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Dear SLPs, Here’s What You Need to Know About Internationally Adopted Children

In the past several years there has been a sharp decline in international adoptions. Whereas in 2004, Americans adopted a record high of 22,989 children from overseas, in 2015, only 5,647 children  (a record low in 30 years) were adopted from abroad by American citizens.

Primary Data Source: Data Source: U.S. State Department Intercountry Adoption Statistics  

Secondary Data Source: Why Did International Adoption Suddenly End?

Despite a sharp decline in adoptions many SLPs still frequently continue to receive internationally adopted (IA) children for assessment as well as treatment – immediately post adoption as well as a number of years post-institutionalization.

In the age of social media, it may be very easy to pose questions and receive instantaneous responses on platforms such as Facebook and Twitter with respect to assessment and treatment recommendations. However, it is very important to understand that many SLPs, who lack direct clinical experience in international adoptions may chime in with inappropriate recommendations with respect to the assessment or treatment of these children.

Consequently, it is important to identify reputable sources of information when it comes to speech-language assessment of internationally adopted children.

There are a number of researchers in both US and abroad who specialize in speech-language abilities of Internationally Adopted children. This list includes (but is by far not limited to) the following authors:

The works of these researchers can be readily accessed in the ASHA Journals or via ResearchGate.

Meanwhile, here are some basic facts regarding internationally adopted children that all SLPs and parents need to know.

Image result for demographicsDemographics:

  • —A greater number of older, preschool and school-aged children and fewer number of infants and toddlers are placed for adoption (Selman, 2012).
  • —Significant increase in special needs adoptions from Eastern European countries (e.g., Ukraine, Kazhakstan, etc.) as well as China.  The vast majority of Internationally Adopted children arrive to the United States with significant physical, linguistic, and cognitive disabilities as well as mental health problems. Consequently, it is important for schools to immediately provide the children with a host of services including speech-language therapy, immediately post-arrival.
  • It is also important to know that in the vast majority of cases the child’s linguistic, cognitive, or mental health deficits may not be documented in the adoption records due to poor record keeping, lack of access to adequate healthcare or often to ensure their “adoptability”. As such, parental interviews and anecdotal evidence become the primary source of information regarding these children’s social and academic functioning in their respective birth countries.

The question of bilingualism: 

  • Internationally Adopted children are NOT bilingual children! In fact, the vast majority of internationally adopted children will very rapidly lose their birth language, in a period of 2-3 months post arrival (Gindis, 2005), since they are most often adopted by parents who do not speak the child’s birth language and as such are unable/unwilling to maintain it.
  • IA children do not need to be placed in ESL classes since they are not bilingual children. Not only are IA children not bilingual, they are also not ‘truly’ monolingual since their first language is lost rather rapidly, while their second language has been gained minimally at the time of loss.
  • IA children need to acquire  Cognitive Language Mastery (CLM) which is language needed for formal academic learning. This includes listening, speaking, reading, and writing about subject area content material including analyzing, synthesizing, judging and evaluating presented information. This level of language learning is essential for a child to succeed in school. CLM takes years and years to master, especially because, IA children did not have the same foundation of knowledge and stimulation as bilingual children in their birth countries.

Image result for assessmentAssessment Parameters: 

  • —IA children’s language abilities should be retested and monitored at regular intervals during the first several years post arrival.  —
  • Glennen (2007) recommends 3 evaluations during the first year post arrival, with annual reevaluations thereafter.  —
  • Hough & Kaczmarek (2011) recommend a reevaluation schedule of 3-4 times a year for a period of two years, post arrival because some IA children continue to present with language-based deficits many years (5+) post-adoption.
  • —If an SLP speaking the child’s first language is available the window of opportunity to assess in the first language is very limited (~2-3 months at most).
  • Similarly, an assessment with an interpreter is recommended immediately post arrival from the birth country for a period of approximately the same time.
  • —If an SLP speaking the child’s first language is not available English-speaking SLP should consider assessing the child in English between 3-6 months post arrival (depending on the child and the situational constraints) in order to determine the speed with which s/he are acquiring English language abilities
    • —Children should be demonstrating rapid language gains in the areas of receptive language, vocabulary as well as articulation (Glennen 2007, 2009)
    • Dynamic assessment is highly recommended
  • It is important to remember that language and literacy deficits are not always very apparent and can manifest during any given period post arrival

Image result for speech therapyTo treat or NOT to Treat?

  • “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)
  • —IA children with medical diagnoses, which impact their speech language abilities should be assessed and considered for S-L therapy services as well (Ladage, 2009).

Helpful Links:

  1. Elleseff, T (2013) Changing Trends in International Adoption: Implications for Speech-Language Pathologists. Perspectives on Global Issues in Communication Sciences and Related Disorders, 3: 45-53
  2. Assessing Behaviorally Impaired Students: Why Background History Matters!
  3. Dear School Professionals Please Be Aware of This
  4. What parents need to know about speech-language assessment of older internationally adopted children
  5. Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted (IA) children
  6. Understanding the extent of speech and language delays in older internationally adopted children

References:

  • Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315.
  • Glennen, S (2009) Speech and language guidelines for children adopted from abroad at older ages.  Topics in language Disorders 29, 50-64.
  • —Ladage, J. S. (2009). Medical Issues in International Adoption and Their Influence on Language Development. Topics in Language Disorders , 29 (1), 6-17.
  • Selman P. (2012) Global trends in Intercountry Adoption 2000-2010. New York: National Council for Adoption, 2012.
  • Selman P. The global decline of intercountry adoption: What lies ahead?. Social Policy and Society 2012, 11(3), 381-397.

Additional Helpful References:

  • Abrines, N., Barcons, N., Brun, C., Marre, D., Sartini, C., & Fumadó, V. (2012). Comparing ADHD symptom levels in children adopted from Eastern Europe and from other regions: discussing possible factors involved. Children and Youth Services Review, 34 (9) 1903-1908.
  • Balachova, T et al (2010). Changing physicians’ knowledge, skills and attitudes to prevent FASD in Russia: 800. Alcoholism: Clinical & Experimental Research. 34(6) Sup 2:210A.
  • Barcons-Castel, N, Fornieles-Deu,A, & Costas-Moragas, C (2011). International adoption: assessment of adaptive and maladaptive behavior of adopted minors in Spain. The Spanish Journal of Psychology, 14 (1): 123-132.
  • Beverly, B., McGuinness, T., & Blanton, D. (2008). Communication challenges for children adopted from the former Soviet Union. Language, Speech, and Hearing Services in Schools, 39, 1-11.
  • Cohen, N. & Barwick, M. (1996). Comorbidity of language and social-emotional disorders: comparison of psychiatric outpatients and their siblings. Journal of Clinical Child Psychology, 25(2), 192-200.
  • Croft, C et al, (2007). Early adolescent outcomes of institutionally-deprived and nondeprived adoptees: II. Language as a protective factor and a vulnerable outcome. The Journal of Child Psychology and Psychiatry, 48, 31–44.
  • Dalen, M. (2001). School performances among internationally adopted children in Norway. Adoption Quarterly, 5(2), 39-57.
  • Dalen, M. (1995). Learning difficulties among inter-country adopted children. Nordisk pedagogikk, 15 (No. 4), 195-208
  • Davies, J., & Bledsoe, J. (2005). Prenatal alcohol and drug exposures in adoption. Pediatric Clinics of North America, 52, 1369–1393.
  • Desmarais, C., Roeber, B. J., Smith, M. E., & Pollak, S. D. (2012). Sentence comprehension in post-institutionalized school-age children. Journal of Speech, Language, and Hearing Research, 55, 45-54
  • Eigsti, I. M., Weitzman, C., Schuh, J. M., de Marchena, A., & Casey, B. J. (2011). Language and cognitive outcomes in internationally adopted children. Development and Psychopathology, 23, 629-646.
  • Geren, J., Snedeker, J., & Ax, L. (2005). Starting over:  a preliminary study of early lexical and syntactic development in internationally-adopted preschoolers. Seminars in Speech & Language, 26:44-54.
  • Gindis (2008) Abrupt native language loss in international adoptees.  Advance for Speech/Language Pathologists and Audiologists.  18(51): 5.
  • Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315. Gindis, B. (1999) Language-related issues for international adoptees and adoptive families. In: T. Tepper, L. Hannon, D. Sandstrom, Eds. “International Adoption: Challenges and Opportunities.” PNPIC, Meadow Lands , PA. , pp. 98-108
  • Glennen, S (2009) Speech and language guidelines for children adopted from abroad at older ages.  Topics in language Disorders 29, 50-64.
  • Glennen, S. (2007) Speech and language in children adopted internationally at older ages. Perspectives on Communication Disorders in Culturally and Linguistically Diverse Populations, 14, 17–20.
  • Glennen, S., & Bright, B. J.  (2005).  Five years later: language in school-age internally adopted children.  Seminars in Speech and Language, 26, 86-101.
  • Glennen, S. & Masters, G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe. American Journal of Speech-Language Pathology, 44, 417-433
  • Gordina, A (2009) Parent Handout: The Dream Referral, Unpublished Manuscript.
  • Hough, S., & Kaczmarek, L. (2011). Language and reading outcomes in young children adopted from Eastern European orphanages. Journal of Early Intervention, 33, 51-57.
  • Hwa-Froelich, D (2012) Childhood maltreatment and communication development. Perspectives on School-Based Issues,  13: 43-53;
  • Jacobs, E., Miller, L. C., & Tirella, G. (2010).  Developmental and behavioral performance of internationally adopted preschoolers: a pilot study.  Child Psychiatry and Human Development, 41, 15–29.
  • Jenista, J., & Chapman, D. (1987). Medical problems of foreign-born adopted children. American Journal of Diseases of Children, 141, 298–302.
  • Johnson, D. (2000). Long-term medical issues in international adoptees. Pediatric Annals, 29, 234–241.
  • Judge, S. (2003). Developmental recovery and deficit in children adopted from Eastern European orphanages. Child Psychiatry and Human Development, 34, 49–62.
  • Krakow, R. A., & Roberts, J. (2003). Acquisitions of English vocabulary by young Chinese adoptees. Journal of Multilingual Communication Disorders, 1, 169-176
  • Ladage, J. S. (2009). Medical issues in international adoption and their influence on language development. Topics in Language Disorders , 29 (1), 6-17.
  • Loman, M. M., Wiik, K. L., Frenn, K. A., Pollak, S. D., & Gunnar, M. R. (2009). Post-institutionalized children’s development: growth, cognitive, and language outcomes. Journal of Developmental Behavioral Pediatrics, 30, 426–434.
  • McLaughlin, B., Gesi Blanchard, A., & Osanai, Y.  (1995). Assessing language development in bilingual preschool children.  Washington, D.C.: National Clearinghouse for Bilingual Education.
  • Miller, L., Chan, W., Litvinova, A., Rubin, A., Tirella, L., & Cermak, S. (2007). Medical diagnoses and growth of children residing in Russian orphanages. Acta Paediatrica, 96, 1765–1769.
  • Miller, L., Chan, W., Litvinova, A., Rubin, A., Comfort, K., Tirella, L., et al. (2006). Fetal alcohol spectrum disorders in children residing in Russian orphanages: A phenotypic survey. Alcoholism: Clinical and Experimental Research, 30, 531–538.
  • Miller, L. (2005). Preadoption counseling and evaluation of the referral. In L. Miller (Ed.), The Handbook of International Adoption Medicine (pp. 67-86). NewYork: Oxford.
  • Pollock, K. E.  (2005) Early language growth in children adopted from China: preliminary normative data.  Seminars in Speech and Language, 26, 22-32.
  • Roberts, J., Pollock, K., Krakow, R., Price, J., Fulmer, K., & Wang, P. (2005). Language development in preschool-aged children adopted from China. Journal of Speech, Language, and Hearing Research, 48, 93–107.
  • Scott, K.A., Roberts, J.A., & Glennen, S. (2011).  How well children who are internationally do adopted acquire language? A meta-analysis. Journal of Speech, Language and Hearing Research, 54. 1153-69.
  • Scott, K.A., & Roberts, J. (2011). Making evidence-based decisions for children who are internationally adopted. Evidence-Based Practice Briefs. 6(3), 1-16.
  • Scott, K.A., & Roberts, J. (2007) language development of internationally adopted children: the school-age years.  Perspectives on Communication Disorders in Culturally and Linguistically Diverse Populations, 14: 12-17. 
  • Selman P. (2012a) Global trends in intercountry adoption 2000-2010. New York: National Council for Adoption.
  • Selman P (2012b). The rise and fall of intercountry adoption in the 21st centuryIn: Gibbons, J.L., Rotabi, K.S, ed. Intercountry Adoption: Policies, Practices and Outcomes. London: Ashgate Press.
  • Selman, P. (2010) “Intercountry adoption in Europe 1998–2009: patterns, trends and issues,” Adoption & Fostering, 34 (1): 4-19.
  • Silliman, E. R., & Scott, C. M. (2009). Research-based oral language intervention routes to the academic language of literacy: Finding the right road. In S. A. Rosenfield & V. Wise Berninger (Eds.), Implementing evidence-based academic interventions in school (pp. 107–145). New York: Oxford University Press.
  • Tarullo, A. R., Bruce, J., & Gunnar, M. (2007). False belief and emotion understanding in post-institutionalized children. Social Development, 16, 57-78
  • Tarullo, A. & Gunnar, M. R. (2005). Institutional rearing and deficits in social relatedness: Possible mechanisms and processes. Cognitie, Creier, Comportament [Cognition, Brain, Behavior], 9, 329-342.
  • Varavikova, E. A. & Balachova, T. N. (2010). Strategies to implement physician training in FAS prevention as a part of preventive care in primary health settings: P120.Alcoholism: Clinical & Experimental Research. 34(8) Sup 3:119A.
  • Welsh, J. A., & Viana, A. G. (2012). Developmental outcomes of children adopted internationally. Adoption Quarterly, 15, 241-264.
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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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Importance of Assessing Social Pragmatic Abilities in Children with Language Difficulties

You’ve received a referral to assess the language abilities of a school aged child with suspected language difficulties. The child has not been assessed before so you know you’ll need a comprehensive language test to look at the child’s ability to recall sentences, follow directions, name words, as well as perform a number of other tasks showcasing the child’s abilities in the areas of content and form (Bloom & Lahey, 1978).

But how about the area of language use? Will you be assessing the child’s pragmatic and social cognitive abilities as well during your language assessment? After all most comprehensive standardized assessments, “typically focus on semantics, syntax, morphology, and phonology, as these are the performance areas in which specific skill development can be most objectively measured” (Hill & Coufal, 2005, p 35). Continue reading Importance of Assessing Social Pragmatic Abilities in Children with Language Difficulties

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Parent Consultation Services

Today I’d like to officially introduce a new parent consultation service which I had originally initiated  with a few out-of-state clients through my practice a few years ago.

The idea for this service came after numerous parents contacted me and initiated dialogue via email and phone calls regarding the services/assessments needed for their monolingual/bilingual internationally/domestically adopted or biological children with complex communication needs. Here are some details about it.

Parent consultations is a service provided to clients who live outside Smart Speech Therapy LLC geographical area (e.g., non-new Jersey residents) who are interested in comprehensive specialized in-depth consultations and recommendations regarding what type of follow up speech language services they should be seeking/obtaining in their own geographical area for their children as well as what type of carryover activities they should be doing with their children at home.

Consultations are provided with the focus on the following specialization areas with a focus on comprehensive assessment and intervention recommendations:

  • Language and Literacy 
  • Children with Social Communication (Pragmatic) Disorders
  • Bilingual and Multicultural Children
  • Post-institutionalized Internationally Adopted Children
  • Children with Psychiatric and Emotional Disturbances
  • Children with Fetal Alcohol Spectrum Disorders

The initial consultation length of this service is  1 hour. Clients are asked to forward their child’s records prior to the consultation for review, fill out several relevant intakes and questionnaires, as well as record a short video (3-5 minutes). The instructions regarding video content will be provided to them following session payment.

Upon purchasing a consultation the client will be immediately emailed the necessary paperwork to fill out as well as 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.

Refunds are available during a 3 day grace period if a mutually convenient time could not be selected for the consultation. Please note that fees will not be refundable from the time the scheduled consultation begins.

Following the consultation the client has the option of requesting a written detailed consultation report at an additional cost, which is determined based on the therapist’s hourly rate. 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 a past parent consultation testimonial.

International Adoption Consultation Parent Testimonial (11/11/13)

I found Tatyana and Smart Speech Therapy online while searching for information about internationally adopted kids and speech evaluations. We’d already taken our three year old son to a local SLP but were very unsatisfied with her opinion, and we just didn’t know where to turn. Upon finding the articles and blogs written by Tatyana, I felt like I’d finally found someone who understood the language learning process unique to adopted kids, and whose writings could also help me in my meetings with the local school system as I sought special education services for my son.

I could have never predicted then just how much Tatyana and Smart Speech Therapy would help us. I used the online contact form on her website to see if Tatyana could offer us any services or recommendations, even though we are in Virginia and far outside her typical service area. She offered us an in-depth phone consultation that was probably one of the most informative, supportive and helpful phone calls I’ve had in the eight months since adopting my son. Through a series of videos, questionnaires, and emails, she was better able to understand my son’s speech difficulties and background than any of the other sources I’d sought help from. She was able to explain to me, a lay person, exactly what was going on with our son’s speech, comprehension, and learning difficulties in a way that a) added urgency to our situation without causing us to panic, b) provided me with a ton of research-orientated information for our local school system to review, and c) validated all my concerns and gut instincts that had previously been brushed aside by other physicians and professionals who kept telling us to “wait and see”.

After our phone call, we contracted Tatyana to provide us with an in-depth consultation report that we are now using with our local school and child rehab center to get our son the help he needs. Without that report, I don’t think we would have had the access to these services or the backing we needed to get people to seriously listen to us. It’s a terrible place to be in when you think something might be wrong, but you’re not sure and no one around you is listening. Tatyana listened to us, but more importantly, she looked at our son as a specific kid with a specific past and specific needs. We were more than just a number or file to her – and we’ve never even actually met in person! The best move we’ve could’ve made was sending her that email that day. We are so appreciative.

Kristen, P. Charlottesville, VA

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Assessing Social Communication Abilities of School-Aged Children

Recently, I’ve published an article in SIG 16 Perspectives on School Based Issues discussing the importance of social communication assessments of school aged children 2-18 years of age. Below I would like to summarize article highlights.

First, I summarize the effect of social communication on academic abilities and review the notion of the “academic impact”. Then, I go over important changes in terminology and definitions as well as explain the “anatomy of social communication”.

Next I suggest a sample social communication skill hierarchy to adequately determine assessment needs (assess only those abilities suspected of deficits and exclude the skills the student has already mastered).

After that I go over pre-assessment considerations as well as review standardized testing and its limitations from 3-18 years of age.

Finally I review a host of informal social communication procedures and address their utility.

What is the away message?

When evaluating social communication, clinicians need to use multiple assessment tasks to create a balanced assessment. We need to chose testing instruments that will help us formulate clear goals.  We also need to add descriptive portions to our reports in order to “personalize” the student’s deficit areas. Our assessments need to be functional and meaningful for the student. This means determining the student’s strengths and not just weaknesses as a starting point of intervention initiation.

Is this an article which you might find interesting? If so, you can access full article HERE free of charge.

Helpful Smart Speech Resources Related to Assessment and Treatment of Social Communication 

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Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know

Image result for evaluationSeveral years after I started my private speech pathology practice, I began performing comprehensive independent speech and language evaluations (IEEs).

For those of you who may be hearing the term IEE for the first time, an Independent Educational Evaluation is “an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.” 34 C.F.R. 300.503. IEE’s can evaluate a broad range of functioning outside of cognitive or academic performance and may include neurological, occupational, speech language, or any other type of evaluations  as long as they bear direct impact on the child’s educational performance.

Independent evaluations can be performed for a wide variety of reasons, including but not limited to:

  • To determine the student’s present level of functioning
  • To determine whether the student presents with hidden, previously undiscovered deficits (e.g., executive function, social communication, etc.)
  • To determine whether the student’s educational classification requires a change
  • To determine if the student requires additional, previously not provided, related services (e.g., language therapy, etc.) or an increase in related services
  • To determine whether a student might benefit from an application of a particular therapy technique or program (e.g, Orton-Gillingham)
  • To determine whether a student with a severe impairment (e.g., severe emotional and behavioral disturbances, genetic syndrome, significant intellectual disability, etc.) is a good candidate for an out of district specialized school

Why can’t similar assessments be performed in school settings?

There are several reasons for that.

Why are IEE’s Needed?

The answer to that is simple:  “To strengthen the role of parents in the educational decision-making process.” According to one Disability Rights site: “Many disagreements between parents and school staff concerning IEP services and placement involve, at some stage, the interpretation of evaluation findings and recommendations. When disagreements occur, the Independent Educational Evaluation (IEE) is one option lawmakers make available to parents, to help answer questions about appropriate special education services and placement“.

Indeed, many of the clients who retain my services also retain the services of educational advocates as well as special education lawyers.  Many of them work on determining appropriate level of services as well as an out of district placement for the children with a variety of special education needs. However, one interesting reoccurring phenomenon I’ve noted over the years is that only a small percentage of special education lawyers, educational advocates, and even parents believed that children with autism spectrum disorders, genetic syndromes, social pragmatic deficits, emotional disturbances, or reading disabilities required a comprehensive language evaluation/reevaluation prior to determining an appropriate out of district placement or an in-district change of service provision.

So today I would like to make a case, in favor of comprehensive independent language evaluations being a routine component of every special education dispute involving a child with impaired academic performance. I will do so through the illustration of past case scenarios that clearly show that comprehensive independent language evaluations do matter, even when it doesn’t look like they may be needed.

Case A: “He is just a weak student”.

Several years ago I was contacted by a parent of a 12 year old boy, who was concerned with his son’s continuously failing academic performance. The child had not qualified for an IEP but was receiving 504 plan in school setting and was reported to significantly struggle due to continuous increase of academic demands with each passing school year.  An in-district language evaluation had been preformed several years prior. It showed that the student’s general language abilities were in the low average range of functioning due to which he did not qualify for speech language services in school setting. However, based on the review of available records it very quickly became apparent that many of the academic areas in which the student struggled (e.g., reading comprehension, social pragmatic ability, critical thinking skills, etc)  were simply not assessed by the general language testing. I had suggested to the parent a comprehensive language evaluation and explained to him on what grounds I was recommending this course of action.  That comprehensive 4 hour assessment broken into several testing sessions revealed that the student presented with severe receptive, expressive, problem solving and social pragmatic language deficits, as well as moderate executive function deficits, which required therapeutic intervention.

Prior to that assessment the parent, reinforced by the feedback from his child’s educational staff believed his son to be an unmotivated student who failed to apply himself in school setting.  However, after the completion of that assessment, the parent clearly understood that it wasn’t his child’s lack of motivation which was impeding his academic performance but rather a true learning disability was making it very difficult for his son to learn without the necessary related services and support. Several months after the appropriate related services were made available to the child in school setting on the basis of the performed IEE, the parent reported significant progress in his child academic performance.

Case B: “She’s just not learning because of her behavior, so there’s nothing we can do”.  

This case involved a six year old girl who presented with a severe speech – language disorder and behavioral deficits in school setting secondary to an intellectual disability of an unspecified origin.

In contrast to Case A scenario, this child had received a variety of assessments and therapies since a very early age; however, her parents were becoming significantly concerned regarding her regression of academic functioning in school setting and felt that a more specialized out of district program with a focus on multiple disabilities would be better suitable to her needs. Unfortunately the school disagreed with them and believed that she could be successfully educated in an in-district setting (despite evidence to the contrary).  Interestingly, an in-depth comprehensive speech language assessment had never been performed on this child because her functioning was considered to be “too low” for such an assessment.

Comprehensive assessment of this little girl’s abilities revealed that via an application of a variety of behavioral management techniques (of non-ABA origin), and highly structured language input, she was indeed capable of significantly better performance then she had exhibited in school setting.  It stood to reason that if she were placed in a specialized school setting composed of educational professionals who were trained in dealing with her complex behavioral and communication needs, her performance would continue to steadily improve.  Indeed, six months following a transfer in schools her parents reported a “drastic” change pertaining to a significant reduction in challenging behavioral manifestations as well as significant increase in her linguistic output.

Case C: “Your child can only learn so much because of his genetic syndrome”.  

This case scenario does not technically involve just one child but rather three different male students between 9 and 11 years of age with several ‘common’ genetic syndromes: Down, Fragile X, and Klinefelter.  All three were different ages, came from completely different school districts, and were seen by me in different calendar years.

However, all three boys had one thing in common, because of their genetic syndromes, which were marked by varying degrees of intellectual disability as well as speech language weaknesses, their parents were collectively told that there could be very little done for them with regards to expanding their expressive language as well as literacy development.

Similarly to the above scenarios, none of the children had undergone comprehensive language testing to determine their strengths, weaknesses, and learning styles. Comprehensive assessment of each student revealed that each had the potential to improve their expressive abilities to speak in compound and complex sentences. Dynamic assessment of literacy also revealed that it was possible to teach each of them how to read.

Following the respective assessments, some of these students had became my private clients, while others’s parents have periodically written to me, detailing their children’s successes over the years.  Each parent had conveyed to me how “life-changing”a comprehensive IEE was to their child.

Case D: “Their behavior is just out of control”

The final case scenario I would like to discuss today involves several students with an educational classification of “Emotionally Disturbed” (pg 71).  Those of you who are familiar with my blog and my work know that my main area of specialty is working with school age students with psychiatric impairments and emotional behavioral disturbances.  There are a number of reasons why I work with this challenging pediatric population. One very important reason is that these students continue to be grossly underserved in school setting. Over the years I have written a variety of articles and blog posts citing a number of research studies, which found that a significant number of students with psychiatric impairments and emotional behavioral disturbances present with undiagnosed linguistic impairments (especially in the area of social communication), which adversely impact their school-based performance.

Here, we are not talking about two or three students rather we’re talking about the numbers in the double digits of students with psychiatric impairments and emotional disturbances, who did not receive appropriate therapies in their respective school settings.

The majority of these students were divided into two distinct categories. In the first category, students began to manifest moderate-to-severe speech language deficits from a very early age. They were classified in preschool and began receiving speech language therapy. However by early elementary age their general language abilities were found to be within the average range of functioning and their language therapies were discontinued.   Unfortunately since general language testing does not assess all categories of linguistic functioning such as critical thinking, executive functions, social communication etc., these students continued to present with hidden linguistic impairments, which continued to adversely impact their behavior.

Students in the second category also began displaying emotional and behavioral challenges from a very early age. However, in contrast to the students in the first category the initial language testing found their general language abilities to be within the average range of functioning. As a result these students never received any language-based therapies and similar to the students in the first category, their hidden linguistic impairments continued to adversely impact their behavior.

Students in both categories ended up following a very similar pattern of behavior. Their behavioral challenges in the school continued to escalate. These were followed by a series of suspensions, out of district placements, myriad of psychiatric and neuropsychological evaluations, until many were placed on home instruction. The one vital element missing from all of these students’ case records were comprehensive language evaluations with an emphasis on assessing their critical thinking, executive functions and social communication abilities. Their worsening patterns of functioning were viewed as “severe misbehaving” without anyone suspecting that their hidden language deficits were a huge contributing factor to their maladaptive behaviors in school setting.

Conclusion:

So there you have it!  As promised, I’ve used four vastly different scenarios that show you the importance of comprehensive language evaluations in situations where it was not so readily apparent that they were needed.  I hope that parents and professionals alike will find this post helpful in reconsidering the need for comprehensive independent evaluations for students presenting with impaired academic performance.

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Improving Emotional Intelligence of Children with Social Communication Disorders

Our ability to recognize our own and other people’s emotions, distinguish between and correctly identify different feelings, as well as use that information to guide our thinking and behavior is called Emotional Intelligence (EI) (Salovey, et al, 2008).

EI encompasses dual areas of: emotion understanding, which is an awareness and comprehension of one’s and others emotions (Harris, 2008) and emotion regulation, which are internal and external strategies people use to regulate emotions (Thompson, 1994).

Many students with social communication challenges experience problems with all aspects of EI, including the perception, comprehension, and regulation of emotions (Brinton & Fujiki, 2012).

A number of recent studies have found that children with language impairments also present with impaired emotional intelligence including impaired perception of facial expressions (Spackman, Fujiki, Brinton, Nelson, & Allen, 2005), prosodic emotions (Fujiki, Spackman, Brinton, & Illig, 2008) as well as abstract emotion comprehension (Ford & Milosky, 2003).

Children with impaired emotional intelligence will experience numerous difficulties during social interactions due to their difficulty interpreting emotional cues of others (Cloward, 2012).  These may include but not be limited to active participation in cooperative activities, as well as full/competent interactions during group tasks (Brinton, Fujiki, & Powell, 1997)

Many students with social pragmatic deficits and language impairments are taught to recognize emotional states as part of their therapy goals. However, the provided experience frequently does not go beyond the recognition of the requisite “happy”, “mad”, “sad” emotions. At times, I even see written blurbs from others therapists, which state that “the student has mastered the goals of emotion recognition”.  However, when probed further it appears that the student had merely mastered the basic spectrum of simple emotional states, which places the student at a distinct disadvantage  as compared to typically developing peers who are capable of recognition and awareness of a myriad of complex emotional states.

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That is why I developed a product to target abstract emotional states comprehension in children with language impairments and social communication disorders. “Gauging Moods and Interpreting Abstract Emotional States: A Perspective Taking Activity Packet” is a social pragmatic photo/question set,  intended for children 7+ years of age, who present with difficulty recognizing abstract emotional states of others (beyond the “happy, mad, sad” option) as well as appropriately gauging their moods.

Many sets contain additional short stories with questions that focus on making inferencing, critical thinking as well as interpersonal negotiation skills.  Select sets require the students to create their own stories with a focus on the reasons why the person in the photograph might be feeling what s/he are feeling.

There are on average 12-15 questions per each photo.  Each page contains a photograph of a person feeling a particular emotion. After the student is presented with the photograph, they are asked a number of questions pertaining to the recognition of the person’s emotions, mood, the reason behind the emotion they are experiencing as well as what they could be potentially thinking at the moment.  Students are also asked to act out the depicted emotion they use of mirror.

Activities also include naming or finding (in a thesaurus or online) the synonyms and antonyms of a particular word in order to increase students’ vocabulary knowledge. A comprehensive two page “emotions word bank” is included in the last two pages of the packet to assist the students with the synonym/antonym selection, in the absence of a thesaurus or online access.

Students are also asked to use a target word in a complex sentence containing an adverbial (pre-chosen for them) as well as to identify a particular word or phrase associated with the photo or the described story situation.

Since many students with social pragmatic language deficits present with difficulty determining a person’s age (and prefer to relate to either younger or older individuals who are perceived to be “less judgmental of their difficulties”), this concept is also explicitly targeted in the packet.

This activity is suitable for both individual therapy sessions as well as group work.  In addition to its social pragmatic component is also intended to increase vocabulary knowledge and use as well as sentence length of children with language impairments.

Intended Audiences:

  • Clients with Language Impairments
  • Clients with Social Pragmatic Language Difficulties
  • Clients with Executive Function Difficulties
  • Clients with Psychiatric Impairments
    • ODD, ADHD, MD, Anxiety, Depression, etc.
  • Clients with Autism Spectrum Disorders
  • Clients with Nonverbal Learning Disability
  • Clients with Fetal Alcohol Spectrum Disorders
  • Adult and pediatric post-Traumatic Brain Injury (TBI) clients
  • Clients with right-side CVA Damage

Areas covered in this packet:

  1. Gauging Age (based on visual support and pre-existing knowledge)
  2. Gauging Moods (based on visual clues and context)
  3. Explaining Facial Expressions
  4. Making Social Predictions and Inferences (re: people’s emotions)
  5. Assuming First Person Perspectives
  6. Understanding Sympathy
  7. Vocabulary Knowledge and Use (pertaining to the concept of Emotional Intelligence)
  8. Semantic Flexibility (production of synonyms and antonyms)
  9. Complex Sentence Production
  10. Expression of Emotional Reactions
  11. Problem Solving Social Situations
  12. Friendship Management and Peer Relatedness

This activity is suitable for both individual therapy sessions as well as group work.  In addition to its social pragmatic component is also intended to increase vocabulary knowledge and use as well as sentence length of children with language impairments. You can find it in my online store (HERE).

Helpful Smart Speech Resources:

References:

  1. Brinton, B., Fujiki, M., & Powell, J. M. (1997). The ability of children with language impairment to manipulate topic in a structured task. Language, Speech and Hearing Services in Schools, 28, 3-11.
  2. Brinton B., & Fujiki, M. (2012). Social and affective factors in children with language impairment. Implications for literacy learning. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy: Development and disorders (2nd Ed.). New York, NY: Guilford.
  3. Cloward, R. (2012). The milk jug project: Expression of emotion in children with language impairment and autism spectrum disorder (Unpublished honor’s thesis). Brigham Young University, Provo, Utah.
  4. Ford, J., & Milosky, L. (2003). Inferring emotional reactions in social situations: Differences in children with language impairment. Journal of Speech, Language, and Hearing Research, 46(1), 21-30.
  5. Fujiki, M., Spackman, M. P., Brinton, B., & Illig, T. (2008). Ability of children with language impairment to understand emotion conveyed by prosody in a narrative passage. International Journal of Language & Communication Disorders, 43(3), 330-345
  6. Harris, P. L. (2008). Children’s understanding of emotion. In M. Lewis, J. M. Haviland-Jones, & L. Feldman Barrett, (Eds.), Handbook of emotions (3rd ed., pp. 320–331). New York, NY: Guilford Press.
  7. Salovey, P., Detweiler-Bedell, B. T., Detweiler-Bedell, J. B., & Mayer, J. D. (2008). Emotional intelligence. In M. Lewis, J. M. Haviland-Jones, & L. Feldman Barrett (Eds.), Handbook of Emotions (3rd ed., pp. 533-547). New York, NY: Guilford Press.
  8. Spackman, M. P., Fujiki, M., Brinton, B., Nelson, D., & Allen, J. (2005). The ability of children with language impairment to recognize emotion conveyed by facial expression and music. Communication Disorders Quarterly, 26(3), 131-143.
  9. Thompson, R. (1994). Emotion regulation: A theme in search of definition. Monographs of the Society for Research in Child Development, 59(2-3), 25-52

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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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What if Its More Than Just “Misbehaving”?

Frequently,  I see a variation of the following scenario on  many speech and language forums.

The SLP is seeing a client with speech and/or language deficits  through early intervention,  in the schools, or in private practice, who is having some kind of behavioral issues.

Some  issues  are described as mild such as  calling out, hyperactivity, impulsivity, or inattention, while others are more severe  and include  refusal, noncompliance, or aggression  such as kicking, biting,  or punching.

An array of advice from well-meaning professionals immediately follows.  Some behaviors may be labeled as “normal” due to the child’s age (toddler),  others may be “partially excused” due to a psychiatric diagnosis (ASD).   Recommendations for reinforcement charts (not grounded in evidence) may be suggested. A call for other professionals to deal with the behaviors is frequently made (“in my setting the ______ (insert relevant professional here) deals with these behaviors and I don’t have to be involved”). Specific judgments on the child may be pronounced: “There is nothing wrong with him/her, they’re just acting out to get what they want.” Some drastic recommendations could be made: “Maybe you should stop therapy until the child’s behaviors are stabilized”.

However, several crucial factors often get overlooked. First, a system to figure out why particular set of behaviors takes place and second, whether these behaviors may be manifestations of non-behaviorally based difficulties such as sensory deficits, medical issues, or overt/subtle linguistically based deficits.

So what are some reasons kids may present with behavioral deficits? Obviously there could be numerous reasons: some benign while others serious, ranging from lack of structure and understanding of expectations to manifestations of psychiatric illnesses and genetic syndromes. Oftentimes the underlying issues are incredibly difficult to recognize without a differential diagnosis. In other words we cannot claim that the child’s difficulties are “just behavior” if we have not appropriately ruled out other causes which may be contributing to the “behavior”.

Here are some possible steps which can ensure appropriate identification of the source of the child’s behavioral difficulties in cases of hidden underlying language disorders (after of course relevant genetic, medical, psychiatric and sensory issues have been ruled out).

Let’s begin by answering a few simple questions. Was a thorough language evaluation with an emphasis on the child’s social pragmatic language abilities been completed? And by thorough I am not referring to general language tests but to a variety of formal and informal social pragmatic language testing (read more HERE).

Please note that none of the general language tests such as the Preschool Language Scale-5 (PLS-5), Comprehensive Assessment of Spoken Language (CASL), the Test of Language Development-4 (TOLD-4) or even the Clinical Evaluation of Language Fundamentals Tests (CELF-P2)/ (CELF-5) tap into the child’s social language competence because they do NOT directly test the child’s social language skills (e.g., CELF-5 assesses them via a parental/teachers questionnaire).  Thus, many children can attain average scores on these tests yet still present with pervasive social language deficits. That is why it’s very important to thoroughly assess social pragmatic language abilities of all children  (no matter what their age is) presenting with behavioral deficits.

                 

But let’s say that the social pragmatic language abilities have been assessed and the child was found/not found to be eligible for services, meanwhile their behavioral deficits persist, what do we do now?

—The first step in establishing a behavior management system is determining the function of challenging behaviors, since we need to understand why the behavior is occurring and what is triggering it (Chandler & Dahlquist, 2006)

—We can begin by performing some basic data collection with a child of any age (even with toddlers) to determine behavior functions or reasons for specific behaviors. Here are just a few limited examples:

  • —Seeking Attention/Reward
  • —Seeking Sensory Stimulation
  • —Seeking Control

Most behavior functions typically tend to be positively, negatively or automatically reinforced (Bobrow, 2002). For example, in cases of positive reinforcement, the child may exhibit challenging behaviors to obtain desirable items such as toys, games, attention, etc. If the parent/teacher inadvertently supplies the child with the desired item, they are reinforcing inappropriate behaviors positively and in a way strengthening the child’s desire to repeat the experience over and over again, since it had positively worked for them before.

In contrast, negative reinforcement takes place when the child exhibits challenging behaviors to escape a negative situation and gets his way. For example, the child is being disruptive in classroom/therapy because the tasks are too challenging and is ‘rewarded’ when therapy is discontinued early or when the classroom teacher asks an aide to take the child for a walk.

Finally, automatic reinforcements occur when certain behaviors such as repetitive movements or self-injury produce an enjoyable sensation for the child, which he then repeats again to recreate the sensation.

In order to determine what reinforces the child’s challenging behaviors, we must perform repeated observations and take data on the following:

  • —Antecedent or what triggered the child’s behavior?
    • —What was happening immediately before behavior occurred?
  • —Behavior
    • —What type of challenging behavior/s took place as a result?
  • —Response/Consequence
    • —How did you respond to behavior when it took place?

Here are just a few antecedent examples:

  • —Therapist requested that child work on task
  • —Child bored w/t task
  • —Favorite task/activity taken away
  • —Child could not obtain desired object/activity

In order to figure them out we need to collect data, prior to appropriately addressing them. After the data is collected the goals need to be prioritized based urgency/seriousness.  We can also use modification techniques aimed at managing interfering behaviors.  These techniques include modifications of: physical space, session structure, session materials as well as child’s behavior. As we are implementing these modifications we need to keep in mind the child’s maintaining factors or factors which contribute to the maintenance of the problem (Klein & Moses, 1999). These include: cognitive, sensorimotor, psychosocial and linguistic deficits. 

We also need to choose our reward system wisely, since the most effective systems which facilitate positive change actually utilize intrinsic rewards (pride in self for own accomplishments) (Kohn, 2001).  We need to teach the child positive replacement behaviors  to replace the use of negative ones, with an emphasis on self-talk, critical thinking, as well as talking about the problem vs. acting out behaviorally.

Of course it is very important that we utilize a team based approach and involve all the professionals involved in the child’s care including the child’s parents in order to ensure smooth and consistent carryover across all settings. Consistency is definitely a huge part of all behavior plans as it optimizes intervention results and achieves the desired therapy outcomes.

So the next time the client on your caseload is acting out don’t be so hasty in judging their behavior, when you have no idea regarding the reasons for it. Troubleshoot using appropriate and relevant steps in order to figure out what is REALLY going on and then attempt to change the situation in a team-based, systematic way.

For more detailed information on the topic of social pragmatic language assessment and behavior management in speech pathology see if the following Smart Speech Therapy LLC products could be of use:

References: 

  1. Bobrow, A. (2002). Problem behaviors in the classroom: What they mean and how to help. Functional Behavioral Assessment, 7 (2), 1–6.
  2. Chandler, L.K., & Dahlquist, C.M. Functional assessment: strategies to prevent and remediate challenging behavior in school settings (2nd ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.
  3. —Klein, H., & Moses, N. (1999). Intervention planning for children with communication disorders: A guide to the clinical practicum and professional practice. (2nd Ed.). Boston, MA.: Allyn & Bacon.
  4. —Kohn, A. (2001, Sept). Five reasons to stop saying “good job!’. Young Children. Retrieved from http://www.alfiekohn.org/parenting/gj.htm