assessment, and treatment of speech and language disorders.

A.  General Assessment and Treatment Start-Up Bundle contains 5 downloads for general speech language assessment and treatment planning and includes:

  1. Speech Language Assessment Checklist for a Preschool Child
  2. Speech Language Assessment Checklist for a School-Aged Child
  3. Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation
  4. Selecting Clinical Materials for Pediatric Therapy
  5. Types and Levels of Cues and Prompts in  Speech Language Therapy

B. The Checklists Bundle contains 7 checklists relevant to screening and assessment in speech language pathology

  1. Speech Language Assessment Checklist for a Preschool Child 3:00-6:11 years of age
  2. Speech Language Assessment Checklist for a School-Aged Child 7:00-11:11 years of age
  3. Speech Language Assessment Checklist for Adolescents 12-18 years of age
  4. Language Processing Deficits (LPD) Checklist for School Aged Children 7:00-11:11 years of age
  5. Language Processing Deficits (LPD) Checklist for Preschool Children 3:00-6:11 years of age
  6. Social Pragmatic Deficits Checklist for School Aged Children 7:00-11:11 years of age
  7. Social Pragmatic Deficits Checklist for Preschool Children 3:00-6:11 years of age

C. Social Pragmatic Assessment and Treatment Bundle  contains 6 downloads for social pragmatic assessment and treatment planning (from 18 months through school age) and includes:

  1. Recognizing the Warning Signs of Social Emotional Difficulties in Language Impaired Toddlers and Preschoolers
  2. Behavior Management Strategies for Speech Language Pathologists
  3. Social Pragmatic Deficits Checklist for School Aged Children
  4. Social Pragmatic Deficits Checklist for Preschool Children
  5. Assessing Social Pragmatic Skills of School Aged Children
  6. Treatment of Social Pragmatic Deficits in School Aged Children

D. Multicultural Assessment and Treatment Bundle contains 2 downloads relevant to assessment and treatment of bilingual/multicultural children

  1. Language Difference vs. Language Disorder:  Assessment  & Intervention Strategies for SLPs Working with Bilingual Children
  2. Impact of Cultural and Linguistic Variables On Speech-Language Services

E. Narrative Assessment Bundle contains 3 downloads relevant to narrative assessment

  1. Narrative Assessments of Preschool and School Aged Children
  2. Understanding Complex Sentences
  3. Vocabulary Development: Working with Disadvantaged Populations

F. Fetal Alcohol Spectrum Disorders Assessment and Treatment Bundle contains 3 downloads relevant to FASD assessment  and treatment

  1. Orofacial Observations of At-Risk Children
  2. Fetal Alcohol Spectrum Disorder: An Overview of Deficits
  3. Speech Language Assessment and Treatment of Children With Alcohol Related Disorders

G. Psychiatric Disorders Bundle contains 7 downloads relevant to language  assessment  and treatment in psychiatrically impaired children

  1. Recognizing the Warning Signs of Social Emotional Difficulties in Language Impaired Toddlers and Preschoolers
  2. Social Pragmatic Deficits Checklist for School Aged Children
  3. Social Pragmatic Deficits Checklist for Preschool Children
  4. Assessing Social Skills in Children with Psychiatric Disturbances
  5. Improving Social Skills of Children with Psychiatric Disturbances
  6. Behavior Management Strategies for Speech Language Pathologists
  7. Differential Diagnosis Of ADHD In Speech Language Pathology

You can find these bundles on SALE in my online store by clicking on the individual bundle links above. You can also purchase these products individually in my online store by clicking HERE.

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Early Intervention Part V: Assessing Feeding and Swallowing in Children Under Three

  1. General speech and language assessments of children under 3 years of age.
  2. Assessments of toddlers with suspected motor speech disorders 
  3. Assessments of children ~16-18 months of age
  4. Assessments of Social Pragmatic Abilities of Children Under 3

Today I’d like to talk about the assessment of feeding abilities of children under 3 years of age. Just to be clear, in my post, I am not offering tips on the assessment of medically fragile or neurologically impaired children with complex swallowing and feeding disorders such as severe food selectivity. Rather, I am offering suggestions for routine orofacial and feeding assessments of young children with normal swallowing but slightly immature feeding abilities.

First, let take a look at what the typical feeding development looks like in children 0-3 years of age. For this, I really like to use a resource from Dr. Joan Arvedson entitledDevelopmental milestones and feeding skills birth to 36 months from her article Swallowing and feeding in infants and young children which was published online in 2006

Age (months) Development/posture Feeding/oral sensorimotor
Source: Adapted from Arvedson and Brodsky (pp. 62–67).
Birth to 4–6 Neck and trunk with balanced flexor and extensor tone
Visual fixation and tracking
Learning to control body against gravity
Sitting with support near 6 months
Rolling over
Brings hands to mouth
Nipple feeding, breast, or bottle
Hand on bottle during feeding (2–4 months)
Maintains semiflexed posture during feeding
Promotion of infant–parent interaction
6–9 (transition feeding) Sitting independently for short time
Self-oral stimulation (mouthing hands and toys)
Extended reach with pincer grasp
Visual interest in small objects
Object permanence
Stranger anxiety
Crawling on belly, creeping on all fours
Feeding more upright position
Spoon feeding for thin, smooth puree
Suckle pattern initially Suckle  suck
Both hands to hold bottle
Finger feeding introduced
Vertical munching of easily dissolvable solids
Preference for parents to feed
9–12 Pulling to stand
Cruising along furniture
First steps by 12 months
Assisting with spoon; some become independent
Refining pincer grasp
Cup drinking
Eats lumpy, mashed food
Finger feeding for easily dissolvable solids
Chewing includes rotary jaw action
12–18 Refining all gross and fine motor skills
Walking independently
Climbing stairs
Running
Grasping and releasing with precision
Self-feeding: grasps spoon with whole hand
Holding cup with 2 hands
Drinking with 4–5 consecutive swallows
Holding and tipping bottle
>18–24 Improving equilibrium with refinement of upper extremity coordination.
Increasing attention and persistence in play activities
Parallel or imitative play
Independence from parents
Using tools
Swallowing with lip closure
Self-feeding predominates
Chewing broad range of food
Up–down tongue movements precise
24–36 Refining skills
Jumping in place
Pedaling tricycle
Using scissors
Circulatory jaw rotations
Chewing with lips closed
One-handed cup holding and open cup drinking with no spilling
Using fingers to fill spoon
Eating wide range of solid food
Total self-feeding, using fork

Now, let’s discuss the importance of examining the child’s facial features and oral structures. During these examinations it is important to document anything out of the ordinary noted in the child’s facial features or oral cavity.

Facial dysmorphia, signs of asymmetry indicative of paresis, unusual spots, nodules, openings, growths, etc, all need to be documented.  Note the condition of the child’s mouth. Is there excessive tooth decay? Do you see an unusual absence of teeth? Is there an unusual bite (open, cross, etc.), unusual voice or a cough, in the absence of a documented illness?  Here’s an example from a write up on a 2-8-year-old male toddler, below:

Facial observations revealed dysmorphic features: microcephaly (small head circumference), anteriorly rotated ears (wide set), and medially deviated, inward set eyes. A presence of mild-moderate hypotonicity (low tone) of the face [and trunk] was also noted.  FA presented with mostly closed mouth posture and appropriate oral postural control at rest but moderate drooling (drool fell on clothes vs. touching chin only) was noted during speech tasks and during play.  It’s important to note that the latter might be primarily behavioral in origin since FA was also observed to engage in “drool play” – gathering oral secretions at lip level then slowly and deliberately expelling them in a thin stream from his mouth and onto his shirt.

Articulatory structures including lips, tongue, hard palate and velum appeared to be unremarkable and are adequate for speech purposes. FA’s dentition was adequate for speech purposes as well.  Oral motor function was appropriate for lingual lateralization, labial retraction, volitional pucker and lingual elevation. Lingual depression was not achieved.  Diadochokinesis for sequential and alternate movements was unremarkable.  Overall, FA’s oral structures and function presented to be adequate for speech production purposes. 

FA’s prosody, pitch, and loudness were within normal limits for age and gender. No clinical dysfluencies were present during the evaluation.  Vocal quality was remarkable for intermittent hoarseness which tended to decrease (clear up) as speech output increased and may be largely due to a cold (he presented with a runny nose during the assessment). Vocal quality should continue to be monitored during therapy sessions for indications of persistent hoarseness in the absence of a cold.

From there I typically segue into a discussion of the child’s feeding and swallowing abilities. Below is an excerpt discussing the strengths and needs of an 18-month-old internationally adopted female.

During the assessment concerns presented regarding AK’s feeding abilities only. No swallowing concerns were reported or observed during the assessment. As per the parental report, at the age of 18 months, AK is still drinking from the bottle and consuming only puréed foods, which is significantly delayed for a child her age. AK’s feeding skills were assessed at snack time via indirect observation and select direct food administration.  The following foods and liquids were presented to AK during the assessment: 2 oz of yogurt, 18 cheerios, 4 banana and 2 apple bites, and 40 ml of water (via cup and straw). AK was observed to accept all of the above foods and liquids readily when offered.

Image result for toddler biting foodSpoon Stripping and Mouth Closure: During the yogurt presentation, AK’s spoon stripping abilities and mouth closure were deemed good (adequate) when fed by a caregiver and fair when AK fed self (incomplete food stripping from the spoon was observed due to only partial mouth closure). According to parental report, AK’s spoon stripping abilities have improved in recent months. Ms. K was observed to present spoon upwardly in AK’s mouth and hold it still until AK placed her lips firmly around the spoon and initiated spoon stripping.  Since this strategy is working adequately for all parties in question no further recommendations regarding spoon feeding are necessary at this time. Skill monitoring is recommended on an ongoing basis for further refinement.  

Biting and Chewing Abilities on Solids and Semi-Solids: AK’s chewing abilities were judged to be immature at this time for both solid (e.g., Cheerios) and semi-solid foods (e.g., banana). AK was observed to feed self Cheerios from a plate (1 at a time). She placed a cheerio laterally on lower right molars and attempted to grind it.  When the cheerio was presented to AK midline she was observed to anteriorly munch it, or mash it against the hard palate.  Notably, when too many cheerios were presented to her, rather than grasping and consuming them AK began to bang on a plate with both hands and throw the cheerios around the room. 

During feeding, the most difficulty was observed with biting and chewing solid and semisolid fruit (e.g., apple and banana pieces). When presented with a banana, AK manifested moderate difficulties biting off an adequately sized piece (she bit off too much). Consequently, due to the fact that she was unable to adequately chew on a piece that large, manual extraction of food from the oral cavity was initiated due to choking concerns.  It is important to note that during all food presentations AK did not display a diagonal rotary chew, which is below age expectancy for a child her age. Feeding strengths noted during today’s assessment included complete mouth closure (including lack of drooling and anterior food loss) during assisted spoon and finger foods feeding.

Image result for toddler drinking from strawCup and Straw Drinking: AK was also observed to drink 40 mls of water from a cup given parental assistance.  Minor anterior spillage was intermittently noted during liquid intake. It is recommended that the parents modify cup presentation by providing AK with a plastic cup with two handles on each side, which would improve her ability to grasp and maintain hold on cup while drinking.

Straw drinking trials were attempted during the assessment as it is a skill which typically emerges between 8-9 months of age and solidifies around 12-13 months of age (Hunt et al, 2000).  When AK was presented with a shortened straw placed in cup, she was initially able to create enough intraoral pressure to suck in a small amount of liquid.  However, AK quickly lost the momentum and began to tentatively chew on the presented straw as which point the trial was discontinued.

Based on the feeding assessment AK presented with mildly decreased abilities in the oral phase of feeding. It is recommended that she receive feeding therapy with a focus on refining her feeding abilities.”  

I follow the above, with a summary of evaluation impressions, recommendations, as well as suggested therapy goals. Finally, I conclude my report with a statement regarding the child’s prognosis (e.g., excellent, good, fair, etc.) as well as list potential maintaining factors affecting the duration of therapy provision.

So what about you? How do you assess the feeding and swallowing of abilities of children under 3 on your caseload? What foods, tasks, and procedures do you use?

   

 

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Early Intervention Evaluations PART IV:Assessing Social Pragmatic Abilities of Children Under 3

Image result for toddlersTo date, I have written 3 posts on speech and language assessments of children under 3 years of age. My first post offered suggestions on what information to include in general speech-language assessments for this age group, my second post specifically discussed assessments of toddlers with suspected motor speech disorders and my third post described what information I tend to include in reports for children ~16-18 months of age.

Today, I’d like to offer some suggestions on the assessment of social emotional functioning and pragmatics of children, ages 3 and under.

For starters, below is the information I found compiled by a number of researchers on select social pragmatic milestones for the 0-3 age group:

  1. Peters, Kimberly (2013) Hierarchy of Social/Pragmatic Skills as Related to the Development of Executive Function 
  2. Hutchins & Prelock, (2016) Select Social Cognitive Milestones from the Theory of Mind Atlas 

3. Development of Theory of Mind (Westby, 2014)

In my social pragmatic assessments of the 0-3 population, in addition, to the child’s adaptive behavior during the assessment, I also describe the child’s joint attention,  social emotional reciprocity, as well as social referencing abilities.

Joint attention is the shared focus of two individuals on an object. Responding to joint attention refers to the child’s ability to follow the direction of the gaze and gestures of others in order to share a common point of reference. Initiating joint attention involves child’s use of gestures and eye contact to direct others’ attention to objects, to events, and to themselves. The function of initiating joint attention is to show or spontaneously seek to share interests or pleasurable experience with others. (Mundy, et al, 2007)

Social emotional reciprocity involves being aware of the emotional and interpersonal cues of others, appropriately interpreting those cues, responding appropriately to what is interpreted as well as being motivated to engage in social interactions with others (LaRocque and Leach,2009).

Social referencing refers to a child’s ability to look at a caregiver’s cues such as facial expressions, body language and tone of voice in an ambiguous situation in order to obtain clarifying information.   (Walden & Ogan, 1988)

Here’s a brief excerpt from an evaluation of a child ~18 months of age:

“RA’s joint attention skills, social emotional reciprocity as well as social referencing were judged to be appropriate for his age.  For example, when Ms. N let in the family dog from the deck into the assessment room, RA immediately noted that the dog wanted to exit the room and go into the hallway.  However, the door leading to the hallway was closed.  RA came up to the closed door and attempted to reach the doorknob.  When RA realized that he cannot reach to the doorknob to let the dog out, he excitedly vocalized to get Ms. N’s attention, and then indicated to her in gestures that the dog wanted to leave the room.”

If I happen to know that a child is highly verbal, I may actually include a narrative assessment, when evaluating toddlers in the 2-3 age group. Now, of course, true narratives do not develop in children until they are bit older. However, it is possible to limitedly assess the narrative abilities of verbal children in this age group. According to Hedberg & Westby (1993) typically developing 2-year-old children are at the Heaps Stage of narrative development characterized by

  • Storytelling in the form of a collection of unrelated ideas  which consist of labeling and describing events
  • Frequent switch of topic is evident with lack of central theme and cohesive  devices
  • The sentences are usually simple declarations which contain repetitive syntax and use of present or present progressive tenses
  • In this stage, children possess limited understanding that the character on the next page is still same as on the previous page

In contrast, though typically developing children between 2-3 years of age in the Sequences Stage of narrative development still arbitrarily link story elements together without transitions, they can:

  • Label and describe events about a central theme with stories that may contain a central character, topic, or setting

Image result for frog where are youTo illustrate, below is a narrative sample from a typically developing 2-year-old child based on the Mercer Mayer’s classic wordless picture book: “Frog Where Are You?”

  • He put a froggy in there
  • He’s sleeping
  • Froggy came out
  • Where did did froggy go?
  • Now the dog fell out
  • Then he got him
  • You are a silly dog
  • And then
  • where did froggy go?
  • In in there
  • Up up into the tree
  • Up there  an owl
  • Froggy 
  • A reindeer caught him
  • Then he dropped him
  • Then he went into snow
  • And then he cleaned up that
  • Then stopped right there and see what wha wha wha what he found
  • He found two froggies
  • They lived happily ever after

Image result for play assessment kidsOf course, a play assessment for this age group is a must. Since, in my first post, I offered a play skills excerpt from one of my early intervention assessments and in my third blog post, I included a link to the Revised Westby Play Scale (Westby, 2000), I will now move on to the description of a few formal instruments I find very useful for this age group.

While some criterion-referenced instruments such as the Rossetti, contain sections on Interaction-Attachment and Pragmatics, there are other assessments which I prefer for evaluating social cognition and pragmatic abilities of toddlers.

Image result for language use inventoryFor toddlers 18+months of age, I like using the Language Use Inventory (LUI) (O’Neill, 2009) which is administered in the form of a parental questionnaire that can be completed in approximately 20 minutes.  Aimed at identifying children with delay/impairment in pragmatic language development it contains 180 questions and divided into 3 parts and 14 subscales including:

  1. Communication w/t gestures
  2. Communication w/t words
  3. Longer sentences

Therapists can utilize the Automated Score Calculator, which accompanies the LUI in order to generate several pages write up or summarize the main points of the LUI’s findings in their evaluation reports.

Below is an example of a summary I wrote for one of my past clients, 35 months of age.

AN’s ability to use language was assessed via the administration of the Language Use Inventory (LUI). The LUI is a standardized parental questionnaire for children ages 18-47 months aimed at identifying children with delay/impairment in pragmatic language development. Composed of 3 parts and 14 subscales it focuses on how the child communicates with gestures, words and longer sentences.

On the LUI, AN obtained a raw score of 53 and a percentile rank of <1, indicating profoundly impaired performance in the area of language use. While AN scored in the average range in the area of varied word use, deficits were noted with requesting help, word usage for notice, lack of questions and comments regarding self and others, lack of reciprocal word usage in activities with others, humor relatedness, adapting to conversations to others, as well as difficulties with building longer sentences and stories.

Based on above results AN presents with significant social pragmatic language weaknesses characterized by impaired ability to use language for a variety of language functions (initiate, comment, request, etc), lack of reciprocal word usage in activities with others, humor relatedness, lack of conversational abilities, as well as difficulty with spontaneous sentence and story formulation as is appropriate for a child his age. Therapeutic intervention is strongly recommended to improve AN’s social pragmatic abilities.

Downloadable DocumentsIn addition to the LUI, I recently discovered the Theory of Mind Inventory-2. The ToMI-2 was developed on a normative sample of children ages 2 – 13 years. For children between 2-3 years of age, it offers a 14 question Toddler Screen (shared here with author’s permission). While due to the recency of my discovery, I have yet to use it on an actual client, I did have fun creating a report with it on a fake client.

First, I filled out the online version of the 14 question Toddler Screen (paper version embedded in the link above for illustration purposes). Typically the parents are asked to place slashes on the form in relevant areas, however, the online version requested that I use numerals to rate skill acquisition, which is what I had done. After I had entered the data, the system generated a relevant report for my imaginary client.  In addition to the demographic section, the report generated the following information (below):

  1. A bar graph of the client’s skills breakdown in the developed, undecided and undeveloped ranges of the early ToM development scale.
  2. Percentile scores of how the client did in the each of the 14 early ToM measures
  3. Median percentiles of scores
  4. Table for treatment planning broken down into strengths and challenges

I find the information provided to me by the Toddler Screen highly useful for assessment and treatment planning purposes and definitely have plans on using this portion of the TOM-2 Inventory as part of my future toddler evaluations.

Of course, the above instruments are only two of many, aimed at assessing social pragmatic abilities of children under 3 years of age, so I’d like to hear from you! What formal and informal instruments are you using to assess social pragmatic abilities of children under 3 years of age? Do you have a favorite one, and if so, why do you like it?

References:

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Early Intervention Evaluations PART III: Assessing Children Under 2 Years of Age

In this post, I am continuing my series of articles on speech and language assessments of children under 3 years of age. My first installment in this series offered suggestions regarding what information to include in general speech-language assessments for this age group, while my second post specifically discussed assessments of toddlers with suspected motor speech disorders.

Today, I’d like to describe what information I tend to include in reports for children ~16-18 months of age.  As I mentioned in my previous posts, the bulk of children I assess under the age of 3, are typically aged 30 months or older. However, a relatively small number of children are brought in for an assessment around an 18-month mark, which is the age group that I would like to discuss today.

Typically,  these children are brought in due to a lack of or minimal speech-language production. Interestingly enough, based on the feedback of colleagues, this group is surprisingly hard to report on. While all SLPs will readily state that 18-month-old children are expected to have a verbal vocabulary of at least 50 words and begin to combine them into two-word utterances (e.g., ‘daddy eat’). When prompted: “Well, what else should my child be capable of?” many SLPs draw a blank regarding what else to say to parents on the spot.

Image result for assessmentAs mentioned in my previous post on assessment of children under 3, the following sections should be an integral part of every early intervention speech-language assessment:

  • Background History
  • Language Development and Use  (Free Questionnaires)
  • Adaptive Behavior
  • Play Assessment (Westby, 2000) (Westby Play Scale-Revised Link)
  • Auditory Function
  • Oral Motor Exam
  • Feeding and Swallowing
  • Vocal Parameters
  • Fluency and Resonance
  • Articulation and Phonology
  • Receptive Language
  • Expressive Language
  • Social Emotional Development
  • Pragmatic Language
  • Impressions
  • Recommendations
  • Suggested Therapy Goals
  • References (if pertinent to a particular report)

In my two previous posts, I’ve also offered examples of select section write-ups (e.g., receptive, expressive phonology, etc.). Below a would like to offer a few more for this age group. Below is an example of a write-up on an 18-month-old bilingual child with a very limited verbal output.

RECEPTIVE LANGUAGE:

L’s receptive language skills were solid at 8 months of age (as per clinical observations and REEL-3 findings) which is significantly below age-expectancy for a child her age (18 months). During the assessment L received credit for appropriately reacting to prohibitive verbalizations (e.g., “No”, “Stop”), attending to speaker when her name was spoken, performing a routine activity upon request (when combined with gestures), looking at familiar object when named, finding the aforementioned familiar object when not in sight, as well as pointing to select body parts on Mrs. L and self (though identification on self was limited).  L is also reported to be able to respond to yes/no questions by head nods and shakes.

However, during the assessment L was unable to consistently follow 1 and 2 step directions without gestural cues, understand and perform simple actions per clinician’s request, select objects from a group of 3-5 items given a verbal command, select familiar puzzle pieces from a visual field of 2 choices, understand simple ‘wh questions (e.g., “what?”, “where?”), point to objects or pictures when named, identify simple pictures of objects in book, or display the knowledge and understanding of age appropriate content, function and early concept words (in either Russian or English) as is appropriate for a child her age.   

EXPRESSIVE LANGUAGE and ARTICULATION

L’s expressive language skills were judged to be solid at 7 months of age (as per clinical observations and REEL-3 findings), which is significantly below age-expectancy for a child her age (18 months). L was observed to spontaneously use proto-imperative gestures (eye gaze, reaching, and leading [by hand]), vocalizations, as well waving for the following language functions: requesting, rejecting, regulating own environment as well as providing closure (waving goodbye).

L’s spontaneous vocalizations consisted primarily of reduplicated babbling (with a limited range of phonemes) which is significantly below age-expectancy for a child her age (see below for developmental norms).  During the assessment, L was observed to frequently vocalize “da-da-da”. However, it was unclear whether she was vocalizing to request objects (in Russian “dai” means “give”) due to the fact that she was not observed to consistently vocalize the above solely when requesting items.  Additionally, L was not observed to engage in reciprocal babbling or syllable/word imitation during today’s assessment, which is a concern for a child her age.  When the examiner attempted to engage L in structured imitation tasks by offering and subsequently denying a toy of interest until L attempted to imitate the desired sound, L became easily frustrated and initiated tantrum behavior. During the assessment, L was not observed to imitate any new sounds trialed with her by the examiner.

During today’s assessment, L’s primary means of communication consisted of eye gaze, reaching, crying, gestures, as well as sound and syllable vocalizations.  L’s phonetic inventory consisted of the following consonant sounds: plosives (/p/, /b/ as reported by Mrs. L), alveolars (/t/, /d/ as reported and observed), fricative (/v/ as observed), velar (/g/ as observed), as well as nasal (/n/, and /m/ as observed).   L was also observed to produce two vowels /a/ and a pharyngeal /u/.  L’s phonotactic repertoire was primarily restricted to reported CV(C-consonant; V-vowel) and VCV syllable shapes, which is significantly reduced for a child her age.

According to developmental norms, a child of L’s age (18 months) is expected to produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000). During this time the child’s vocabulary size increases to 50+ words at which point children begin to combine these words to produce simple phrases and sentences (as per Russian and English developmental norms).  Additionally, an, 18 months old child is expected to begin monitoring and repairing own utterances, adjusting speech to different listeners, as well as practicing sounds, words, and early sentences. (Clark, adapted by Owens, 2015)

Based on the above guidelines L’s receptive and expressive language, as well as articulation abilities, are judged to be significantly below age expectancy at this time. Speech and language therapy is strongly recommended in order to improve L’s speech and language skills.

Typically when the assessed young children exhibit very limited comprehension and expression, I tend to provide their caregivers with a list of developmental expectations for that specific age group (given the range of a few months) along with recommendations of communication facilitation. Below is an example of such a list, pulled a variety of resources.

Image result for milestonesDevelopmental Milestones expected of a 16-18 months old toddler:

 Attention/Gaze:

  • Make frequent spontaneous eye contact with adults during interactions
  • Turn head to look towards the new voice, when another person begins to talk
  • Make 3-point gaze shifts by 1. looking at a toy in hand, 2. then at an adult, 3. then back to the toy
  • Make 4-point gaze shifts if more than one person is in the room – by looking from a toy in hand to one person, then the other person, then back to the toy,
  • Spontaneously attend to book, activity for 2-3+ minutes without redirection

Reaching and Gestures:

  • Show objects in hand to an adult (without actually giving them)
  • Push away items that aren’t wanted
  • Engage in give and take games when holding objects with an adult
  • Imitate simple gestures such as clapping hands or waving bye-bye
  • Hand an object to an adult to ask for help with it
  • Shake head “no?”

Image result for playPlay Skills/Routines:

  • Attempt to actively explore toys (e.g., push or spin parts of toys, turn toys over, roll them back and forth)
  • Repeat interesting actions with toys (e.g., make a toy produce an unusual noise, then attempt to make the noise again)
  • Imitate simple play activities (adult bangs two blocks together, then child imitates)
  • Use objects on daily basis (e.g., when given a spoon or cup the child attempts to feed himself. When putting on clothes the child begins to lift his arms in anticipation of a shirt going on.)

 Receptive (Listening Skills):

  • Consistently follow 1 and 2 step directions without gestural cues
  • Understand and perform simple actions per request (“sit down” or “come here”) without gestures
  • Select objects from a group of 3 items given a verbal command
  • Select familiar puzzle pieces from a visual field of 2 choices
  • Understand simple ‘wh questions (e.g., “what?”, “where?”)
  • Point to objects or pictures when named
  • Spontaneously and consistently identify simple pictures of objects in book
  • Stop momentarily what he is doing if an adult says “no” in a firm voice
  • Identify 2-3 common everyday objects or body parts when asked

 Expressive (Speaking Skills): 

  • Produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000).
  • Have a vocabulary size nearing 50 words (e.g., 35-40)
  • Imitate adult words or vocalizations
  • Attempt to practice sounds and words (Clark, adapted by Owens, 2015)
  • Appropriately label familiar objects (foods, toys, animals)

Related imageMaterials to use with the child to promote language and play:

  • Bubbles
  • Cause and effect toys
  • Toys with a variety of textures (soft toys, plastic toys, cardboard blocks, ridged balls)
  • Toys with multiple actions
  • Toys with special effects: lights, sounds, movement (push and go vehicles)
  • Building and linking toys
  • Toys with multiple parts
  • Balls, cars and trucks, animals, dolls
  • Puzzles
  • Pop-up picture books
  • Toys the child demonstrates an interest in (parents should advise)

Strategies:

  • Reduce distractions (noise, clutter etc)
  • Provide one on one interaction in a structured space (e.g., sitting at the play table or sitting on parent’s lap) to improve attention
  • Offer favorite activities and toys of interest initially before branching out to new materials
  • Offer favorite foods/toys as reinforcers to continue working
  • Offer choices of two toys, then remove one toy and focus interaction with one toy of interest
  • Try to prolong attention to toy for several minutes at a time
  • Change activities frequently, HOWEVER, repeat same activities in cycles over and over again during home practice in order to solidify skills
  • Label objects and actions in the child’s immediate environment
  • Use brief but loud utterances (2-3 words not more) to gain attention and understanding
  • Frequently repeat words in order to ensure understanding of what is said/expected of child
  • Use combination of gestures, signs, words, and pictures to teach new concepts
  • Do not force child to speak if he doesn’t want to rather attempt to facilitate production of gestures/sounds (e.g., use “hand over hand” to show child the desired gesture such as pointing/waving/motioning in order to reduce his/her frustration
  • Use play activities as much as possible to improve child’s ability to follow directions and comprehend language
    • Doll House (with Little People)
    • Garage
    • Farm, etc

Related imageCore vocabulary categories for listening and speaking:

  • Favorite and familiar toys and objects
  • Names of people in the child’s life as well as his own name
  • Pets
  • Favorite or familiar foods
  • Clothing
  • Body parts
  • Names of daily activities and actions (go, fall, drink, eat, walk, wash, open)
  • Recurrence (more)
  • Names of places (bed, outside)
  • Safety words (hot, no, stop, dangerous, hurt, don’t touch, yuck, wait)
  • Condition words (boo-boo, sick/hurt, mad, happy)
  • Early pronouns (me, mine)
  • Social words (hi, bye, please, sorry)
  • Early concepts: in, off, on, out, big, hot, one, up, down, yucky, wet, all done)
  • Yes/no

 Select References:

  • Owens, R. E. (2015). Language development: An introduction (9th ed.). Boston, MA: Allyn & Bacon.
  • Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587–599.
  • Rescorla, L., Hadicke-Wiley, M., & Escarce, E. (1993). Epidemiological investigation of expressive language delay
    at age two. First Language, 13, 5–22.
  • Robb, M. P., & Bleile, K. M. (1994). Consonant inventories of young children from 8 to 25 months. Clinical Linguistics and Phonetics, 8, 295-320.
  • Selby, J. C., Robb, M. P., & Gilbert, H. R. (2000). Normal vowel articulations between 15 and 36 months of age. Clinical Linguistics and Phonetics, 14, 255-266.

Click HERE for the Early Intervention Evaluations PART IV: Assessing Pragmatic Abilities of Children Under 3

Stay Tuned for the next installment in this series:

  • Early Intervention Evaluations PART V: Assessing Feeding and Swallowing in Children Under Two

 

 

 

 

 

 

 

 

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Early Intervention Evaluations PART II: Assessing Suspected Motor Speech Disorders in Children Under 3

In my previous post on this topic, I brought up concerns regarding the paucity of useful information in EI SLP reports for children under 3 years of age and made some constructive suggestions of how that could be rectified. In 2013, I had written about another significant concern, which involved neurodevelopmental pediatricians (rather than SLPs), diagnosing Childhood Apraxia of Speech (CAS), without the adequate level of training and knowledge regarding motor speech disorders. Today, I wanted to combine both topics and delve deeper into another area of EI SLP evaluations, namely, assessments of toddlers with suspected motor speech disorders.

Firstly, it is important to note that CAS is disturbingly overdiagnosed. A cursory review of both parent and professional social media forums quickly reveals that this diagnosis is doled out like candy by both SLPs and medical professionals alike, often without much training and knowledge regarding the disorder in question.   The child is under 3, has a limited verbal output coupled with a number of phonological processes,  and the next thing you know,  s/he is labeled as having Childhood Apraxia of Speech (CAS).  But is this diagnosis truly that straightforward?

Let us begin with the fact that all reputable organizations involved in the dissemination of information on the topic of CAS (e.g., ASHA, CASANA, etc.), strongly discourage the diagnosis of CAS in children under three years of age with limited verbal output,  and limited time spent in EBP therapy specifically targeting the remediation of motor speech disorders.

Assessment of motor speech disorders in young children requires solid knowledge and expertise. That is because CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc). Furthermore, symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of  “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis. Finally, the diagnosis of CAS is also problematic due to the fact that there are still to this day no valid or reliable standardized assessments sensitive to CAS detection (McCauley & Strand, 2008).

In March 2017, Dr. Edythe Strand wrote an excellent article for the ASHA Leader entitled: “Appraising Apraxia“, in which she used a case study of a 3-year-old boy to describe how a differential diagnosis for CAS can be performed. She reviewed CAS characteristics, informal assessment protocols, aspects of diagnosis and treatment, and even included ‘Examples of Diagnostic Statements for CAS’ (which illustrate how clinicians can formulate their impressions regarding the child’s strengths and needs without explicitly labeling the child’s diagnosis as CAS).

Today, I’d like to share what information I tend to include in speech-language reports geared towards the assessing motor speech disorders in children under 3 years of age. I have a specific former client in mind for whom a differential diagnosis was particularly needed. Here’s why.

This particular 30-month client, TQ, (I did mention that I get quite a few clients for assessment around that age), was brought in due to parental concerns over her significantly reduced speech and expressive language abilities characterized by unintelligible “babbling-like” utterances and lack of expressive language.  All of TQ’s developmental milestones with the exception of speech and language had been achieved grossly at age expectancy. She began limitedly producing word approximations at ~16 months of age but at 30 months of age, her verbal output was still very restricted. She mainly communicated via gestures, pointing, word approximations, and a handful of signs.

Interestingly, as an infant, she had a restricted lingual frenulum.  However, since it did not affect her ability to feed, no surgical intervention was needed. Indeed, TQ presented with an adequate lingual movement for both feeding and speech sound production, so her ankyloglossia (or anterior tongue tie) was definitely not the culprit which caused her to have limited speech production.

Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.

Assessment of TQ’s social-emotional functioning, play skills, and receptive language  (via a combination of Revised Westby Play Scale (Westby, 2000), REEL-3, & PLS-5) quickly revealed that she was a very bright little girl who was developing on target in all of the tested areas. Assessment of TQ’s expressive language (via REEL-3, PLS-5 & LUI*), revealed profoundly impaired, expressive language abilities.  But due to which cause?

Despite lacking verbal speech, TQ’s communicative frequency (how often she attempted to spontaneously and appropriately initiate interactions with others), as well as her communicative intent (e.g., gaining attention, making requests, indicating protests, etc), were judged to be appropriate for her age. She was highly receptive to language stimulation given tangible reinforcements and as the assessment progressed she was observed to significantly increase the number and variety of vocalizations and word approximations including delayed imitation of words and sounds containing bilabial and alveolar nasal phonemes.  

For the purpose of TQ’s speech assessment, I was interested in gaining knowledge regarding the following:

  • Automatic vs. volitional control
  • Simple vs. complex speech production
  • Consistency of productions on repetitions of the same words/word approximations
  • Vowel Productions
  • Imitation abilities
  • Prosody
  • Phonetic inventory
  • Phonotactic Constraints
  • Stimulability

TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender.  Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.

  1. Phonetic inventory of all the sounds TQ produced during the assessment is as follows:
    • Consonants:  plosive nasals (/m/) and alveolars (/t/, /d/, n), as well as a glide (/w/)
    • Vowels: (/a/, /e/, /i/, /o/)
  2. TQ’s phonotactic repertoire was primarily comprised of word approximations restricted to specific sounds and consisted of CV (e.g., ne), VCV (e.g., ada), CVC (e.g., nyam), CVCV (e.g., nada), VCVC (e.g., adat), CVCVCV (nadadi), VCVCV(e.g., adada) syllable shapes
  3. TQ’s speech intelligibility in known and unknown contexts was profoundly reduced to unfamiliar listeners. However, her word approximations were consistent across all productions.
  4. Due to the above I could not perform an in-depth phonological processes analysis

However, by this time I had already formulated a working hypothesis regarding TQ’s speech production difficulties. Based on her speech sound assessment TQ presented with severe phonological disorder characterized by restricted sound inventory, simplification of sound sequences, as well as patterns of sound use errors (e.g., predominance of alveolar /d/ and nasal /n/ sounds when attempting to produce most word approximations) in speech (Stoel-Gammon, 1987).

TQ’s difficulties were not consistent with the diagnosis Childhood Apraxia of Speech (CAS) at that time due to the following:

  • Adequate and varied production of vowels
  • Lack of restricted use of syllables during verbalizations (TQ was observed to make verbalizations up to 3 syllables in length)
  • Lack of disruptions in rate, rhythm, and stress of speech
  • Frequent and spontaneous use of consistently produced verbalizations
  • Lack of verbal groping behaviors when producing word-approximations
  • Good control of pitch, loudness and vocal quality during vocalizations

I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.

I still, however, wanted to be cautious as there were a few red flags I had noted which may have potentially indicative of a non-CAS motor speech involvement, due to which I wanted to include some recommendations pertaining to motor speech remediation.

Now it is possible that after 6 months of intensive application of EBP phonological and motor speech approaches TQ would have turned 3 and still presented with highly restricted speech sound inventory and profoundly impaired speech production, making her eligible for the diagnosis of CAS in earnest.  However,  at the time of my assessment,  making such diagnosis in view of all the available evidence would have been both clinically inappropriate and unethical.

So what were my recommendations you may ask? Well, I provisionally diagnosed TQ with a severe phonological disorder and recommended that among a variety of phonologically-based approaches to trial, an EBP approach to the treatment of motor speech disorders be also used with her for a period of 6 months to determine if it would expedite speech gains.

*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the Rapid Syllable Transition Treatment (ReST). ReST is a free EBP treatment developed by the SLPs at the University of Sydney, which uses nonsense words, designed to help children coordinate movements across syllables in long words and phrases as well as helps them learn new speech movements. It is, however, important to note for young children with highly restricted sound inventories, characterized by a lack of syllable production, ReST will not be applicable. For them, the Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC) approaches do have some limited empirical support.

I also made sure to make a note in my report regarding the inappropriate use of non-speech oral motor exercises (NSOMEs) in therapy, indicating that there is NO research to support the use of NSOMEs to stimulate speech production (Lof, 2010).

In addition to the trialing of phonological and motor based approaches I also emphasized the need to establish consistent lexicon via development of functional words needed in daily communication and listed a number of examples across several categories. I made recommendations regarding select approaches and treatment techniques to trial in therapy,  as well as suggestions for expansion of sounds and structures. Finally, I made suggestions for long and short term therapy goals for a period of 6 months to trial with TQ in therapy and provided relevant references to support the claims I’ve made in my report.

You may be interested in knowing that nowadays TQ is doing quite well, and at this juncture, she is still, ineligible for the diagnosis CAS (although she needs careful ongoing monitoring with respect to the development of reading difficulties when she is older).

Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of questionable and even downright harmful bunk treatments for their children,  the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.

That is why the correct diagnosis is so important for young children under 3 years of age. But before it can be made, extensive (reputable and evidence supported) training and education are needed by evaluating SLPs on the assessment and treatment of motor speech disorders in young children.

References:

  1. Davis, B & Velleman, S (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. 10 (3): 177 – 192.
  2. Lof, G., & Watson, M. (2010). Five reasons why nonspeech oral-motor exercises do not work. Perspectives on School-Based Issues, 11.109-117.
  3. McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
  4. McCauley R.J., Strand E., Lof, G.L., Schooling T. & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech, American Journal of Speech-Language Pathology, 18, 343-360.
  5. Murray, E., McCabe, P. & Ballard, K.J. (2015). A Randomized Control Trial of Treatments for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research 58 (3) 669-686.
  6. Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
  7. Strand, E (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, L & Campbell, T (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.
  8. Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.
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Early Intervention Evaluations PART I: Assessing 2.5 year olds

Today, I’d  like to talk about speech and language assessments of children under three years of age.  Namely, the quality of these assessments.   Let me be frank,  I  am not happy with what I am seeing.  Often times,  when I receive a speech-language report on a child under three years of age,  I am struck by how little functional information it contains about the child’s  linguistic strengths and weaknesses.  Indeed,  conversations with parents often reveal that at best the examiner spent no more than half an hour or so playing with the child and performed very limited functional testing of their actual abilities.   Instead, they interviewed the parent and based their report on parental feedback alone.   Consequently, parents often end up with a report of very limited value,  which does not contain any helpful information on how delayed is the child as compared to peers their age.

So today I like to talk about what information should such speech-language reports should contain.   For the purpose of this particular post,  I will choose a particular developmental age at which children at risk of language delay are often assessed by speech-language pathologists. Below you will find what information I typically like to include in these reports as well as developmental milestones for children 30 months or 2.5 years of age.

Why 30 months, you may ask?   Well, there isn’t really any hard science to it. It’s just that I noticed that a significant percentage of parents who were already worried about their children’s speech-language abilities when they were younger, begin to act upon those worries as the child is nearing 3 years of age and their abilities are not improving or are not commensurate with other peers their age.

So here is the information I include in such reports (after I’ve gathered pertinent background information in the form of relevant intakes and questionnaires, of course).  Naturally, detailed BACKGROUND HISTORY section is a must! Prenatal, perinatal, and postnatal development should be prominently featured there.   All pertinent medical history needs to get documented as well as all of the child’s developmental milestones in the areas of cognition,  emotional development, fine and gross motor function, and of course speech and language.  Here,  I also include a family history of red flags: international or domestic adoption of the child (if relevant) as well as familial speech and language difficulties, intellectual impairment, psychiatric disorders, special education placements, or documented deficits in the areas of literacy (e.g., reading, writing, and spelling). After all, if any of the above issues are present in isolation or in combination, the risk for language and literacy deficits increases exponentially, and services are strongly merited for the child in question.

For bilingual children,  the next section will cover LANGUAGE BACKGROUND AND USE.  Here, I describe how many and which languages are spoken in the home and how well does the child understand and speak any or all of these languages (as per parental report based on questionnaires).

After that,  I  move on to describe the child’s ADAPTIVE BEHAVIOR during the assessment.  In this section, I cover emotional relatedness, joint attention, social referencing,  attention skills, communicative frequency, communicative intent,  communicative functions, as well as any and all unusual behaviors noted during the therapy session (e.g., refusal, tantrums, perseverations, echolalia, etc.) Then I move on to PLAY SKILLS. For the purpose of play assessment, I use the Revised Westby Play Scale (Westby, 2000). In this section,  I describe where the child is presently with respect to play skills,  and where they actually need to be developmentally (excerpt below).

During today’s assessment, LS’s play skills were judged to be significantly reduced for his age. A child of LS’s age (30 months) is expected to engage in a number of isolated pretend play activities with realistic props to represent daily experiences (playing house) as well as less frequently experienced events (e.g., reenacting a doctor’s visit, etc.) (corresponds to Stage VI on the Westby Play Scale, Revised Westby Play Scale (Westby, 2000)). Contrastingly, LS presented with limited repertoire routines, which were characterized primarily by exploration of toys, such as operating simple cause and effect toys (given modeling) or taking out and then putting back in playhouse toys.  LS’s parents confirmed that the above play schemas were representative of play interactions at home as well. Today’s LS’s play skills were judged to be approximately at Stage II (13 – 17 months) on the Westby Play Scale, (Revised Westby Play Scale (Westby, 2000)) which is significantly reduced for a child of  LS’s age, since it is almost approximately ±15 months behind his peers. Thus, based on today’s play assessment, LS’s play skills require therapeutic intervention. “

Sections on AUDITORY FUNCTION, PERIPHERAL ORAL MOTOR EXAM, VOCAL PARAMETERS, FLUENCY AND RESONANCE (and if pertinent FEEDING and SWALLOWING follow) (more on that in another post).

Now, it’s finally time to get to the ‘meat and potatoes’ of the report ARTICULATION AND PHONOLOGY as well as RECEPTIVE and EXPRESSIVE LANGUAGE (more on PRAGMATIC ASSESSMENT in another post).

First, here’s what I include in the ARTICULATION AND PHONOLOGY section of the report.

  1. Phonetic inventory: all the sounds the child is currently producing including (short excerpt below):
    • Consonants:  plosive (/p/, /b/, /m/), alveolar (/t/, /d/), velar (/k/, /g/), glide (/w/), nasal (/n/, /m/) glottal (/h/)
    • Vowels and diphthongs: ( /a/, /e/, /i/, /o/, /u/, /ou/, /ai/)
  2. Phonotactic repertoire: What type of words comprised of how many syllables and which consonant-vowel variations the child is producing (excerpt below)
    • LS primarily produced one syllable words consisting of CV (e.g., ke, di), CVC (e.g., boom), VCV (e.g., apo) syllable shapes, which is reduced for a child his age. 
  3. Speech intelligibility in known and unknown contexts
  4. Phonological processes analysis

Now that I have described what the child is capable of speech-wise,  I discuss where the child needs to be developmentally:

“A child of LS’s age (30 months) is expected to produce additional consonants in initial word position (k, l, s, h), some consonants (t, d, m, n, s, z) in final word position (Watson & Scukanec, 1997b), several consonant clusters (pw, bw, -nd, -ts) (Stoel-Gammon, 1987) as well as evidence a more sophisticated syllable shape structure (e.g., CVCVC)   Furthermore, a 30 month old child is expected to begin monitoring and repairing own utterances, adjusting speech to different listeners, as well as practicing sounds, words, and early sentences (Clark, adapted by Owens, 1996, p. 386) all of which LS is not performing at this time.  Based on above developmental norms, LS’s phonological abilities are judged to be significantly below age-expectancy at this time. Therapy is recommended in order to improve LS’s phonological skills.”

At this point, I am ready to move on to the language portion of the assessment.   Here it is important to note that a number of assessments for toddlers under 3 years of age contain numerous limitations. Some such as REEL-3 or Rosetti (a criterion-referenced vs. normed-referenced instrument) are observational or limitedly interactive in nature, while others such as PLS-5,  have a tendency to over inflate scores,  resulting in a significant number of children not qualifying for rightfully deserved speech-language therapy services.  This is exactly why it’s so important that SLPs have a firm knowledge of developmental milestones!  After all,  after they finish describing what the child is capable of,  they then need to describe what the developmental expectations are for a child this age (excerpts below).

RECEPTIVE LANGUAGE

LS’s receptive language abilities were judged to be scattered between 11-17 months of age (as per clinical observations as well as informal PLS-5 and REEL-3 findings), which is also consistent with his play skills abilities (see above).  During the assessment LS was able to appropriately understand prohibitive verbalizations (e.g., “No”, “Stop”), follow simple 1 part directions (when repeated and combined with gestures), selectively attend to speaker when his name was spoken (behavioral), perform a routine activity upon request (when combined with gestures), retrieve familiar objects from nearby (when provided with gestures), identify several major body parts (with prompting) on a doll only, select a familiar object when named given repeated prompting, point to pictures of familiar objects in books when named by adult, as well as respond to yes/no questions by using head shakes and head nods. This is significantly below age-expectancy.

A typically developing child 30 months of age is expected to spontaneously follow (without gestures, cues or prompts) 2+ step directives, follow select commands that require getting objects out of sight, answer simple “wh” questions (what, where, who), understand select spatial concepts, (in, off, out of, etc), understand select pronouns (e.g., me, my, your), identify action words in pictures, understand concept sizes (‘big’, ‘little’), identify simple objects according to their function, identify select clothing items such as shoes, shirt, pants, hat (on self or caregiver) as well as understand names of farm animals, everyday foods, and toys. Therapeutic intervention is recommended in order to increase LS’s receptive language abilities.

EXPRESSIVE LANGUAGE:

During today’s assessment, LS’s expressive language skills were judged to be scattered between 10-15 months of age (as per clinical observations as well as informal PLS-5 and REEL-3 findings). LS was observed to communicate primarily via proto-imperative gestures (requesting and object via eye gaze, reaching) as well as proto-declarative gestures (showing an object via eye gaze, reaching, and pointing). Additionally, LS communicated via vocalizations, head nods, and head shakes.  According to parental report, at this time LS’s speaking vocabulary consists of approximately 15-20 words (see word lists below).  During the assessment LS was observed to spontaneously produce a number of these words when looking at a picture book, playing with toys, and participating in action based play activities with Mrs. S and clinician.  LS was also observed to produce a number of animal sounds when looking at select picture books and puzzles.  For therapy planning purposes, it is important to note that LS was observed to imitate more sounds and words, when they were supported by action based play activities (when words and sounds were accompanied by a movement initiated by clinician and then imitated by LS). Today LS was observed to primarily communicate via a very limited number of imitated and spontaneous one word utterances that labeled basic objects and pictures in his environment, which is significantly reduced for his age.

A typically developing child of LS’s chronological age (30 months) is expected to possess a minimum vocabulary of 200+ words (Rescorla, 1989), produce 2-4 word utterance combinations (e.g., noun + verb, verb + noun + location, verb + noun + adjective, etc), in addition to asking 2-3 word questions as well as maintaining a topic for 2+ conversational turns. Therapeutic intervention is recommended in order to increase LS’s expressive language abilities.”

Here you have a few speech-language evaluation excerpts which describe not just what the child is capable of but where the child needs to be developmentally.   Now it’s just a matter of summarizing my IMPRESSIONS (child’s strengths and needs), RECOMMENDATIONS as well as SUGGESTED (long and short term) THERAPY GOALS.  Now the parents have some understanding regarding their child’s  strengths and needs.   From here,  they can also track their child’s progress in therapy as they now have some idea to what it can be compared to.

Now I know that many of you will tell me,  that this is a ‘perfect world’ evaluation conducted by a private therapist with an unlimited amount of time on her hands.   And to some extent, many of you will be right! Yes,  such an evaluation was a result of more than 30 minutes spent face-to-face with the child.  All in all, it took probably closer to 90 minutes of face to face time to complete it and a few hours to write.   And yes,  this is a luxury only a few possess and many therapists in the early intervention system lack.  But in the long run, such evaluations pay dividends not only, obviously, to your clients but to SLPs who perform them.  They enhance and grow your reputation as an evaluating therapist. They even make sense from a business perspective.  If you are well-known and highly sought after due to your evaluating expertise, you can expect to be compensated for your time, accordingly. This means that if you decide that your time and expertise are worth private pay only (due to poor insurance reimbursement or low EI rates), you can be sure that parents will learn to appreciate your thoroughness and will choose you over other providers.

So, how about it? Can you give it a try? Trust me, it’s worth it!

Selected References:

  • Owens, R. E. (1996). Language development: An introduction (4th ed.). Boston, MA: Allyn & Bacon.
  • Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587–599.
  • Selby, J. C., Robb, M. P., & Gilbert, H. R. (2000). Normal vowel articulations between 15 and 36 months of age. Clinical Linguistics and Phonetics, 14, 255-266.
  • Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
  • Watson, M. M., & Scukanec, G. P. (1997b). Profiling the phonological abilities of 2-year-olds: A longitudinal investigation. Child Language Teaching and Therapy, 13, 3-14.

For more information on EI Assessments click on any of the below posts: