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Assessing Behaviorally Impaired Students: Why Background History Matters!

As a speech language pathologist (SLP) who works in an outpatient psychiatric school-based setting, I frequently review incoming students previous speech language evaluation reports.  There are a number of trends I see in these reports which I have written about in the past as well as planned on writing about in the future.

For example, in the past I wrote about my concern regarding the lack of adequate or even cursory social communication assessments for students with documented psychiatric impairments and emotional behavioral deficits.

This leads many professionals to do the following: 

a. Miss vital assessment elements which denies students appropriate school based services and

b. Assume that the displayed behavioral challenges are mere results of misbehaving. 

Today however I wanted express my thoughts regarding another disturbing trend I see in numerous incoming speech-language reports in both outpatient school/hospital setting as well as in private practice  – and that is lack of background information in the students assessment reports.

Despite its key role in assessment, this section is frequently left bare. Most of the time it contains only the information regarding the students age and grade levels as well as the reasons for the referral (e.g., initial evaluation, triennial evaluation).  Some of the better reports will include cursory mention of the student’s developmental milestones but most of the time information will be sorely lacking.

Clearly this problem is not just prevalent in my incoming assessment reports. I frequently see manifestations of it in a variety of speech pathology related social media forums such as Facebook. Someone will pose a question regarding how to distinguish a _____ from ____ (e.g., language difference vs. language disorder, behavioral noncompliance vs. social communication deficits, etc.) yet when they’re questioned further many SLPs will admit that they are lacking any/most information regarding the students background history.

When questioned regarding the lack of this information, many SLPs get defensive. They cite a variety of reasons such as lack of parental involvement (“I can’t reach the parents”), lack of access to records (“it’s a privacy issue”), division of labor (e.g., “it’s the social worker’s responsibility and not mine to obtain this information”) as well as other justifications why this information is lacking.

Now, I don’t know about you, but one of my earliest memories of the ‘diagnostics’ class in graduate school involved collecting data and writing comprehensive ‘Background Information’ section of the report. I still remember multiple professors imparting upon me the vital importance is this section plays in the student’s evaluation report.

Indeed, many years later, I clearly see its vital role in assessment. Unearthing the student’s family history, developmental milestones, medical/surgical history, as well as history of past therapies is frequently the key to a successful diagnosis and appropriate provision of therapy services.  This is the information that frequently plays a vital role in subsequent referrals of “mystery” cases to relevant health professionals as well as often leads to resolution of particularly complicated diagnostic puzzles.

Of course I understand that frequently there are legitimate barriers to obtaining this information.  However, I also know that if one digs deep enough one will frequently find the information they’re seeking despite the barriers. To illustrate, at the psychiatric hospital level where I work,  I frequently encounter a number of barriers to accessing the student’s background information during the assessment process. This may include parental language/education barrier, parental absence, Division of Child Protective Services involvement,  etc.  Yet I always try to ensure that my reports contain all the background information that I’m able to unearth because I know how vitally important it is for the student in question.

In the past I have been able to use the student’s background information to make important discoveries, which were otherwise missed by other health professionals. This included undocumented history of traumatic brain injuries, history of language and literacy disabilities in the family, history of genetic disorders and/or intellectual disabilities in the family, history of maternal alcohol abuse during pregnancy, and much much more.

So what do I consider to be an adequate Background History section of the assessment report?

For starters, the basics, of course.

I begin by stating the child’s age and grade levels, who referred the child (and for what reason), as well as whether the child previously received any form of speech language assessment/therapy services in the past.

If I am preforming a reassessment (especially if it happens shortly after the last assessment took place) I provide a clear justification why the present reassessment is taking place. Here is an actual excerpt from one of my reevaluation reports. “Despite receiving average language scores on his _______ speech language testing which resulted in the  recommendation for speech therapy only, upon his admission to ______, student was referred for a language reassessment in _____, by the classroom staff who expressed significant concerns regarding validity and reliability of past speech and language testing on the ground of the student’s persistent “obvious” listening comprehension and verbal expression deficits.”

For those of you in need of further justification I’ve created a brief list of reasons why a reassessment, closely following recent testing may be needed.

  1. SLP/Parent feels additional testing is needed to create comprehensive goals for child.
  2. Previous testing was inadequate. Here it’s very important to provide comprehensive rationale  and list the reasons for it.
  3. A reevaluation was requested due to third party  concerns (e.g., psychiatrist, psychologist, etc.)

Secondly, it is important to document all relevant medical history, which includes: prenatal, perinatal, and early childhood diseases, surgical interventions and incidents. It is important to note that if a child has a long standing history of documented psychiatric difficulties, you may want to separate these sections and describe psychiatric history/diagnoses following the section that details the onset of the child’s emotional and behavioral deficits.

Let us now move on to the child’s developmental history, which should include, gross/fine motor, speech/ language milestones, and well as cognitive and socioemotional functioning.  This is a section where I typically add information regarding any early intervention services which may have been provided to the child prior to the age of three.

In my next section I discuss the child’s academic functioning to date. Here I mention whether the student qualified for a preschool disabled eligibility category and received services from the age of 3+.  I also discuss their educational classification (if one exists), briefly mention the results of previous most recent cognitive and educational testing (if available) as well as mention any academic struggles (if applicable).

After that I move on to the child’s psychiatric history. I briefly document when did the emotional behavioral problems first arose, and what had been done about them to date (out of district placements, variety of psychiatric services, etc.)  Here I also document  the student’s most recent psychiatric diagnoses (if available) and mention any medication they may be currently on (applicable due to the effect of psychiatric medications on language and memory skills).

The following section is perhaps the most important one in the  report. It is the family’s history of genetic disorders, psychiatric impairments, special education placements, as well as language, learning, and literacy deficits.  This section plays a vital importance in my determination of the contributions to the student’s language difficulties as well as guides my assessment recommendations in the presence of borderline assessment results.

I finish this section by briefly discussing the student’s Family Composition as well as Language Knowledge and Use.

I discuss family composition due to several factors.  For example, lack of consistent caregivers, prolonged absence of parental figures, as well as presence of a variety of people in the home can serve as significant stressor for children with psychiatric impairments and learning difficulties.  As a result of this information is pertinent to the report especially when it comes to figuring out the antecedents for the child’s behavior fluctuation on daily basis.

Language knowledge and use  is particularly relevant to culturally and linguistically diverse children. It is very important to understand what languages does the child understand and use at home and at school as well as what do the parents think about the child’s language abilities in both languages. These factors will guide my decision making process regarding what type of assessments would be most relevant for this child.

So there you have it.  This is the information I include in the background history section of every single one of my reports.  I believe that this information contributes to the making of the appropriate and accurate diagnosis of the child’s difficulties.

Please don’t get me wrong. This information is hugely relevant for all students that we SLPs are assessing.

However, the above is especially relevant for such vulnerable populations as children with emotional and behavioral disturbances, whose struggle with social communication is frequently misinterpreted as “it’s just behavior“. As a result, they are frequently denied social communication therapy services, which ultimately leads to denial of Free Appropriate Public Education (FAPE) that they are entitled to.

Let us ensure that this does not happen by doing all that we can to endure that the student receives a fair assessment, correct diagnosis, and can have access to the best classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.  And the first step of that process begins with obtaining a detailed background history!

Helpful Resources: 

 

 

 

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Professional Consultation Services for Speech Language Pathologists

Today I’d like to officially introduce a new professional consultation service for  speech language pathologists (SLPs), which I initiated  with select few clinicians through my practice some time ago.

The idea for this service came after numerous SLPs contacted me and initiated dialogue via email and phone calls regarding cases they were working on or asked for advice on how to initiate assessment or therapy services to new clients with complex communication issues. Here are some details about it.

Professional consultation is a service provided to Speech Language Pathologists (SLPs) seeking specialized in-depth assessment and/or treatment recommendations regarding specific client cases or who are looking to further their professional education in the following specialization areas:

  • Performing Independent Evaluations (IEEs) in Special Education Disputes
  • Comprehensive Early Intervention Assessments of Monolingual and Bilingual Children
  • Speech Language Assessment and Treatment of post-institutionalized Internationally Adopted Children
  • Speech Language Assessment and Treatment of Children with Psychiatric and Emotional Disturbances
  • Speech and Language Assessment and Treatment of Children with Fetal Alcohol Spectrum Disorders
  • Assessment and Management of Social Pragmatic Language Disorders
  • Speech Language Assessment and Treatment of Bilingual and Multicultural Children
  • Speech Language Assessment and Treatment of Severely Cognitively Impaired Clients
  • Speech Language Assessment and Treatment of Children with Genetic Disorders

These professional consultation sessions are conducted via GoTo Meeting and includes video conferencing as well as screen sharing.

The goal of this service is to facilitate the SLPs learning process in the desired specialization area. The initial consultation includes extensive literature, material and resource website recommendations, with the exception of Smart Speech Therapy LLC products, which are available separately for purchase through the online store.

The initial consultation length is 1 hour. SLPs are encouraged to forward de-identified client records prior to the consultation for review. In select cases (and with appropriate permissions) forwarding a short video/audio recording (~7 minutes)  of the client in question is recommended.

Upon purchasing a consultation the client will be immediately emailed potential dates and times for the consultation to take place.   Afternoon, Evening and Weekend hours are available for the client’s convenience. In cases of emergencies consultations may be rescheduled at the client’s/Smart Speech Therapy’s mutual convenience.

While refunds are not available for this type of service, in an unlikely event that the consultation lasts less than 1 hour, leftover time can be banked for future calls without any expiration limits.  Call sessions can be requested as needed and conveyed in advance via email.  For further information click HERE. You can also call 917-916-7487 or email [email protected] if you wanted to find out whether this service is right for you. 

Below is the recent professional consultation testimonial.

Professional Independent Evaluation Consultation Testimonial (8/20/15)

Tatyana,

I just wanted to thank you from the bottom of my heart for the mentorship consultation with you yesterday. I learned a great deal, and appreciated your straight forward approach, and most of all, your scholarly input. You are a thorough professional. This new service that you offer is invaluable for many reasons, one of which is that it buffers the clinical isolation of solo private practice.  I look forward to our next session, about which I will email you in the next week or so. If stars are given, I give you the maximum number of stars possible!    The consultations are pure wonderful!
With gratitude,
Aletta Sinoff Ph.D., CCC-SLP, BCBA-D
Licensed Speech-Language Pathologist
Board Certified Behavior Analyst
Beachwood  OH 44122
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SLP Efficiency Bundles™ for Graduating Speech Language Pathologists

Graduation time is rapidly approaching and many graduate speech language pathology students are getting ready to begin their first days in the workforce. When it comes to juggling caseloads and managing schedules, time is money and efficiency is the key to success. Consequently,  a few years ago I created  SLP Efficiency Bundles™, which are materials highly useful for Graduate 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.   Continue reading SLP Efficiency Bundles™ for Graduating Speech Language Pathologists

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Dear Pediatrician: Please Don’t Say That!

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Recently, a new client came in for therapy.  He was a little over three years of age with limited verbal abilities,  and a number of stereotypical behaviors consistent with autism spectrum disorder.  During the course of parental interview, the child’s mother mentioned that he had previously briefly received early intervention services  but  aged out from the early intervention system after only a few months.  As we continued to discuss the case, his mother revealed that she  had significant concerns regarding her son’s language abilities and behavior from a very early age  because it  significantly differed from his older sister’s developmental trajectory. However,  every time she brought it up to her pediatrician  she invariably received the following answers:  “Don’t compare him to his sister, they are different  children”  and   “Don’t  worry,  he will catch up”,  which resulted in the child being referred for early intervention services when he was almost 3 years of age,  and unable to receive consistent  speech therapy services prior to aging out of the program all together.

This is not the first time I heard such a story,  and I’m sure it won’t be the last time as well.  Sadly, myself and other speech language therapists are very familiar with such cases and that is such a shame.  It is a shame, because  a parent was absolutely correct in trusting her instincts but was not validated by a medical professional she trusted the most, her child’s pediatrician.  Please don’t get me wrong,  I am not  playing the blame game  or trying to denigrate members of another profession.   My  aim  today is rather different and that is along with my colleagues to continue increasing awareness among all health professionals  regarding the early identification  of communication disorders  in children in order for them to receive  effective early intervention services  to improve their long-term outcomes.

getty_rf_photo_of_toddler_feeding_teddy_bear

 Whenever one “Googles” the term “Language Milestones In Children”  or “When  do children begin to talk?”   Numerous links pop-up,  describing developmental milestones in children.  Most of them contain  fairly typical information such as: first word emerge at approximately 12 months of age,   2 word combinations emerge when the child has a lexicon of approximately 50 words or more, which corresponds  to  a period between  18 months to 2 years of age,  and sentences emerge when a child is approximately 3 years of age. While most of this information is hopefully common knowledge for many healthcare professionals working with children including pediatricians,  is also important to understand that when the child comes in for a checkup one should not look at these abilities in isolation but  rather  look at the child  holistically.  That means  asking the parents the right questions to compare the child’s cognitive, adaptive,  social emotional, as well as communicative functioning  to that of typically developing peers  or siblings  in order to determine whether anything is amiss.  Thus, rather than to discourage the  parent  from  comparing their child to typically developing children his age, the parents  should actually be routinely asked the variation of the following question: “How  do your child’s abilities  and functioning compare to other typically developing children your child age?”

woman-talking-to-doctorWhenever I ask this question during the process of evaluation or initiation of therapy  services,  90% of the time I receive highly detailed and intuitive responses  from well-informed parents. They immediately begin describing in significant detail the difference in functioning  between their own delayed child  and  his/her  siblings/peers.   That is why in the majority of cases  I find the background information provided by the parent to be almost as valuable  as the evaluation itself.  For example, I recently assessed  a 3-5 year-old child  due to communication concerns.   The pediatrician was very reluctant to refer to the child for services due to the fact that the child was adequately verbal.   However,  the child’s  parents were insistent,  a script for services was written, and the child was brought to me for an evaluation.  Parents reported that while their child was very verbal and outgoing,  most of the time they had significant difficulty  understanding what she was trying to tell them due to poor grammar as well as nonsensical content of her messages.   They also reported that the child had a brother , who was older than her last several years.  However,  they stated that they had never experienced similar difficulties with the child’s brother when he was her age,  which is why they became so concerned with each passing day regarding the child’s language abilities.

Indeed, almost  as soon as the evaluation began, it became apparent that while the child’s verbal output was adequate, the semantic content of those messages  as well as the pragmatic use in conversational exchanges  was significantly impaired. In  other words,  the  child may have been adequately verbose but  the coherence of her discourse left a lot to be desired.   This child was the perfect candidate for therapy but had parents not insisted, the extent of her expressive language difficulties  may have been overlooked until she was old enough to go to kindergarten. By then  many valuable intervention  hours would have been lost  and the extent of the child deficits have been far greater.

So dear pediatrician,  the next time  a concerned parent utters the words: “I think something is wrong…” or “His language is nothing like his brother’s/sister’s when s/he was that age” don’t be so hasty in dismissing their concerns. Listen to them,  understand that while you are the expert in childhood health and diseases,   they are  the expert  in their own child,  and are highly attuned  to their child’s functioning and overall abilities. Encourage them to disclose their worries by asking follow-up questions and validating their concerns.

why_your_doctor_needs_to_know_your_life_story_4461_98044748There are significant benefits  to receiving early targeted  care  beyond the improvement in language abilities.  These include but are not limited to:  reduced chances of behavioral deficits or mental illness, reduced chances of reading, writing and learning difficulties  when older,  reduced chances of  impaired socialization abilities and self-esteem,  all of which can affect children with language deficits when appropriate services are delayed or never provided.  So please, err on the side of caution  and refer the children with suspected deficits to speech language pathologists.  Please give us an opportunity to thoroughly assess these children in order to find out  whether there truly is  speech/language disorder/delay.  Because by doing this you truly will be serving the interests of your clients.

Helpful Smart Speech Therapy Resources:

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Review of Social Language Development Test Elementary: What SLPs Need to Know

sldtelAs the awareness of social pragmatic language disorders continues to grow, more and more speech language pathologists are asking questions regarding various sources of social pragmatic language testing.  Today I am reviewing one such test entitled:  Social Language Development Test Elementary  (SLDTE) currently available from PRO-ED.

Basic overview

Release date: 2008
Age Range: 6:00-11:11
Authors:Linda Bowers, Rosemary Huisingh, Carolyn LoGiudice
Publisher: Linguisystems (PRO-ED as of 2014)

This test assesses the students’ social language competence and addresses their ability to take on someone else’s perspective, make correct inferences, negotiate conflicts with peers, be flexible in interpreting situations and supporting friends diplomatically. 

The test is composed of 4 subtests, of which the first two subtests are subdivided into 2 and 3 tasks respectively.

The Making Inferences subtest (composed of 2 tasks) of the SLDT-E is administered to assess student will’s ability to infer what someone in the picture is thinking (task a) as well as state the visual cues that aided the student in the making of that inference (task b). 

On task /a/ errors can result due to student’s difficulty correctly assuming first person perspective (e.g., “Pretend you are this person. What are you thinking?”) and infering (guessing) what someone in the picture was thinking. Errors can also result due to vague, associated and unrelated responses which do not take into account the person’s context (surroundings) as well as emotions expressed by their body language.   

On task /b/ errors can result due to the student’s inability to coherently verbalize his/her responses which may result in the offer of vague, associated, or unrelated answers to presented questions, which do not take into account facial expressions and body language but instead may focus on people’s feelings, or on the items located in the vicinity of the person in the picture. 

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The Interpersonal Negotiation subtest (composed of 3 tasks) of the SLDT-E is administered to assess the student’s ability to resolve personal conflicts in the absence of visual stimuli.  Student is asked to state the problem (task a) from first person perspective (e.g., pretend the problem is happening with you and a friend), propose an appropriate solution (task b), as well as explain why the solution she was proposing was a good solution (task c).

On task /a/ errors can result due to the student’s difficulty recognizing that a problem exists in the presented scenarios. Errors can also result due to the student’s difficulty stating a problem from a first person perspective, as a result of which they may initiate their responses with reference to other people vs. self (e.g., “They can’t watch both shows”; “The other one doesn’t want to walk”, etc.). Errors also can also result due to the student’s attempt to provide a solution to the presented problem without acknowledging that a problem exists. Here’s an example of how one student responded on this subtest. When presented with: “You and your friend found a stray kitten in the woods. You each want to keep the kitten as a pet. What is the problem?” A responded: “They can’t keep it.”  When presented with:  You and your friend are at an afterschool center. You both want to play a computer game that is played by one person, but there’s only one computer. What is the problem?” A responded: “You have to play something else.”

On task /b/ errors can result due to provision of inappropriate, irrelevant, or ineffective solutions, which lack arrival to a mutual decision based on dialog.  

On task /c/ errors can result due to vague and inappropriate explanations as to why the solution proposed was a good solution.  

The Multiple Interpretations subtest assesses the student’s flexible thinking ability via the provision of two unrelated but plausible interpretations of what is happening in a photo. Here errors can result due to an inability to provide two different ideas regarding what is happening in the pictures. As a result the student may provide vague, irrelevant, or odd interpretations, which do not truly reflect the depictions in the photos. 

The Supporting Peers subtest assesses student’s ability to take the perspective of a person involved in a situation with a friend and state a supportive reaction to a friend’s situation (to provide a “white lie” rather than hurt the person’s feelings).  Errors on this subtest may result due to the student’s difficulty appropriately complementing, criticizing, or talking with peers.  Thus students who as a rule tend to be excessively blunt, tactless, or ‘thoughtless’ regarding the effect their words may have on others will do poorly on this subtest.   However, there could be situations when a high score on this subtest may also be a cause for concern (see the details on why that is HERE). That is because simply repeating the phrase “I like your ____” over and over again without putting much thinking into their response will earn the responder an average subtest score according to the SLDT-E subtest scoring guidelines.   However, such performance will not be reflective of true subtest competence and needs to be interpreted with significant caution

goal-setting

The following goals can be generated based on the performance on this test:

Long Term Goals: Student will improve social pragmatic language competence in order to effectively communicate with a variety of listeners/speakers in all conversational and academic contexts

Short Term Goals

  • Student will improve ability to  make inferences based on social scenarios
  • Student will improve ability to interpret facial expressions, body language, and gestures
  • Student will improve ability to recognize conflicts from a variety of perspectives (e.g., first person, mutual, etc.)
  • Student will improve ability to  resolve personal conflicts using effective solutions relevant to presented scenarios
  • Student will improve ability  to effectively  justify solutions to presented situational conflicts
  • Student will ability to provide multiple interpretations of presented social situations
  • Student will provide effective responses to appropriately support peers in social situations
  • Student will improve ability to engage in perspective taking (e.g., the ability to infer mental states of others and interpret their knowledge, intentions, beliefs, desires, etc.)

Caution

A word of caution regarding testing eligibility: 

I would also not administer this test to the following populations:

  • Students with social pragmatic impairments secondary to intellectual disabilities (IQ <70)
  • Students with severe forms of Autism Spectrum Disorders
  • Students with severe language impairment and limited vocabulary inventories
  • English Language Learners (ELL) with suspected social pragmatic deficits 
  • Students from low SES backgrounds with suspected pragmatic deficits 

—I would not administer this test to Culturally and Linguistically Diverse (CLD)  students due to significantly increased potential for linguistic and cultural bias, which may result in test answers being marked incorrect due to the following:

  • Lack of relevant vocabulary knowledge
  • Lack of exposure to certain cultural and social experiences related to low SES status or lack of formal school instruction
  • Life experiences that the child simply hasn’t encountered yet
    • For example the format of the Multiple Interpretations subtest may be confusing to students unfamiliar with being “tested” in this manner (asked to provide two completely different reasons for what is happening ina particular photo)

What I like about this test: 

  • I like the fact that the test begins at 6 years of age, so unlike some other related tests such as the CELF-5:M, which begins at 9 years of age or the informal  Social Thinking Dynamic Assessment Protocol® which can be used when the child is approximately 8 years of age, you can detect social pragmatic language deficits much earlier and initiate early intervention in order to optimize social language gains.
  • I like the fact that the test asks open-ended questions instead of offering orally/visually based multiple choice format as it is far more authentic in its representation of real-world experiences
  • I really like how the select subtests are further subdivided into tasks in order to better determine the students’ error breakdown

Overall, when you carefully review what’s available in the area of assessment of social pragmatic abilities this is an important test to have in your assessment toolkit as it provides very useful information for social pragmatic language treatment goal purposes.

Have YOU purchased SLDTE yet? If so how do you like using it?Post your comments, impressions and questions below.

NEW: Need an SLDTE Template Report? Find it HERE

Helpful Resources Related to Social Pragmatic Language Overview, Assessment  and Remediation:

 Disclaimer: The views expressed in this post are the personal opinion of the author. The author is not affiliated with PRO-ED or Linguisystems in any way and was not provided by them with any complimentary products or compensation for the review of this product. 

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Why is FASD diagnosis so important?

Recently, I’ve participated in various on-line and in-person discussions with both school-based speech language pathologists (SLPs) as well as medical health professionals (e.g., neurologists, pediatricians, etc.) regarding their views on the need of formal diagnosis for school aged children with suspected alcohol related deficits. While their responses differed considerably from: “we do not base intervention on diagnosis, but rather on demonstrated student need” to “with a diagnosis of ASD ‘these children’ would get the same level of services“, the message I was receiving loud and clear was: “Why? What would be the point?”  So today I decided to share my views on this matter and explain why I think the diagnosis matters.
Continue reading Why is FASD diagnosis so important?

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

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

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

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

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

One General Language Test Does Not Fit All! 

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

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

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

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

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

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

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

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Creating Successful Team Collaboration: Behavior Management in the Schools

In March 2014, ASHA SIG 16 Perspectives on School Based Issues, I’ve written an article on how SLPs can collaborate with other school based professionals to successfully work with children exhibiting challenging behaviors secondary to psychiatric diagnoses and emotional and behavioral disturbances. In this post I would like to summarize the key points of my article as well as offer helpful professional resources on this topic. Continue reading Creating Successful Team Collaboration: Behavior Management in the Schools

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Enough with “grow out”, “grow in” and “it’s normal” or why a differential diagnosis is so important!

If someone asked me today how long I’ve been thinking about writing this post I wouldn’t hesitate and say… 3 years.  I know this because that’s when I encountered my very first case of “it’s normal”. I had been in private practice for several years, when I was contacted by parents who wanted me to evaluate their 4 year old son due to concerns over his language abilities.   When I first opened my office door to let them in I encountered a completely non-verbal child with significant behavioral deficits and limited communicative intent.

I have to confess, as I was conducting an extremely difficult assessment, I was very shocked by the fact that prior to seeing me, the child had not undergone any in-depth assessments with any related professionals despite presenting with pretty significant symptoms, which included: lack of meaningful interaction with toys,  stereotypical behaviors (e.g., rapid flicking of his fingers in front of his eyes for extended period of time, perseverative repetitions of unintelligible sounds out of context, etc), temper tantrums, as well as complete absence of words, phrases and sentences for his age. Very tactfully I broached the subject with the parents only to find out that the parents were concerned regarding their child’s development for quite a while, only to be told by over and over again by their pediatrician that “it’s normal”. I hastily bit back my reply, before I could rudely blurt out: “in which universe?”  Instead, I finished the assessment, wrote my 8 page report with extensive recommendations and referrals, and began treating the client. Luckily, since that time he had received numerous appropriate interventions from a variety of related professionals and made some nice gains. But to this day I wonder: Would his gains have been greater had his intervention was initiated at an earlier age (e.g., 2 instead of 4)?

Of course, this is by far one of the more extreme examples that I have seen during the course of my relatively short career (less than 10 years of practice) as a speech language pathologist.  But I have certainly seen others.

For example, a few years ago through my hospital based job I’ve treated a child with significant unilateral facial weakness, and a host of phonation, articulation, respiration, and resonance symptoms which included: difficulty managing oral secretions, weak voice, hypernasality, dysarthric vocal quality, and a few others. Again, the parent was told by the physician that the child’s facial asymmetry and symptomology was ‘not significant’’ despite the fact that in addition to the above signs, the child also presented with significantly delayed language development, cognitive limitations and severe behavioral manifestations.

Then of course there were a few stutterers with a host of social history red flags who stuttered for a few years well into early school age, each of whose parents were told by their child’s doctor that s/he will grow out of it.

I am not even counting dozens and dozens of phone calls from concerned parents of  language delayed toddlers and preschoolers whose pediatricians told them that they’ll “grow out of it” despite the fact that many of these children ended up receiving speech language services for language delays/disorders for several years afterwards.

I’ve also seen professionals without a specialization in International Adoption diagnosing recently adopted older post-institutionalized children with history of severe trauma, profound language delays, alcohol related deficits and symptoms of institutional autism as Pervasive Developmental Disorder (PDD).

But I don’t want you to think that I am singling out pediatricians in this post. The truth is that if we look closely we will find that this trend of overconfident recommendations is common to a vast majority of both medical and ancillary professionals (e.g., psychologists, occupational therapists, etc) with speech language pathologists not exempt from the above.

I’ve read a psychiatrist’s report, which diagnosed a child with Asperger’s based on a 15 minute conversation with the child, coupled with a brief physical examination (as documented in the child’s clinical record).  At my urging (based on the child’s adaptive behavior, linguistic profile and rather superior social pragmatic functioning) the parents sought a second opinion with another psychiatrist, which revealed that the child wasn’t even on the spectrum but had a anxiety disorder, some of which symptoms mimicked Asperger’s (e.g., perseveration on topics of interest).

I’ve read numerous neurological and neuropsychological reports which diagnosed children with ADD based on the symptoms of inattention and impulsivity in select settings (e.g., school only) without a differential diagnosis to rule out language deficits, auditory processing deficits, medical conditions, or acquired syndromes such as Fetal Alcohol Spectrum Disorders.

I’ve reviewed occupational therapy evaluations which reported on the language abilities of children vs. fine and gross motor function and sensory integration skills.

One parent even told me that when she asked a speech language therapist (who was treating her child for articulation difficulties) regarding her 10 year old son’s “ginormous” (parent’s words not mine) overbite she was told “he’ll grow into it”. I was told that the pediatric orthodontist did not appreciate that opinion and vigorously voiced his own as he was fitting the child for braces.

So when exactly did some of us decide that a differential diagnosis doesn’t matter? I’d be very curious to know what prompts professionals, who upon seeing some ‘garden variety’ symptoms, which could have a multitude of causes (e.g., inattention, echolalia, lack of speech, etc) decide that there could be only one definitive diagnosis or who merely shrug the displayed signs and accompanying parental concerns aside, expecting both to disappear on their own volition, given the passage of time.

Is it carelessness?

Is it overconfidence in own abilities?

Is it fear of losing face in front of the parent if you don’t have a ready answer?

Is it misguided belief that the child is displaying “textbook” behavior?

Is it “jadedness” or I’ve seen it all, so I know what it is, attitude?

I can venture hundreds more guesses, but it would be merely pointless speculation. Rather I prefer to focus on the intent of this post which is to outline why a differential diagnosis is so important!

1. Differential diagnosis saves lives!

Yes, I know I am only a speech pathologist and it’s true that I have yet to hear from anyone “I need a speech pathologist stat!” After all I don’t specialize in pediatric dysphagia and treat preemies in NICU.

But imagine the following scenario. A young preschool child shows up to your office with a hoarse vocal quality and a history of behavior tantrums. No problem you think, textbook vocal nodules, I got this, case closed! But what if the child was displaying additional symptoms such as stridor, coughing and difficulty breathing when sleeping? What if a few days after you’ve initiated voice therapy or told the parent that the child is too young for it, the child was rushed into the hospital because his airway was obstructed due to a laryngeal papilloma, which almost caused the child to asphyxiate. Still feel confident in your first diagnosis? Yet some speech language therapists routinely accept children into voice therapy without first referring them for an ENT consult that involves endoscopic imaging.  Some of you may scoff and tell me, common, when does thing ever happen? Wouldn’t a doctor have picked up on something like that well before a child seen an SLP? Guess what … not necessarily!

Although it may be hard to believe but an EI or school-based SLP may be the first diagnostic professional many children from at-risk backgrounds come in contact with. Obstacles to receiving appropriate early medical care and ancillary services like early intervention may include limited financial means, lack of education or information, and cultural and linguistic barriers.  Bilingual, multicultural, domestically adopted and foster care children from low-income households are particularly at risk since their deficits may not be detected until they begin receiving services in EI or preschool. After all, specialized medical care and related services must be sought out and paid for, which may be very hard to do for families from low SES households if they don’t have medical insurance or are having difficulty applying for Medicaid or state health insurance.

Similarly internationally adopted children are also at significant risk of despite the fact that most are adopted by middle class, financially solvent and highly educated parents. With this particular group the barriers to early identification are pre-adoption environmental risk factors (length of institutionalization and quality of medical care in that setting), combined with limited access to information (paucity of prenatal, medical and developmental history details in the adoption records).

2. Sometimes diagnosis DOES matter!  

I know, I know, a number of you will try to convince me that we need to treat the symptoms and NOT the label!  But humor me for a second! Let’s say you are a medical/ancillary professional (depending whom the child get’s to see first and for what reason) who gets to assess a new preschool patient/client, let’s call him Johnny.  So little 4 year old Johnny walk into your office with the following symptoms:

  • aggressive /inappropriate behaviors
  • odd fine and gross motor movements
  • clumsiness
  • blunted affect (facial expression)
  • inconsistent eye contact
  • speech/language deficits
  • picky eater with a history of stomach issues (e.g., nausea, vomiting, belly pain)

Everything you observe points to the diagnosis of Autism, after all you are the professional, and you’ve seen hundreds of such cases. It’s textbook, right? WRONG! I’ve just described to you some of the symptoms of Wilson’s disease.  It’s a genetic disorder in which large amounts of copper build up in the liver and brain. This disorder has degrees of severity ranging from mild/progressive to acute/severe.  It can cause brain and nervous system damage, hence the psychiatric and neuromuscular symptoms.  The bad news is that this condition can be fatal if misdiagnosed/undiagnosed! The good news is that it is also VERY treatable and can be easily managed with medication, dietary changes, and of course relevant therapies (e.g, PT, OT, ST, etc)!

3. Correct Diagnosis can lead to Appropriate Treatment!

So we all know that ADHD diagnosis is currently being doled out like candy to practically every child with the symptoms of Inattention, Hyperactivity and Impulsivity. But can you actually GUESS how many children are misdiagnosed with it?

Elder (2010), found that nearly 1 million children in US are potentially misdiagnosed with ADHD simply because they are the youngest and most immature in their kindergarten class. Here’s what he has to say on the subject: “A child’s birth date relative to the eligibility cutoff … strongly influences teachers’ assessments of whether the child exhibits ADHD symptoms but is only weakly associated with similarly measured parental assessments, suggesting that many diagnoses may be driven by teachers’ perceptions of poor behavior among the youngest children in a classroom. These perceptions have long-lasting consequences: the youngest children in fifth and eighth grades are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.”  (Elder, 2010, 641)

Here are a few examples of ADHD misdiagnosis straight from my caseload.

Case A:  9 year old girl, Internationally Adopted at the age of 16 months diagnosed with ADHD based on the following symptoms:

  • Inattentive
  • Frequently misheard verbal messages
  • Difficulty following verbal directions
  • Very distractible
  • Blurted things out impulsively
  • Constantly forgot what had been told to her
  • Made careless mistakes on school/home work

Prior to medicating the child, the parents sought a language evaluation at the advice of a private social worker. My assessment revealed a language processing disorder and a recommendation for a comprehensive APD assessment with an audiologist. Comprehensive audiological assessment revealed the diagnosis of APD with recommendations for language intervention. After language therapy with a focus on improving the child’s auditory processing skills was initiated, her symptoms improved dramatically. The recommendations for medication were scrapped.

Case B: 12 year old boy attending outpatient school in a psychiatric hospital diagnosed with ADHD and medicated unsuccessfully for it for several years based on the following symptoms:

  • Severely Impulsive and Inattentive
  • Occasional tantrums, opposition and aggressive  behaviors
  • Difficulty with transitions
  • Odd Behaviors/Inappropriate Statements
  • Off-topic/Unrelated Comments
  • Topic Perseverations
  • Poor memory
  • Poor ability to follow directions

Detailed case history interview performed prior to initiation of a comprehensive language assessment revealed a history of Traumatic Brain Injury (TBI) at 18 months of age. Apparently the child was dropped on concrete floor head first by his biological father. However, no medical follow up took place at the time due to lack of household stability. The child was in and out of shelter with mother due to domestic abuse in the home perpetrated by biological father.

The child’s mother reported that he developed speech and language early without difficulties but experienced a significant skills regression around 1.5-2 years of age (hint, hint).  Comprehensive language assessment revealed numerous language difficulties, many of which were in the areas of memory, comprehension as well as social pragmatic language. Following the language assessment, relevant medical referrals at the age of 12 substantiated the diagnosis of TBI (better late than never). So no wonder the medication had no effect!

So what can parents do to ensure that their child is being diagnosed appropriately and receives the best possible services from various health professionals?

For starters, make sure to carefully describe all the symptoms that your child presents with (write them down to keep track of them if necessary). It is important to understand that many conditions are dynamic in nature and may change symptoms over time. For example, children with alcohol related disorders may display feeding deficits as infants, delayed developmental milestones as toddlers, good conversational abilities but poor social behavior and abstract thinking skills as school aged children and low academic achievement as adolescents.

Ensure that the professional spends adequate period of time with the child prior to generating a report or rendering a diagnosis.  We’ve all been in situations when reports/diagnoses were generated based on a 15 minute cursory visit, which did not involve any follow up testing or when the report was generated based on parental interview vs. actual face to face contact and interaction with the child.  THIS IS NOT HOW IT’S SUPPOSED TO WORK! THIS IS HOW MISDIAGNOSES HAPPEN!

Don’t be afraid to ask follow up questions or request rationale for the professionals’ decisions.  If you don’t understand something or are skeptical of the results, don’t be afraid to question the findings in a professional way.  If the information provided to you seems inadequate or poorly justified consider getting a second opinion with another professional.

Make sure that your child is being treated as a unique individual and not as a textbook subject.  Don’t you just hate it when you are trying to describe something to a professional and they look like they are listening but in reality they are not really ‘hearing’ you because they already “know what you have”.  Or they are looking at your child but they are not really seeing him/her, because he/she is just another ‘textbook case’ in a long cue of clients.  THIS IS NOT THE TREATMENT YOU ARE SUPPOSED TO GET FROM PROFESSIONALS! If this is how your child being treated then maybe it’s time to switch providers!

And another thing there are NO textbook clients! All clients are unique! I currently have about 10 post institutionalized Internationally Adopted children on my caseload with similar deficits but completely different symptom presentation, degrees of severely, as well as overall functioning. Even though some are around the same age, they are so dramatically different from one another that I need to use completely different approaches when I am planning their respective interventions.

Here’s how we as health professionals can better serve our clients/patients needs

It’s all in the details! Carefully collect the client’s background history without leaving anything out.  No piece of information is too small/inconsequential! You never know what might be relevant.

Get down to the nitty gritty by asking specific questions.  If you ask general questions you’ll get general responses.  For example, numerous health care professionals in various fields (doctors, psychiatrists, psychologists, SLPs, etc) routinely ask biological, adoptive and foster parents and adoptive caregivers whether substance abuse of drugs/alcohol took place before and during pregnancy (that they know of with respect to the latter two).   A number will respond that yes it took place during pregnancy but stopped as soon as the mother found out she was pregnant. Many professionals will leave it at that and move on to the next line of questioning. However, the follow up question to the above response should always be: “How many months along was the biological mother when she found out she was pregnant?” You’d be surprised at the responses you’ll get, which may significantly clarify the “mystery” of the child’s current symptomology.

Pretend that each new case is your very first case! Remember how you were fresh out of grad school/residency? How much enthusiasm, time, and effort you’ve put in leaving no stone unturned to diagnose your clients? That’s the passion and dedication the parents are looking for.

It’s always fun to play a detective! How cool was “House” when it first came out?  House and his team left no stone unturned in trying to correctly diagnose their patients. At times they even went to their houses or places of work in order to find any shred of information that would lead them on the right path. Admittedly you don’t have to go quite that far, but a consultation with a related professional might do the trick if a client is exhibiting certain symptoms outside your experience.

Turn your weakness into strength! No one likes to admit that they don’t have the answer. Many of us worry that our clients (those who work with adults) or their parents (those who work with children) may lose confidence in us and go elsewhere for services.  But everything depends on how you frame it! If you simply explain to the parent the rationale for the referral and why you want them to see another specialist prior to formulating the final diagnosis, they will only THANK YOU! It will show them that rather than making a casual decision, you want to make the best decision in their child’s case and they will only appreciate your candor as to them it shows your commitment to the care of their child.

It doesn’t matter how well educated and well trained many medical and related professionals are, the fact remains – no one knows everything! That is why each of us has our own unique scope of practice! That is why we should operate within our scope of practice and referral clients for additional assessments when needed.  Differential diagnosis should not be an exception; it should be a rule for any patient who does not show ‘unique’ symptoms indicative of very specific disorders/conditions! It should be performed with far greater frequency than it is done right now by medical and related health professionals!

After all: “When you have excluded all possibilities, then what remains -however improbable – must be the truth”. ~Sherlock Holmes

References:

  1. Elder, T (2010).  The Importance of Relative Standards in ADHD Diagnoses: Evidence Based on a Child’s Date of Birth, Journal of Health Economics, 29(5): 641-656.
  2. Zacharisen, M & Conley, S (2006) Recurrent Respiratory Papillomatosis in Children: Masquerader of Common Respiratory Diseases. Pediatrics 118 (5): 1925-1931.
  3. Gow P, Smallwood R, Angus P, Smith A, Wall A, Sewell R. (2000) Diagnosis of Wilson’s disease: an experience over three decades. GUT: International Journal of Gastroenterology and Hepatology, 46: 415–419.

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Language Processing Deficits (LPD) Checklist for School Aged Children

Need a Language Processing Deficits Checklist for School Aged Children

You can find it in my online store HERE

This checklist was created to assist speech-language pathologists (SLPs) with figuring out whether the student presents with language processing deficits which require further follow-up (e.g., screening, comprehensive assessment). The SLP should provide this form to both teacher and caregiver/s to fill out to ensure that the deficit areas are consistent across all settings and people.

Checklist Categories:

  • Listening Skills and Short Term Memory
  • Verbal Expression
  • Emergent Reading/Phonological Awareness
  • General Organizational Abilities
  • Social-Emotional Functioning
  • Behavior
  • Supplemental* Caregiver/Teacher Data Collection Form
  • Select assessments sensitive to Auditory Processing Deficits