Those of you familiar with my blog, know that a number of my posts take on a form of extended responses to posts and comments on social media which deal with certain questionable speech pathology trends and ongoing issues (e.g., controversial diagnostic labels, questionable recommendations, non-evidence based practices, etc.). So, today, I’d like to talk about sweeping general recommendations as pertaining to literacy interventions. Continue reading But is this the Best Practice Recommendation?
I frequently see numerous posts on Facebook that ask group members, “What are your activities/goals for a particular age group (e.g., preschool, middle school, high school, etc.) or a particular disorder (e.g., Down Syndrome)? After seeing these posts appear over and over again in a variety of groups, I decided to write my own post on this topic, explaining why asking such broad questions will not result in optimal therapeutic interventions for the clients in question. Continue reading Dear SLPs, Try Asking This Instead
Last year a new Facebook Group was launched for SLPs interested in evidence-based practice in speech-language pathology. It was created for clinicians to explore and make sense of a myriad of intervention promises and questionable treatments in the fields of health care and education.
The group was established specifically for the purpose of research inquiry. It has now reached almost 10.5K membership and contains numerous threads on a variety of scientific and pseudoscientific methods, assessments, and interventions for a wide variety of conditions.
In my previous post on this topic, I brought up concerns regarding the paucity of useful information in EI SLP reports for children under 3 years of age and made some constructive suggestions of how that could be rectified. In 2013, I had written about another significant concern, which involved neurodevelopmental pediatricians (rather than SLPs), diagnosing Childhood Apraxia of Speech (CAS), without the adequate level of training and knowledge regarding motor speech disorders. Today, I wanted to combine both topics and delve deeper into another area of EI SLP evaluations, namely, assessments of toddlers with suspected motor speech disorders.
Firstly, it is important to note that CAS is disturbingly overdiagnosed. A cursory review of both parent and professional social media forums quickly reveals that this diagnosis is doled out like candy by both SLPs and medical professionals alike, often without much training and knowledge regarding the disorder in question. The child is under 3, has a limited verbal output coupled with a number of phonological processes, and the next thing you know, s/he is labeled as having Childhood Apraxia of Speech (CAS). But is this diagnosis truly that straightforward?
Let us begin with the fact that all reputable organizations involved in the dissemination of information on the topic of CAS (e.g., ASHA, CASANA, etc.), strongly discourage the diagnosis of CAS in children under three years of age with limited verbal output, and limited time spent in EBP therapy specifically targeting the remediation of motor speech disorders.
Assessment of motor speech disorders in young children requires solid knowledge and expertise. That is because CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc). Furthermore, symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis. Finally, the diagnosis of CAS is also problematic due to the fact that there are still to this day no valid or reliable standardized assessments sensitive to CAS detection (McCauley & Strand, 2008).
In March 2017, Dr. Edythe Strand wrote an excellent article for the ASHA Leader entitled: “Appraising Apraxia“, in which she used a case study of a 3-year-old boy to describe how a differential diagnosis for CAS can be performed. She reviewed CAS characteristics, informal assessment protocols, aspects of diagnosis and treatment, and even included ‘Examples of Diagnostic Statements for CAS’ (which illustrate how clinicians can formulate their impressions regarding the child’s strengths and needs without explicitly labeling the child’s diagnosis as CAS).
Today, I’d like to share what information I tend to include in speech-language reports geared towards the assessing motor speech disorders in children under 3 years of age. I have a specific former client in mind for whom a differential diagnosis was particularly needed. Here’s why.
This particular 30-month client, TQ, (I did mention that I get quite a few clients for assessment around that age), was brought in due to parental concerns over her significantly reduced speech and expressive language abilities characterized by unintelligible “babbling-like” utterances and lack of expressive language. All of TQ’s developmental milestones with the exception of speech and language had been achieved grossly at age expectancy. She began limitedly producing word approximations at ~16 months of age but at 30 months of age, her verbal output was still very restricted. She mainly communicated via gestures, pointing, word approximations, and a handful of signs.
Interestingly, as an infant, she had a restricted lingual frenulum. However, since it did not affect her ability to feed, no surgical intervention was needed. Indeed, TQ presented with an adequate lingual movement for both feeding and speech sound production, so her ankyloglossia (or anterior tongue tie) was definitely not the culprit which caused her to have limited speech production.
Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.
Assessment of TQ’s social-emotional functioning, play skills, and receptive language (via a combination of Revised Westby Play Scale (Westby, 2000), REEL-3, & PLS-5) quickly revealed that she was a very bright little girl who was developing on target in all of the tested areas. Assessment of TQ’s expressive language (via REEL-3, PLS-5 & LUI*), revealed profoundly impaired, expressive language abilities. But due to which cause?
Despite lacking verbal speech, TQ’s communicative frequency (how often she attempted to spontaneously and appropriately initiate interactions with others), as well as her communicative intent (e.g., gaining attention, making requests, indicating protests, etc), were judged to be appropriate for her age. She was highly receptive to language stimulation given tangible reinforcements and as the assessment progressed she was observed to significantly increase the number and variety of vocalizations and word approximations including delayed imitation of words and sounds containing bilabial and alveolar nasal phonemes.
For the purpose of TQ’s speech assessment, I was interested in gaining knowledge regarding the following:
- Automatic vs. volitional control
- Simple vs. complex speech production
- Consistency of productions on repetitions of the same words/word approximations
- Vowel Productions
- Imitation abilities
- Phonetic inventory
- Phonotactic Constraints
TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender. Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.
- Phonetic inventory of all the sounds TQ produced during the assessment is as follows:
- Consonants: plosive nasals (/m/) and alveolars (/t/, /d/, n), as well as a glide (/w/)
- Vowels: (/a/, /e/, /i/, /o/)
- TQ’s phonotactic repertoire was primarily comprised of word approximations restricted to specific sounds and consisted of CV (e.g., ne), VCV (e.g., ada), CVC (e.g., nyam), CVCV (e.g., nada), VCVC (e.g., adat), CVCVCV (nadadi), VCVCV(e.g., adada) syllable shapes
- TQ’s speech intelligibility in known and unknown contexts was profoundly reduced to unfamiliar listeners. However, her word approximations were consistent across all productions.
- Due to the above I could not perform an in-depth phonological processes analysis
However, by this time I had already formulated a working hypothesis regarding TQ’s speech production difficulties. Based on her speech sound assessment TQ presented with severe phonological disorder characterized by restricted sound inventory, simplification of sound sequences, as well as patterns of sound use errors (e.g., predominance of alveolar /d/ and nasal /n/ sounds when attempting to produce most word approximations) in speech (Stoel-Gammon, 1987).
TQ’s difficulties were not consistent with the diagnosis Childhood Apraxia of Speech (CAS) at that time due to the following:
- Adequate and varied production of vowels
- Lack of restricted use of syllables during verbalizations (TQ was observed to make verbalizations up to 3 syllables in length)
- Lack of disruptions in rate, rhythm, and stress of speech
- Frequent and spontaneous use of consistently produced verbalizations
- Lack of verbal groping behaviors when producing word-approximations
- Good control of pitch, loudness and vocal quality during vocalizations
I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.
I still, however, wanted to be cautious as there were a few red flags I had noted which may have potentially indicative of a non-CAS motor speech involvement, due to which I wanted to include some recommendations pertaining to motor speech remediation.
Now it is possible that after 6 months of intensive application of EBP phonological and motor speech approaches TQ would have turned 3 and still presented with highly restricted speech sound inventory and profoundly impaired speech production, making her eligible for the diagnosis of CAS in earnest. However, at the time of my assessment, making such diagnosis in view of all the available evidence would have been both clinically inappropriate and unethical.
So what were my recommendations you may ask? Well, I provisionally diagnosed TQ with a severe phonological disorder and recommended that among a variety of phonologically-based approaches to trial, an EBP approach to the treatment of motor speech disorders be also used with her for a period of 6 months to determine if it would expedite speech gains.
*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the Rapid Syllable Transition Treatment (ReST). ReST is a free EBP treatment developed by the SLPs at the University of Sydney, which uses nonsense words, designed to help children coordinate movements across syllables in long words and phrases as well as helps them learn new speech movements. It is, however, important to note for young children with highly restricted sound inventories, characterized by a lack of syllable production, ReST will not be applicable. For them, the Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC) approaches do have some limited empirical support.
I also made sure to make a note in my report regarding the inappropriate use of non-speech oral motor exercises (NSOMEs) in therapy, indicating that there is NO research to support the use of NSOMEs to stimulate speech production (Lof, 2010).
In addition to the trialing of phonological and motor based approaches I also emphasized the need to establish consistent lexicon via development of functional words needed in daily communication and listed a number of examples across several categories. I made recommendations regarding select approaches and treatment techniques to trial in therapy, as well as suggestions for expansion of sounds and structures. Finally, I made suggestions for long and short term therapy goals for a period of 6 months to trial with TQ in therapy and provided relevant references to support the claims I’ve made in my report.
You may be interested in knowing that nowadays TQ is doing quite well, and at this juncture, she is still, ineligible for the diagnosis CAS (although she needs careful ongoing monitoring with respect to the development of reading difficulties when she is older).
Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of questionable and even downright harmful bunk treatments for their children, the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.
That is why the correct diagnosis is so important for young children under 3 years of age. But before it can be made, extensive (reputable and evidence supported) training and education are needed by evaluating SLPs on the assessment and treatment of motor speech disorders in young children.
- Davis, B & Velleman, S (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. 10 (3): 177 – 192.
- Lof, G., & Watson, M. (2010). Five reasons why nonspeech oral-motor exercises do not work. Perspectives on School-Based Issues, 11.109-117.
- McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
- McCauley R.J., Strand E., Lof, G.L., Schooling T. & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech, American Journal of Speech-Language Pathology, 18, 343-360.
- Murray, E., McCabe, P. & Ballard, K.J. (2015). A Randomized Control Trial of Treatments for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research 58 (3) 669-686.
- Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
- Strand, E (2003). Childhood apraxia of speech: suggested diagnostic markers for the young child. In Shriberg, L & Campbell, T (Eds) Proceedings of the 2002 childhood apraxia of speech research symposium. Carlsbad, CA: Hendrix Foundation.
- Strand, E, McCauley, R, Weigand, S, Stoeckel, R & Baas, B (2013) A Motor Speech Assessment for Children with Severe Speech Disorders: Reliability and Validity Evidence. Journal of Speech Language and Hearing Research, vol 56; 505-520.
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:
- Boris Gindis
- Sharon Glennen
- Deborah Hwa-Froelich
- Kathleen A. Scott
- Jenny A. Roberts
- Karen E. Pollock
- M. Gay Masters
- Monica Dalen
Meanwhile, here are some basic facts regarding internationally adopted children that all SLPs and parents need to know.
- 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.
- 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
To 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).
- 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
- Assessing Behaviorally Impaired Students: Why Background History Matters!
- Dear School Professionals Please Be Aware of This
- What parents need to know about speech-language assessment of older internationally adopted children
- Understanding the risks of social pragmatic deficits in post institutionalized internationally adopted (IA) children
- Understanding the extent of speech and language delays in older internationally adopted children
- 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 century. In: 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.
In the past two years, I wrote a series of research-based posts (HERE and HERE) regarding the validity of (Central) Auditory Processing Disorder (C/APD) as a standalone diagnosis as well as questioned the utility of it for classification purposes in the school setting.
Once again I want to reiterate that I was in no way disputing the legitimate symptoms (e.g., difficulty processing language, difficulty organizing narratives, difficulty decoding text, etc.), which the students diagnosed with “CAPD” were presenting with.
Rather, I was citing research to indicate that these symptoms were indicative of broader linguistic-based deficits, which required targeted linguistic/literacy-based interventions rather than recommendations for specific prescriptive programs (e.g., CAPDOTS, Fast ForWord, etc.), or mere accommodations.
I was also significantly concerned that overfocus on the diagnosis of (C)APD tended to obscure REAL, language-based deficits in children and forced SLPs to address erroneous therapeutic targets based on AuD recommendations or restricted them to a receipt of mere accommodations rather than rightful therapeutic remediation.
Today I wanted to update you regarding new developments, which took place since my last blog post was written 1.5 years ago, regarding the validity of “C/APD” diagnosis.
In April 2016, de Wit and colleagues published a systematic review in the Journal of Speech, Language, and Hearing Research. Their purpose was to review research studies describing the characteristics of APD in children and determine whether these characteristics merited a label of a distinct clinical disorder vs. being representative of other disorders. After they searched 6 databases they chose 48 studies which satisfied appropriate inclusion criteria. Unfortunately, only 1 study had strong methodological quality and what’s even more disappointing, the children in their studies were very dissimilar and presented with incredibly diverse symptomology. The authors concluded that: “the listening difficulties of children with APD may be a consequence of cognitive, language, and attention issues rather than bottom-up auditory processing.”
In other words, because APD is not a distinct clinical disorder, a diagnosis of APD would not contribute anything to the child’s functioning beyond showing that the child is experiencing linguistically based deficits, which bear further investigation.
To continue, you may remember that in my first CAPD post I extensively cited a tutorial written by Dr. David DeBonis, who is an AuD. In his article, he pointed out numerous inconsistencies involved in CAPD testing and concluded that “routine use of CAPD test protocols cannot be supported” and that [CAPD] “intervention needs to be contextualized and functional.”
In July 2016, Iliadou, Sirimanna, & Bamiou published an article: “CAPD Is Classified in ICD-10 as H93.25 and Hearing Evaluation—Not Screening—Should Be Implemented in Children With Verified Communication and/or Listening Deficits” protesting DeBonis’s claim that CAPD is not a unique clinical entity and as such should not be included in any disease classification system. They stated that DeBonis omitted the fact that “CAPD is included in the U.S. version of the International Statistical Classification of Diseases and Related Health Problems–10th Revision (ICD-10) under the code H93.25” (p. 368). They also listed what they believed to be a number of article omissions, which they claimed biased DeBonis’s tutorial’s conclusions.
The authors claimed that DeBonis provided a limited definition of CAPD based only on ASHA’s Technical report vs. other sources such as American Academy of Audiology (2010), British Society of Audiology Position Statement (2011), and Canadian Guidelines on Auditory Processing Disorder in Children and Adults: Assessment & Intervention (2012). (p. 368)
The also authors claimed that DeBonis did not adequately define the term “traditional testing” and failed to provide several key references for select claims. They disagreed with DeBonis’s linkage of certain digit tests, as well as his “lumping” of studies which included children with suspected and diagnosed APD into the same category. (p. 368-9) They also objected to the fact that he “oversimplified” results of positive gains of select computer-based interventions for APD, and that in his summary section he listed only selected studies pertinent to the topic of intelligence and auditory processing skills. (p. 369).
Their main objection, however, had to do with the section of DeBonis’s article that contained “recommended assessment and intervention process for children with listening and communication difficulties in the classroom”. They expressed concerns with his recommendations on the grounds that he failed to provide published research to support that this was the optimal way to provide intervention. The authors concluded their article by stating that due to the above-mentioned omissions they felt that DeBonis’s tutorial “show(ed) unacceptable bias” (p. 370).
In response to the Iliadou, Sirimanna, & Bamiou, 2016 concerns, DeBonis issued his own response article shortly thereafter (DeBonis, 2016). Firstly, he pointed out that when his tutorial was released in June 2015 the ICD-10 was not yet in effect (it was enacted Oct 1, 2015). As such his statement was factually accurate.
Secondly, he also made a very important point regarding the C/APD construct validity, namely that it fails to satisfy the Sydenham–Guttentag criteria as a distinct clinical entity (Vermiglio, 2014). Namely, despite attempts at diagnostic uniformity, CAPD remains ambiguously defined, with testing failing to “represent a homogenous patient group.” (p. 906).
For those who are unfamiliar with this terminology (as per direct quote from Dr. Vermiglio’s presentation): “The Sydenham-Guttentag Criteria for the Clinical Entity Proposed by Vermiglio (accepted 2014, JAAA) is as follows:
- “The clinical entity must possess an unambiguous definition (Sydenham, 1676; FDA, 2000)
- It must represent a homogeneous patient group (Sydenham, 1676; Guttentag, 1949, 1950; FDA, 2000)
- It must represent a perceived limitation (Guttentag, 1949)
- It must facilitate diagnosis and intervention (Sydenham, 1676; Guttentag, 1949; FDA, 2000)“
Thirdly, DeBonis addressed Iliadou, Sirimanna, & Bamiou, 2016 concerns that he did not use the most recent definition of APD by pointing out that he was most qualified to discuss the US system and its definitions of CAPD, as well as that “the U.S. guidelines, despite their limitations and age, continue to have a major impact on the approach to auditory processing disorders worldwide” (p.372). He also elucidated that: the AAA’s (2010) definition of CAPD is “not so much built on previous definitions but rather has continued to rely on them” and as such does not constitute a “more recent” source of CAPD definitions. (p.372)
DeBonis next addressed the claim that he did not adequately define the term “traditional testing”. He stated that he defined it on pg. 125 of his tutorial and that information on it was taken directly from the AAA (2010) document. He then explained how it is “aligned with bottom-up aspects of the auditory system” by citing numerous references (see p. 372 for further details). After that, he addressed Iliadou, Sirimanna, & Bamiou, 2016 claim that he failed to provide references by pointing out the relevant citation in his article, which they failed to see.
Next, he proceeded to address their concerns “regarding the interaction between cognition and auditory processing” by reiterating that auditory processing testing is “not so pure” and is affected by constructs such as memory, executive function skills, etc. He also referenced the findings of Beck, Clarke and Moore (2016) that “most currently used tests of APD are tests of language and attention…lack sensitivity and specificity” (p. 27).
The next point addressed by DeBonis was the use of studies which included children with suspected vs. confirmed APD. He agreed that “one cannot make inferences about one population from another” but added that the data from the article in question “provided insight into the important role of attention and memory in children who are poor listeners” and that “such listeners represent the population [which] should be [AuD’s] focus.” (p.373)
From there on, DeBonis moved on to address Iliadou, Sirimanna, & Bamiou, 2016 claims that he “oversimplified” the results of one CBAT study dealing with effects of computer-based interventions for APD. He responded that the authors of that review themselves stated that: “the evidence for improving phonological awareness is “initial”.
Consequently, “improvements in auditory processing—without subsequent changes in the very critical tasks of reading and language—certainly do not represent an endorsement for the auditory training techniques that were studied.” (p.373)
Here, DeBonis also raised concerns regarding the overall concept of treatment effectiveness, stating that it should not be based on “improved performance on behavioral tests of auditory processing or electrophysiological measures” but rather “on improvements on complex listening and academic tasks“. (p.373) As such,
- “This limited definition of effectiveness leads to statements about the impact of certain interventions that can be misinterpreted at best and possibly misleading.”
- “Such a definition of effectiveness is unlikely to be satisfying to working clinicians or parents of children with communication difficulties who hope to see changes in day-to-day communication and academic abilities.” (p.373)
Then, DeBonis addressed Iliadou, Sirimanna, & Bamiou, 2016 concerns regarding the omission of an article supporting CAPD and intelligence as separate entities. He reiterated that the aim of his tutorial was to note that “performance on commonly used tests of auditory processing is highly influenced by a number of cognitive and linguistic factors” rather than to “do an overview of research in support of and in opposition to the construct”. (p.373)
Subsequently, DeBonis addressed the Iliadou, Sirimanna, & Bamiou, 2016 claim that he did not provide research to support his proposed testing protocol, as well as that he made a figure error. He conceded that the authors were correct with respect to the figure error (the information provided in the figure was not sufficient). However, he pointed out that the purpose of his tutorial was to “to review the literature related to ongoing concerns about the use of the CAPD construct in school-aged children and to propose an alternative assessment/intervention procedure that moves away from testing “auditory processing” and moves toward identifying and supporting students who have listening challenges”. As such, while the effectiveness of his model is being tested, it makes sense to “use of questionnaires and speech-in-noise tests with very strong psychometric characteristics” and thoroughly assess these children’s “language and cognitive skills to reduce the chance of misdiagnosis” in order to provide functional interventions (p.373).
Finally, Debonis addressed the Iliadou, Sirimanna, & Bamiou, 2016 accusation that his tutorial contained “unacceptable bias”. He pointed out that “the reviewers of this [his 2015 article article] did not agree” and that since the time of that article’s publication “readers and other colleagues have viewed it as a vehicle for important thought about how best to help children who have listening difficulties.” (p. 374)
Having read the above information, many of you by now must be wondering: “Why is the research on APD as a valid stand alone diagnosis continues to be published at regular intervals?”
To explain the above phenomenon, I will use several excerpts from an excellent presentation by Kamhi, A, Vermiglio, A, & Wallach, G (2016), which I attended during the 2016 ASHA Convention in Philadephia, PA.
It has been suggested that the above has to do with: “The bias of the CAPD Convention Committee that reviews submissions.” Namely, “The committee only accepts submissions consistent with the traditional view of (C)APD espoused by Bellis, Chermak and others who wrote the ASHA (2005) position statement on CAPD.”
Kamhi Vermiglio, and Wallach (2016) supported this claim by pointing out that when Dr. Vermiglio attempted to submit his findings on the nature of “C/APD” for the 2015 ASHA Convention, “the committee did not accept Vermiglio’s submission” but instead accepted the following seminar: “APD – It Exists! Differential Diagnosis & Remediation” and allocated for it “a prominent location in the program planner.”
Indeed, during the 2016 ASHA convention alone, there was a host of 1 and 2-hour pro-APD sessions such as: “Yes, You CANS! Adding Therapy for Specific CAPDs to an IEP“, “Perspectives on the Assessment & Treatment of Individuals With Central Auditory Processing Disorder (CAPD)“, as well as “The Buffalo Model for CAPD: Looking Back & Forward“, in addition to a host of posters and technical reports attempting to validate this diagnosis despite mounting evidence refuting that very fact. Yet only one session, “Never-Ending Controversies With CAPD: What Thinking SLPs & Audiologists Know” presented by Kamhi, Vermiglio, & Wallach (two SLPs and one AuD) and accepted by a non-AuD committee, discussed the current controversies raging in the fields of speech pathology and audiology pertaining to “C/APD”.
In 2016, Diane Paul, the Director of Clinical Issues in Speech-Language Pathology at ASHA had asked Kamhi, Vermiglio, and Wallach “to offer comments on the outline of audiology and SLP roles in assessing and treating CAPD”. According to Kamhi, et al, 2016, the outline did not mention any of controversies in assessment and diagnosis documented by numerous authors dating as far as 2009. It also did not “mention the lack of evidence on the efficacy of auditory interventions documented in the systematic review by Fey et al. (2011) and DeBonis (2015).”
At this juncture, it’s important to start thinking regarding possible incentives a professional might have to continue performing APD testing and making prescriptive program recommendations despite all the existing evidence refuting the validity and utility of APD diagnosis for children presenting with listening difficulties.
- There is still no compelling evidence that APD is a stand-alone diagnosis with clear diagnostic criteria
- There is still no compelling evidence that auditory deficits are a “significant risk factor for language or academic performance”
- There is still no compelling evidence that “auditory interventions provide any unique benefit to auditory, language, or academic outcomes” (Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009)
- APD deficits are linguistically based deficits which accompany a host of developmental conditions ranging from developmental language disorders to learning disabilities, etc.
- SLPs should continue comprehensively assessing children diagnosed with “C/APD” to determine the scope of their linguistic deficits
- SLPs should continue formulating language goals to determine linguistic areas of weaknesses
- SLPS should be wary of any goals or recommendations which focus on remediation of isolated skills such as: “auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming” since studies have definitively confirmed their lack of effectiveness (Fey, et al, 2011)
- SLPs should be wary of any prescriptive programs offering C/APD “interventions”
- SLPs should focus on improving children’s abilities for functional communication including listening, speaking, reading, and writing
- Please see excellent article written by Dr. Wallach in 2014 entitled: Improving Clinical Practice: A School-Age and School-Based Perspective. It “presents a conceptual framework for intervention at school-age levels” and discusses “advanced levels of language that move beyond preschool and early elementary grade goals and objectives with a focus on comprehension and meta-abilities.”
So there you have it, sadly, despite research and logic, the controversy is very much alive! Except I am seeing some new developments!
I see SLPs, newly-minted and seasoned alike, steadily voicing their concerns regarding the symptomology they are documenting in children diagnosed with so-called “CAPD” as being purely auditory in nature.
I see more and more SLPs supporting research evidence and science by voicing their concerns regarding the numerous diagnostic markers of ‘CAPD’ which do not make sense to them by stating “Wait a second – that can’t be right!”.
I see more and more SLPs documenting the lack of progress children make after being prescribed isolated FM systems or computer programs which claim to treat “APD symptomology” (without provision of therapy services). I see more and more SLPs beginning to understand the lack of usefulness of this diagnosis, who switch to using language-based interventions to teach children to listen, speak, read and write and to generalize these abilities to both social and academic settings.
I see more and more SLPs beginning to understand the lack of usefulness of this diagnosis, who switch to using language-based interventions to teach children to listen, speak, read and write and to generalize these abilities to both social and academic settings.
So I definitely do see hope on the horizon!
(arranged in chronological order of citation in the blog post):
- de Wit, E., Visser-Bochane, M.I., Steenbergen, B., van Dijk, P., van der Schans, C.P., & Luinge, M.R. (2016). Characteristics of Auditory Processing Disorders: A Systematic Review. Journal of Speech, Language, and Hearing Research, 59, 384–413.
- DeBonis, D. A. (2015) It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology. v. 24, 124-136.
- Iliadou, V., Sirimanna, T., & Bamiou, D.-E. (2016). CAPD is classified in ICD-10 as H93.25 and hearing evaluation—not screening—should be implemented in children with verified communication and/or listening deficits. American Journal of Audiology. v. 25, 368-370
- DeBonis, D. A. (2016) Response to the Letter to the Editor From Iliadou, Sirimanna, and Bamiou Regarding DeBonis (2015). American Journal of Audiology, December, V. 25, 371-374.
- Vermiglio, A (2014) Application of a Medical Definition of the Clinical Entity to (C)APD. North Carolina Speech Language and Hearing Association
- Vermiglio, A. J. (2014). On the clinical entity in audiology: (Central) auditory processing and speech recognition in noise disorders. Journal of American Academy of Audiology, 25, 904–917.
- Beck, D. L., Clarke, J. L., & Moore, D. R. (2016). Contemporary issues in auditory processing disorders: 2016. The Hearing Review, 23(4), 36–40.
- Kamhi, A, Vermiglio, A, & Wallach, G (2016) Never-Ending Controversies With CAPD: What Thinking SLPs and Audiologists Know. Presented at ASHA Annual Convention, Philadelphia, PA.
- Fey, M. E., Richard, G. J., Geffner, D., Kamhi, A. G., Medwetsky, L., Paul, D., Schooling, T. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.
- Wallach, Geraldine (2014) Improving Clinical Practice: A School-Age and School-Based Perspective. Language, Speech, and Hearing Services in Schools. Vol. 45, 127-136
- Hazan, V., Messaoud-Galusi, S., Rosen, S., Nouwens, S., Shakespeare, B. (2009). Speech perception abilities of adults with dyslexia: Is there any evidence for a true deficit?. Journal of Speech, Language, and Hearing Research. 52 1510–1529
- Watson, C., Kidd, G. (2009). Associations between auditory abilities, reading, and other language skills in children and adults. Cacace, A., McFarland, D. Controversies in central auditory processing disorder. 218–242 San Diego, CA Plural.
- Why (C) APD Diagnosis is NOT Valid!
- If It’s NOT CAPD Then Where do SLPs Go From There?
- How Early can “Dyslexia” be Diagnosed in Children?
- Components of Comprehensive Dyslexia Testing: Part I- Introduction and Language Testing
- Part II: Components of Comprehensive Dyslexia Testing – Phonological Awareness and Word Fluency Assessment
- Part III: Components of Comprehensive Dyslexia Testing – Reading Fluency and Reading Comprehension
- Part IV: Components of Comprehensive Dyslexia Testing – Writing and Spelling
- Review of the Test of Integrated Language and Literacy (TILLS)
- Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know
- What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?
- Why Are My Child’s Test Scores Dropping?
- Comprehensive Assessment of Adolescents with Suspected Language and Literacy Disorders