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Intervention at the Last Moment or Why We Need Better Preschool Evaluations

“Well, the school did their evaluations and he doesn’t qualify for services” tells me a parent of a 3.5 year old, newly admitted private practice client.  “I just don’t get it” she says bemusedly, “It is so obvious to anyone who spends even 10 minutes with him that his language is nowhere near other kids his age!” “How can this happen?” she asks frustratedly?

This parent is not alone in her sentiment. In my private practice I frequently see preschool children with speech language impairments who for all intents and purposes should have qualified for preschool- based speech language services but do not due to questionable testing practices.

To illustrate, several years ago in my private practice, I started seeing a young preschool girl, 3.2 years of age. Just prior to turning 3, she underwent a collaborative school-based social, psychological, educational, and speech language evaluation.  The 4 combined evaluators from each field only used one standardized assessment instrument “The Battelle Developmental Inventory – Second Edition (BDI-2)” along with a limited ‘structured observation’, without performing any functional or dynamic assessments and found the child to be ineligible for services on account of a low average total score on the BDI-2.

However, during the first session working 1:1 with this client at the age of 3.2 a number of things became very apparent.  The child had very limited highly echolalic verbal output primarily composed of one-word utterances and select two-word phrases.  She had highly limited receptive vocabulary and could not consistently point to basic pictures denoting common household objects and items (e.g., chair, socks, clock, sun, etc.)  Similarly, expressively she exhibited a number of inconsistencies when labeling simple nouns (e.g., called tree a flower, monkey a dog, and sofa a chair, etc.)  Clearly this child’s abilities were nowhere near age level, so how could she possibly not qualify for preschool based services?

Further work with the child over the next several years yielded slow, labored, and inconsistent gains in the areas of listening, speaking, and social communication.  I’ve also had a number of concerns regarding her intellectual abilities that I had shared with the parents.  Finally, two years after preschool eligibility services were denied to this child, she underwent a second round of re-evaluations with the school district at the age of 5.2.

This time around she qualified with bells on! The same speech language pathologist and psychologist who assessed her first time around two years ago, now readily documented significant communication (Preschool Language Scale-5-PLS-5 scores in the 1st % of functioning) and cognitive deficits (Full Scale Intelligence Quotient-FSIQ in low 50’s).

Here is the problem though. This is not a child who had suddenly regressed in her abilities.  This is a child who actually had improved her abilities in all language domains due to private language therapy services.  Her deficits very clearly existed at the time of her first school-based assessment and had continued to persist over time. For the duration of two years this child could have significantly benefited from free and appropriate education in school setting, which was denied to her due to highly limited preschool assessment practices.

Today, I am writing this post to shed light on this issue, which I’m pretty certain is not just confined to the state of New Jersey.  I am writing this post not simply to complain but to inform parents and educators alike on what actually constitutes an appropriate preschool speech-language assessment.

As per NJAC 6A:14-2.5  Protection in evaluation procedures (pgs. 29-30)

(a) In conducting an evaluation, each district board of education shall:

  1. Use a variety of assessment tools and strategies to gather relevant functional and developmental information, including information:
  2. Provided by the parent that may assist in determining whether a child is a student with a disability and in determining the content of the student’s IEP; and
  3. Related to enabling the student to be involved in and progress in the general education curriculum or, for preschool children with disabilities, to participate in appropriate activities;
  4. Not use any single procedure as the sole criterion for determining whether a student is a student with a disability or determining an appropriate educational program for the student; and
  5. Use technically sound instruments that may assess the relative contribution of cognitive and behavioral factors, in addition to physical or developmental factors.

Furthermore, according to the New Special Education Code: N.J.A.C. 6A:14-3.5(c)10 (please refer to your state’s eligibility criteria to find similar guidelinesthe eligibility of a “preschool child with a disability” applies to any student between 3-5 years of age with an identified disabling condition adversely affecting learning/development  (e.g., genetic syndrome), a 33% delay in one developmental area, or a 25% percent delay in two or more developmental areas below :

  1. Physical, including gross/fine motor and sensory (vision and hearing)
  2. Intellectual
  3. Communication
  4. Social/emotional
  5. Adaptive

—These delays can be receptive (listening) or expressive (speaking) and need not be based on a total test score but rather on all testing findings with a minimum of at least two assessments being performed.  A determination of adverse impact in academic and non-academic areas (e.g., social functioning) needs to take place in order for special education and related services be provided.  Additionally, a delay in articulation can serve as a basis for consideration of eligibility as well.

—Moreover, according to  the —State Education Agencies Communication Disabilities Council (SEACDC) Consulatent for NJ – Fran Liebner, the BDI-2 is not the only test which can be used to determine eligibility, since the nature and scope of the evaluation must be determined based on parent, teacher and IEP team feedback.

In fact, New Jersey’s Special Education Code, N.J.A.C. 6A:14 prescribes no specific test in its eligibility requirements.  While it is true that for NJ districts participating in Indicator 7 (Preschool Outcomes) BDI-2 is a required collection tool it does NOT preclude the team from deciding what other diagnostic tools are needed to assess all areas of suspected disability to determine eligibility. 

Speech pathologists have many tests available to them when assessing young preschool children 2 to 6 years of age.

SELECT SPEECH PATHOLOGY TESTS FOR PRESCHOOL CHILDREN (2-6 years of age)

 Articulation:

  • Sunny Articulation Test (SAPT)** Ages: All (nonstandardized)
  • Clinical Assessment of Articulation and Phonology-2 (CAAP-2) Ages: 2.6+
  • Linguisystems Articulation Test (LAT) Ages: 3+
  • Goldman Fristoe Test of Articulation-3 (GFTA-3)    Ages: 2+

 Fluency:

  • Stuttering Severity Instrument -4 (SSI-4) Ages: 2+
  • Test of Childhood Stuttering (TOCS) Ages 4+

General Language: 

  • Preschool Language Assessment Instrument-2 (PLAI-2)  Ages: 3+
  • Clinical Evaluation of Language Fundamentals -Preschool 2 (CELF-P2) Ages: 3+
  • Test of Early Language Development, Third Edition (TELD-3) Ages: 2+
  • Test of Auditory Comprehension of Language Third Edition (TACL-4)      Ages: 3+
  • Preschool Language Scale-5 (PLS-5)* (use with extreme caution) Ages: Birth-7:11

Vocabulary

  • Receptive One-Word Picture Vocabulary Test-4 (ROWPVT-4)  Ages 2+
  • Expressive One-Word Picture Vocabulary Test-4 (EOWPVT-4) Ages 2+
  • Montgomery Assessment of Vocabulary Acquisition (MAVA) 3+
  • Test of Word Finding-3 (TWF-3) Ages 4.6+

Auditory Processing and Phonological Awareness

  • Auditory Skills Assessment (ASA)    Ages 3:6+
  • Test of Auditory Processing Skills-3 (TAPS-3) Ages 4+
  • Comprehensive Test of Phonological Processing-2 (CTOPP-2) Ages 4+

Pragmatics/Social Communication

  • —Language Use Inventory LUI (O’Neil, 2009) Ages 18-47 months
  • —Children’s Communication Checklist-2 (CCC-2) (Bishop, 2006) Ages 4+

—In addition to administering standardized testing SLPs should also use play scales (e.g., Westby Play Scale, 1980) to assess the given child’s play abilities. This is especially important given that “play—both functional and symbolic has been associated with language and social communication ability.” (Toth, et al, 2006, pg. 3)

Finally, by showing children simple wordless picture books, SLPs can also obtain of wealth of information regarding ——the child’s utterance length, as well as narrative abilities ( a narrative assessment can be performed on a verbal child as young as two years of age).

—Comprehensive school-based speech-language assessments should be the norm and not an exception when determining preschoolers eligibility for speech language services and special education classification.

Consequently, let us ensure that our students receive fair and adequate assessments to have access to the best classroom placements, appropriate accommodations and modifications as well as targeted and relevant therapeutic services. Anything less will lead to the denial of Free Appropriate Public Education (FAPE) to which all students are entitled to!

Helpful Smart Speech Therapy Resources Pertaining to Preschoolers: 

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What’s Memes Got To Do With It?

Today, after a long hiatus, I am continuing my series of blog posts on “Scholars Who do Not Receive Enough Mainstream Exposure” by summarizing select key points from Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“.

Alan Kamhi

Some of you may be wondering: “Why is she reviewing an article that is more than a decade old? The answer is simple.  It is just as relevant, if not more so today, as it was 12 years ago, when it first came out.

In this article, Dr. Kamhi, asks a provocative question: “Why do some terms, labels, ideas, and constructs [in the field of speech pathology] prevail whereas others fail to gain acceptance?

He attempts to answer this question by explaining the vital role the concept of memes play in the evolution and spread of ideas.

—A meme (shortened from the Greek mimeme to imitate) is an idea, behavior, or style that spreads from person to person within a culture”. The term was originally coined by British evolutionary biologist Richard Dawkins in The Selfish Gene (1976) to explain the spread of ideas and cultural phenomena such as tunes, ideas, catchphrases, customs, etc.

‘Selfish’ in this case means that memes “care only about their own self-replication“.  Consequently, “successful memes are those that get copied accurately (fidelity), have many copies (fecundity), and last a long time (longevity).” Therefore, “memes that are easy to understand, remember, and communicate to others” have the highest risk of survival and replication (pp. 105-106).

So what were some of the more successful memes which Dr. Kamhi identified in his article, which still persist more than a decade later?

  • Learning Disability
  • Auditory Processing Disorder
  • Sensory Integration Disorder
  • Dyslexia
  • Articulation disorder
  • Speech Therapist/ Pathologist

Interestingly the losers of the “contest” were memes that contained the word language in it:

  • Language disorder
  • Language learning disability
  • Speech-language pathologist (albeit this term has gained far more acceptance in the past decade)

Dr. Kamhi further asserts that ‘language-based disorders have failed to become a recognizable learning problem in the community at large‘ (p.106).

So why are labels with the words ‘language’ NOT successful memes?

According to Dr. Kamhi that is because “language-based disorders must be difficult to understand, remember, and communicate to others“. Professional (SLP) explanations of what constitutes language are lengthy and complex (e.g., ASHA’s comprehensive definition) and as a result are not frequently applied in clinical practice, even when its aspects are familiar to SLPs.

Some scholars have suggested that the common practice of evaluating language with standardized language tools, restricts full understanding of the interactions of all of its domains (“within larger sociocultural context“) because they only examine isolated aspects of language. (Apel, 1999)

Dr. Kamhi, in turn explains this within the construct of the memetic theory: namely “simple constructs are more likely to replicate than complex ones.” In other words: “even professionals who understand language may have difficulty communicating its meaning to others and applying this meaning to clinical practice” (p. 107).

Let’s talk about the parents who are interested in learning the root-cause of their child’s difficulty learning and using language.  Based on specific child’s genetic and developmental background as well as presenting difficulties, an educated clinician can explain to the parent the multifactorial nature of their child’s deficits.

However, these informed but frequently complex explanations are certainly in no way simplistic. As a result, many parents will still attempt to seek other professionals who can readily provide them with a “straightforward explanation” of their child’s difficulty.  Since parents are “ultimately interested in finding the most effective and efficient treatment for their children” it makes sense to believe/hope that “the professional who knows the cause of the problem will also know the most effective way to treat it“(p. 107).

This brings us back to the concept of successful memes such as Auditory Processing Disorder (C/APD) as well as Sensory Processing Disorder (SPD) as isolated diagnoses.

Here are just some of the reasons behind their success:

  • They provide a simple solution (which is not necessarily a correct one) that “the learning problem is the result of difficulty processing auditory information or difficulty integrating sensory information“.
  • The assumption is “improving auditory processing and sensory integration abilities” will improve learning difficulties
  • Both, “APD and SID each have only one cause“, so “finding an appropriate treatment …seems more feasible because there is only one problem to eliminate
  • Gives parents “a sense of relief” that they finally have an “understandable explanation for what is wrong with their child
  • Gives parents  hope that the “diagnosis will lead to successful remediation of the learning problem

For more information on why APD and SPD are not valid stand-alone diagnoses please see HERE and HERE respectively.

A note on the lack of success of “phonological” memes:

  • They are difficult to understand and explain (especially due to a lack of consensus of what constitutes a phonological disorder)
  • Lack of familiarity with the term ‘phonological’ results in poor comprehension of “phonological bases of reading problems since its “much easier to associate reading with visual processing abilities, good instruction, and a literacy rich environment” (p. 108).

Let’s talk about MEMEPLEXES (Blackmore, 1999)  or what occurs whennonprofessionals think they know how children learn language and the factors that affect language learning (Kamhi, 2004, p.108).

A memplex is a group of memes, which become much more memorable to individuals (can replicate more efficiently) as a team vs. in isolation.

Why is APD Memeplex So Appealing? 

According to Dr. Kamhi, if one believes that ‘a) sounds are the building blocks of speech and language and (b) children learn to talk by stringing together sounds and constructing meanings out of strings of sounds’ (both wrong assumptions) then its quite a simple leap to make with respect to the following fallacies:

  • Auditory processing are not influenced by language knowledge
  • You can reliably discriminate between APD and language deficits
  • You can validly and reliably assess “uncontaminated” auditory processing abilities and thus diagnose stand-alone APD
  • You can target auditory abilities in isolation without targeting language
  • Improvements in discrimination and identification of ‘speech sounds will lead to improvements in speech and language abilities

For more detailed information, why the above is incorrect, click: HERE

On the success of the Dyslexia Meme:

  • Most nonprofessionals view dyslexia as visually based “reading problem characterized by letter reversals and word transpositions that affects bright children and adults
  • Its highly appealing due to the simple nature of its diagnosis (high intelligence and poor reading skills)
  • The diagnosis of dyslexia has historically been made by physicians and psychologists rather than educators‘, which makes memetic replication highly successful
  • The ‘dyslexic’ label is far more appealing and desirable than calling self ‘reading disabled’

For more detailed information, why the above is far too simplistic of an explanation, click: HERE and HERE

Final Thoughts:

As humans we engage in transmission of  ideas (good and bad) on constant basis. The popularity of powerful social media tools such as Facebook and Twitter ensure their instantaneous and far reaching delivery and impact.  However, “our processing limitations, cultural biases, personal preferences, and human nature make us more susceptible to certain ideas than to others (p. 110).”

As professionals it is important that we use evidence based practices and the latest research to evaluate all claims pertaining to assessment and treatment of language based disorders. However, as Dr. Kamhi points out (p.110):

  • “Competing theories may be supported by different bodies of evidence, and the same evidence may be used to support competing theories.”
  • “Reaching a scientific consensus also takes time.”

While these delays may play a negligible role when it comes to scientific research, they pose a significant problem for parents, teachers and health professionals who are seeking to effectively assist these youngsters on daily basis. Furthermore, even when select memes such as APD are beneficial because they allow for a delivery of services to a student who may otherwise be ineligible to receive them, erroneous intervention recommendations (e.g., working on isolated auditory discrimination skills) may further delay the delivery of appropriate and targeted intervention services.

So what are SLPs to do in the presence of persistent erroneous memes?

Spread our language-based memes to all who will listen” (Kamhi, 2004, 110) of course! Since we are the professionals whose job is to treat any difficulties involving words. Consequently, our scope of practice certainly includes assessment, diagnosis and treatment of children and adults with speaking, listening, reading, writing, and spelling difficulties.

As for myself, I intend to start that task right now by hitting the ‘publish’ button on this post!

I am a SLP

 References:

Kamhi, A. (2004). A meme’s eye view of speech-language pathology. [PDFLanguage, Speech, and Hearing Services in Schools35, 105-112.

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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