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Speech, Language, and Literacy Fun with Helen Lester’s Picture Books

Picture books are absolutely wonderful for both assessment and treatment purposes! They are terrific as narrative elicitation aids for children of various ages, ranging from pre-K through fourth grade.  They are amazing treatment aids for addressing a variety of speech, language, and literacy goals that extend far beyond narrative production.

There are numerous children books authors whom I absolutely adore (e.g., Karma Wilson, Keiko Kasza, Jez Alborough, M. Christina Butler, etc.). Today I wanted to describe how I implement books by Helen Lester into my treatment sessions with elementary aged children. (For information on how I use her books: “Pookins Gets Her Way” and “A Porcupine Named Fluffy” for narrative elicitation purposes click HERE.)

It is important to note that while Ms. Lester’s books are intended for younger children (4-7 years; pre-K-3rd grade), older children (~10 years of age) with significant language and learning difficulties and/or intellectual disabilities have enjoyed working with them and have significantly benefited from reading/listening to them.

Two reasons why I love using Ms. Lester’s books are versatility and wealth of social themes. To illustrate, “Hooway for Wodney Wat” and “Wodney Wat’s Wobot” are two books about a shy rat who cannot pronounce his ‘r’ sounds. Wodney is hugely embarrassed by that fact, and since there are no speech-language pathologists in Rodentia-land, Wodney spends his recess, hiding inside his jacket, trying to be as inconspicuous as possible. The arrival of a bullying, Miss-know-it-all, Camilla Capybara, brings some unexpected changes into the school’s dynamic, as well as provides Wodney with a very welcome opportunity to shine socially.

Image result for wodney wobotSpeech Production: Not only is there a phenomenal opportunity to use this book with children struggling with /r/ sound production, but it’s also heavily laden with a plethora of /r/ words in a variety of word positions (e.g., rodeo, robot, contraption, barrel, terrific, fur, prickled, bigger, fear, classroom, smarter, sure, etc.).

Language: There are numerous language goals that could be formulated based on Helen Lester’s books including answering concrete and abstract listening comprehension questions, defining story-embedded vocabulary words, producing word associations, synonyms, antonyms, and multiple meaning words (semantic awareness), formulating compound and complex sentences (syntax), answering predicting and inferencing questions (critical thinking), gauging moods and identifying emotional reactions of characters (social communication), assuming characters’ perspectives and frame of reference (social cognition, theory of mind, etc.), identifying main ideas in text (Gestalt processing) and much, much more.

  • Select Highlights:
    • VocabularyFor the ages/grades that there’ve written for (4-7 years; pre-K-3rd grade), Ms. Lester’s books are laden with a wealth of sophisticated vocabulary words such a: curtsy, contraption, trembled, dreary, shudder, varmint, fashionable, rodent, rattled, shenanigans, chanting, surgical, plunked, occasion, exception, etc.
    • Word Play:  Ms. Lester infuses a great deal of humor and wit in her books. Just look at the names of her characters in “A Sheep in Wolf’s Clothing”, which are: Ewetopia, Ewecalyptus, Ewetensil, Heyewe, Rambunctious, Ramshackle, and Ramplestiltskin.  Her ovine characters live in Pastureland and attend Woolyones’ Costume Balls while her porcine characters eat in a trough-a-teria.  
    • Social Communication: Many of Ms. Lester’s book themes focus on the celebration of neurodiversity (e.g., “Tacky the Penguin”), learning valuable life lessons (e.g., “Me First”), addressing one’s fears (e.g., “Something Might Happen”) and feeling uncomfortable in own skin (e.g., “A Sheep in Wolf’s Clothing”), etc.

Literacy: Similar to the above, numerous literacy goals can be formulated based on these books. These include but are not limited to, goals targeting phonological (e.g., rhyming words, counting syllables in words, etc.) and phonemic awareness, phonics, reading fluency and comprehension, spelling, as well as the composition of written responses to story questions.

  • Image result for princess penelope's parrotSelect Highlights:
    • Phonics: Students can practice reading words containing a variety of syllable shapes as well as decode low-frequency words containing a variety of consonantal clusters (Examples from “Princess Penelope’s Parrot” are:  hissed, parrot, buzzard, horribly, flicked, plucked, field,  flapped, silence, Percival, velvet, cloak, caviar, clippy-clopped, poofiest, impressed, expensive, galloping, gulped, bouquet, squawked, etc.)
    • Morphology: There’s a terrific opportunity to introduce a discussion on roots and affixes when using Ms. Lester’s books to discuss how select prefixes and suffixes (e.g., ante-, -able, -ive, -ion, etc.) can significantly increase word sophistication of numerous root words (e.g., impressive, exception, etc.)
    • Spelling: There is a terrific opportunity for children to practice spelling numerous spelling patterns to solidify their spelling abilities, including -ee-, -ea-, -ou-,-oo-, -oa-, -ui-, -ck, -tt-, -rr-, -ss-, -cc-, etc.

When working with picture books, I typically spend numerous sessions working with the same book. That is because research indicates that language disordered children require 36 exposures  (as compared with 12 exposures for typically developing children) to learn new words via interactive book reading (Storkel et al, 2016). As such, I discuss vocabulary words before, during, and after the book reading, by asking the children to both repeatedly define and then use selected words in sentences so the students can solidify their knowledge of these words.

I also spent quite a bit of time on macrostructure, particularly on the identification and definitions of story grammar elements as well as having the student match the story grammar picture cards to various portions of the book.

When working with picture books, here are some verbal prompts that I provide to the students with a focus on story Characters and Setting

  • Who are the characters in this story?
  • Where is the setting in this story?
  • Are there multiple settings in this story?
  • What are some emotions the characters experience throughout this story?
  • When did they experience these emotions in the story?
  • How do you think this character is feeling when ____?
    • Why?
    • How do you know?
  • What do you think this character is thinking?
    • Why?
    • How do you know?
  • What are some actions the characters performed throughout the story?
  • What were the results of some of those actions?

Here is a sampling of verbal prompts I provide to the students with a focus on story Sequencing 

  • What happened at the beginning of the story?
    • What words can we use to start a story?
  • What happened next?
  • What happened after that?
  • What happened last?
  • How do we end a story?
  • What was the problem in the story?
  • Was there more than one problem?
    • What happened?
    • Who solved it?
    • How did s/he solve it?
  • Was there adventure in the story?
    • If yes, how did it start and end?

Here is a sampling of verbal prompts I provide to the students with a focus on Critical Thinking 

  • How are these two characters alike/different? (compare/contrast)
  • What do you think will happen next? (predicting)
  •  Why/How do you think ___ happened (inferencing)
  • Why shouldn’t you, couldn’t s/he ____ ? (answering negative questions)
  • What do you thing s/he must do to ______? (problem-solving)
  • How would you solve his problem? (determining solutions)
  • Why is your solution ______ a good solution? (providing justifications)

Image result for tacky penguinHere is a small sampling of verbal prompts I provide to the students with a focus on Social Communication and Social Cognition 

  • How would you feel if ____?
  • What is his/her mood at ____ point in the story?
    • How do you know?
  • What is his/her reaction to the ____?
    • How do you know?
  • How does it make you feel that s/he are _____?
  • Can you tell me two completely different results of this character’s actions?
  • What could you say to this character to make him/her feel better?
    • Why?
  • What would you think if?

At times, I also use Ms. Lester’s guide for the following books: ‘It Wasn’t My Fault’, ‘Listen, Buddy’, ‘Me First’, and ‘A Porcupine Named Fluffy‘ to supplement my therapy sessions goals. It provides additional helpful ideas and suggestions on how her books can be further used in both therapy room as well as the classroom.

Finally, one of the major reasons why I really like Ms. Lester’s books is because some of them are ‘art imitating life’ and do not necessarily end up in a ‘traditional’ happily ever after. To, illustrate, “Princess Penelope’s Parrot” is a book about a spoiled princess who cannot get her new parrot to talk, even after threatening it and calling it insulting names. When Prince Percival comes courting, the parrot takes his hilarious revenge on Princess Penelope, and the parrot and Prince Percival do end up living happily ever after. However, Princess Penelope quickly gets over her embarrassment and goes back to her unrepentantly spoiled way of acting.

There you have it! Just a few of my many reasons why I adore using Helen Lester’s books for language and literacy treatment purposes. How about you? Do you use any of her books for assessment and treatment purposes? If yes, comment below which ones you use and why do you use them?

References:

Helpful Related Smart Speech Therapy Resources: 

 

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Tips on Reducing ‘Summer Learning Loss’ in Children with Language/Literacy Disorders

Related imageThe end of the school year is almost near. Soon many of our clients with language and literacy difficulties will be going on summer vacation and enjoying their time outside of school. However, summer is not all fun and games.  For children with learning needs, this is also a time of “learning loss”, or the loss of academic skills and knowledge over the course of the summer break.  Students diagnosed with language and learning disabilities are at a particularly significant risk of greater learning loss than typically developing students.

 However, there are a number of things that parents can do in an attempt to address this problem. Firstly, consistency is important, so is that there is an opportunity for the students to attend an extended school year it should definitely be taken. Similarly, while all students deserve a hard-earned break, taking an extended break (e.g., two months) from private therapies is not recommended. In the absence of an opportunity to attend an extended school year program, attendance at a summer camp with a good educational component may be the next best option (if financially viable for the parents).

However, in the absence of these options, parents can still do a great deal with the children at home in order to promote learning as well as mitigate the effects of summer learning loss. Consider creating a learning schedule for the week.  Sit down with your child and determine how many minutes a day s/he would be willing to engage in learning.  Rather than doing everything in one day, create a schedule of dates and times when reading, math, as well as science and social studies may be tackled in manageable quantities.

There are a number of fun educational outings for families to embark on in the summer.  While attendance of museums, zoos, or fairs, is often paid, there are still many free events accessible to parents out of which one could potentially create wonderful learning opportunities.

Image result for free admissionDenizens of major cities such as Washington DC or New York have a plethora of free educational events accessible to them. The Washington Mall offers free admission while numerous New York museums offer free admission on selected days of the week. However, a quick search also reveals that many US states, offer wonderful free educational attractions. Here’s a list of major free educational attractions in the state of NJ, which includes an art museum, a living farm, a center for contemporary art, a naval museum, and a 9/11 memorial, just to name a few.  All of these locations could be turned into wonderful learning opportunities replete with novel vocabulary words with science and social study themes.

In addition to these outings is strongly recommended that parents encourage their children to read for pleasure.   There are numerous lists of books available by grade level for the purpose of summer reading.  Furthermore, it is strongly recommended that parents read aloud to their kids, (link to read aloud book recommendations HERE) especially those who are still emergent readers to facilitate vocabulary growth and “introduce young ears to complex and nuanced syntax“.

But it’s not all books and direct learning. A lot of learning can actually be accomplished indirectly via educational summer games as well.   Games such as A to Z Jr, Tribond Jr, Fib or Not, etc., are terrific for working on word finding, verbal reasoning, problem-solving, storytelling, etc. Furthermore, games such as Hedbanz are fantastic for improving executive function skills in the areas of emotional control, self-monitoring, organization, task initiation, etc.

Summer may be a time when learning slows down, but it doesn’t have to stop! Children can still accomplish a great deal of learning through read alouds, educational outings, fun language promoting games, and much, much more!

FOR A PDF HANDOUT FOR PARENTS PLEASE CLICK HERE

References:

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Speech, Language, & Literacy Disorders in School Aged Children with Psychiatric Impairments

Recently I did a presentation for Rutgers University on the subject of  “Speech, Language, & Literacy Disorders in School-Aged Children with Psychiatric Impairments“. The learning objectives for this presentation were as follows:  

  • Explain the comorbidity between language impairments and psychiatric disturbances of school-aged children
  • Describe language and literacy deficits of school-aged children with psychiatric impairments
  • List warning signs of language and literacy deficits in school-aged children that warrant a referral to speech-language pathologists for a potential assessment

It focused on the fact that health professionals need to be aware of a significant comorbidity between psychiatric impairments and language disorders, in order to appropriately refer relevant children for potential assessment and treatment services to improve their social and academic outcomes.

This presentation was video recorded and can be accessed in its entirety below as we as on Youtube. You can also access the handouts which accompany the video HERE

References:

  • Angus, L. E., & McLeod, J. (Eds.) (2004). The handbook of narrative and psychotherapy. London, UK: Sage Publications
  • Aram, D.M., Ekelman, B.E., & Nation, J.E. (1984). Preschoolers with language disorders: 10 years later. Journal of Speech and Hearing Research, 27, 232-244.
  • Baltaxe,  C.  A. M., & Simmons,  J.  Q. (1988b).  Pragmatic deficits in  emotionally  disturbed  children  and  adolescents.  In  R. Schiefelbusch & L. Lloyd  (Eds.), Language perspectives (2nd ed.,  pp. 223-253).  Austin, TX: Pro-Ed.
  • Baker,  L.,  & Cantwell,  D. P. (1987b).  A prospective psychiatric  follow-up  of children  with  speech/language  disorders. Journal of the American Academy  of Child and Adolescent Psychiatry, 26, 546-553.
  • Beitchman, J., Cohen, N., Konstantareas, M., & Tannock, R. (Eds.) (1996). Language, learning and behaviour disorders: Developmental, biological and clinical perspectives. Cambridge, NY: Cambridge University Press.
  • Benner, G.J., Nelson, R., & Epstein, M.H. (2002). Language skills of children with EBD: a literature review-emotional and behavioral disorders- statistical data included. Journal of Emotional and Behavioral Disorders, 10, 43-59.
  • Bishop, D. V., & Baird, G. (2001). Parent and teacher report of pragmatic aspects of communication: Use of the Children’s Communication Checklist in a clinical setting. Developmental Medicine & Child Neurology, 43(12), 809–818.
  • Brosnan, M.J. et al. (2004) Gestalt processing in autism: failure to process perceptual relationships and the implications for contextual understanding. The Journal of Child Psychology and Psychiatry, 45, 459–469
  • Bryan, T. (1991). Social problems and learning disabilities. In B. Y. L. Wong (Ed.), Learning about learning disabilities (pp. 195-229). San Diego, CA: Academic Press.
  • 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.
  • Cohen, N., Barwick, M., Horodezky, N., Vallance, D., & Im, N. (1998). Language, achievement, and cognitive processing in psychiatrically disturbed children with previously identified and unsuspected language impairments. Journal of Child Psychology and Psychiatry, 39, 865–877.
  • Cohen, N., & Horodezky, N. (1998). Prevalence of language impairments in psychiatrically referred children at different ages: Preschool to adolescence [Letter to the editor]. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 461–262.
  • Emde, R., Wolf, D., & Oppenheim, D. (Eds.) (2003). Revealing the inner worlds of young children—The MacArthur story stem battery. New York, NY: Oxford University Press.
  • —Gallagher, T. M. (1999). Interrelationships  among children’s language, behavior,  and emotional problems. Topics in  Language Disorders, 19, 1–15.
  • Gardner, R. (1993). Storytelling in psychotherapy with children. London, UK: Jason Aronson.
  • —Gilmour J, et al (2004). Social communication deficits in conduct disorder: a clinical and community study. J Child Psychol Psychiatry45: 967– 78.
  • Goldman, L. G. (1987). Social implications of learning disorders. Reading, Writing and Learning Disabilities, 3, 119-130.
  • —Gurney, D., Gersten, R., Dimino, J. & Carnine, D. (1990). Story grammar: Effective literature instruction for high school students with learning disabilities. Journal of Learning Disabilities, 23, 335-348.
  • Happé, F. G. E. (1994). An Advanced Test of Theory of Mind: Understanding of Story Characters’ Thoughts and Feelings by Able Autistic, Mentally Handicapped and Normal Children and Adults. Journal of Autism and Developmental Disorders, 24, 129-154.
  • Hill, J. W., & Coufal, K. L. (2005). Emotional/behavioral disorders: A retrospective examination of social skills, linguistics, and student outcomes. Communication Disorders Quarterly27(1), 33–46.
  • Hollo, A., Wehby, J. H., & Oliver, R. O.  (2014). Unsuspected language deficits in children with emotional and behavioral disorders: A meta-analysis. Exceptional Children, Vol. 80, No. 2, pp. 169-186.
  • Hummel, L. J., & Prizant, B. M. (1993) A socioemotional perspective for understanding social difficulties of school-age children with language disorders. Language, Speech, and Hearing Services in Schools, 24, 216–224
  • Hyter, Y. D. (2003). Language intervention  for children with emotional or behavioral disorders. Behavioral  Disorders, 29, 65–76.
  • —Hyter, Y. D., et al (2001). Pragmatic language intervention for children with language and emotional/behavioral disorders. Communication Disorders Quarterly, 23(1), 4–16.—
  • Langton,S et al, (2000) Do the eyes have it? Cues to the direction of social attention. Trends in Cognitive Sciences, 4 (2) 50-59.
  • Losh, M., & Capps, L. (2003). Narrative ability in high-functioning children with autism or Asperger’s syndrome. Journal of Autism and Developmental Disorders, 33, 239–251.
  • Nelson, J. R., Benner, G. J., & Cheney, D. (2005).An investigation of the language skills of students with emotional disturbance served in public school settings. Journal of Special Education39, 97–105.
  • Pearce, P. et al. (2014). Use of narratives to assess language disorders in an inpatient pediatric psychiatric population. Clin Child Psychol Psychiatry, 19(2) 244-259.—
  • Prizant, B.M., et al. (1990). Communication disorders and emotional/behavioral disorders in children and adolescents. The Journal of Speech and Hearing Disorders, 55, 179-192.
  • —Semrud-Clikeman, M., & Glass, K. (2010).  The Relation of Humor and Child Development: Social, Adaptive, and Emotional Aspects.  Journal of Child Neurology, 25, 1248-1260.
  • Sanger, D., Maag, J. W., & Shapera, N. R. (1994). Language problems among students with emotional and behavioral disorders. Intervention in School and Clinic30(2), 103–108.
  • —Tallal, P., Dukette, D,. and Curtiss, S (1989) Behavioral Emotional Profiles of Preschool language impaired children. Development and Psychopathology (1) 51-67.
  • Toppelberg, C., & Shapiro, T. (2000). Language disorders: A 10-year research update review. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 143–152.
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On the Disadvantages of Parents Ceasing to Speak the Birth Language with Bilingual Language Impaired Children

ChildrenDespite significant advances in the fields of education and speech pathology, many harmful myths pertaining to multilingualism continue to persist. One particularly infuriating and patently incorrect recommendation to parents is the advice to stop speaking the birth language with their bilingual children with language disorders.

There is a plethora of evidence available regarding how bilingualism facilitates, increases, and improves language gains in children with developmental language disorders (DLD) as well as genetic conditions and syndromes (e.g., ASD, DS, FXS, etc.) Numerous researchers have released results of studies indicating the advantages of being bilingual for language impaired children (see this issue of Journal of Communication Disorders for starters for some studies on this subject).

But today in addition to briefly reiterating these advantages, I’d like to also explicitly discuss the disadvantages, which can result when parents are told to stop speaking the birth language with their language impaired children and switch to English-only interactions.

Cognitive advantages of maintaining the birth language for bilingual children with language impairments  (whose parents are able to provide them with that opportunity in the home) include increased attentional control and working memory, as well as perspective taking abilities. Linguistic advantages include increased awareness of vocabulary and grammar. Even social skills of these children have been reported to be more advanced as compared to monolingual only peers (See Pena, 2016, pp. 88-89 for a review of pertinent studies)

But what happens when parents decide to speak English only to their language impaired bilingual child? In the words of Helen Lester’s ‘Pookins’, lots! And I don’t mean it in a good way!

—Research indicates that children with language disorders will have language deficits in all the languages that they speak. As such, no matter which language is being used, the child will still present with some difficulty acquiring it and will do so at a much slower pace (Kohnert, 2010).

The problem is that NOT using the native language, can limit language and early literacy practices at home during sensitive periods of language acquisition. This will result in poorer language outcomes as compared to bilingual language impaired peers whose birth language continued to be supported at home. (Ijalba, 2010)

“There is also evidence to show that young minority L1 learners with impaired language systems are even more vulnerable than unaffected bilingual peers to loss or early plateaus in the home language if it is not supported ().” (Kohnert, 2010, p. 8)

“Minority-language families are especially affected since English is usually recommended as the target language.”  (Yu, 2016, p. 424) Some studies have reported that: “parents expressed personal loss and sadness (Fernandez y Garcia et al., 2012) if they chose to speak only English to their child with ASD.” Other studies have reported that “some [parents] also expressed discomfort and difficulty when speaking a non-native language with their child (Yu, 2013) or said they talked less frequently to their child when they used the majority language because it felt less natural.” (Bird, Genesee, Verhoeven, 2016. p. 5)

Perhaps the most disturbing findings are the studies that show that eliminating speaking birth language at home causes an emotional disconnect between immediate and extended family members and the child in question (Kouritzin, 1999; Tseng & Fuligni, 2000; Wharton et al 2000). Wharton and colleagues found that immigrant parents were more affective and engaging with their autistic children when they used their native language Wharton et al (2000).  Contrastingly, Kremer-Sadlik (2005) found that parents are less likely to engage their children in conversation when they cannot use their native language and that it further isolates a child who needs help with interactive skills.

“The advice to stick with a language that the family doesn’t speak well only intensifies the alienation experienced by these children.”  “You’re taking a child who is already socially isolated and you’re making them even more isolated”. Consequently, “development of heritage languages and bilingual competencies may be especially important for children with ASD given their core challenges in socialization, communication, and relational development.” (Yu, 2016, p. 434)

Given the combined results of the above studies, it is hugely important for professionals to appropriately support the parents of bilingual children with language and learning needs when it comes to offering them relevant recommendations on the topic of language use in the home. This can be accomplished by sharing with them the synthesis of currently available studies on the topic of bilingualism and language disorders, as well as encouraging them to speak the birth language in the home if they are willing and able to, rather than embracing English only practices, which may result in significant detrimental effects for both bilingual children and their families.

FOR A PDF HANDOUT FOR PARENTS AND PROFESSIONALS PLEASE CLICK HERE

Select Parent-Friendly Resources:

 References:

  1. Fernandez y Garcia, E., Brelau, J., Hansen, R., & Miller, E. (2012). Unintended consequences: An ethnographic narrative case series exploring language recommendations for bilingual families of children with autistic spectrum disorders. Journal of Medical Speech-Language Pathology, 20, 10–16.
  2. Hakansson G, Salameh E, Nettelbladt U. (2003) Measuring language development in bilingual children: Swedish-Arabic children with and without language impairmentLinguistics. 41:255–288.
  3. Ijalba, E (2010) Supporting early-literacy and language acquisition among bilingual children in HeadStart ASHA Convention Handout: Philadelphia, PA.
  4. Kay-Raining Bird, E, Genesee, F & Verhoeven, L (2016) Bilingualism in children with developmental disorders: A narrative review.  Journal of Communication Disorders, (63), pp. 1-14.
  5. Kohnert, K. (2010). Bilingual children with primary language impairment: Issues, evidence and implications for clinical actions. Journal of Communication Disorders43, 465–473.
  6. Kouritzin, S (1999) Face[t]s of First Language Loss. Routledge.
  7. Kremer-Sadlik, T. (2005). To be or not to be bilingual: Autistic children from multilingual families. Proceedings of the 4th International Symposium on Bilingualism, ed. James Cohen, Kara T. McAlister, Kellie Rolstad, and Jeff MacSwan, 1225-1234.
  8. Peña, E (2016) Supporting the home language of bilingual children with developmental disabilities: From knowing to doing. Journal of Communication Disorders, (63), pp. 85-92.
  9. Restrepo MA, Kruth K. (2001) Grammatical characteristics of a Spanish-English bilingual child with specific language impairment. Communication Disorders Quarterly. 21:66–76.
  10. Salameh E, Hakansson G, Nettelbladt U. (2004) Developmental perspectives on bilingual Swedish-Arabic children with and without language impairment: A longitudinal study. International Journal of Language & Communication Disorders. 39:65–91
  11. Tseng, Vivian. & Fuligni, Andrew J.(2000). Parent-adolescent language use and relationships among immigrant families with east Asian, Filipino and Latin American background. Journal of Marriage & Family, Vol. 62, No. 2,
  12. Wharton, R et al. (2000). Children with special need in bilingual families: A developmental approach to language recommendations. ICDL Clinical Practice Guidelines. The Unicorn Children’s Foundation: ICDL Press, Ch. 7. Pp 141-151.
  13. Yu, B. (2013). Issues in bilingualism and heritage language maintenance: Perspectives of minority-language mothers of children with Autism Spectrum Disorders. American Journal of Speech-Language Pathology, 22, 10–24.
  14. Yu, B. (2016). Bilingualism as conceptualized and bilingualism as lived: A critical examination of the monolingual socialization of a child with autism in a bilingual family. Journal of Autism and Developmental Disorders, 46, 424-435.

For more information on Evidence-Based Practices in Speech-Language Pathologists, SLPs can check out SLPs for Evidence-Based Practice 

For more Smart Speech LLC bilingual resources and topics click HERE

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Analyzing Narratives of School-Aged Children

Related imageIn the past, I have written about why narrative assessments should be an integral part of all language evaluations.  Today, I’d like to share how I conduct my narrative assessments for comprehensive language testing purposes.

As mentioned previously, for elicitation purposes, I frequently use the books recommended by the SALT Software website, which include: ‘Frog Where Are You?’ by Mercer Mayer, ‘Pookins Gets Her Way‘ and ‘A Porcupine Named Fluffy‘ by  Helen Lester, as well as ‘Dr. DeSoto‘ by William Steig.

Depending on the child’s age, I may read the story to the child or ask the child to read the story to me. One of the reasons why I like to utilize the second option is because it also allows me to ascertain, to some extent, the child’s reading skills in the areas of phonological awareness, phonics, reading fluency, vocabulary, as well as reading comprehension.

After that, I ask the child to retell the story back to me. Once again, depending on the child’s age as well as the estimated extent of his/her language severity, I may show the pictures from the story (and cover up the words) or ask the child to tell the story back to me without the benefit of visual support

Frog Where Are You IntroAs the child is retelling the story I digitally record his/her narrative so I can later transcribe and analyze it.  As the child is retelling the story, I may use verbal prompts such as: ‘What else can you tell me?’ and ‘Can you tell me more?’ to elicit additional information. However, I try not to prompt the child excessively; otherwise, the child is merely producing heavily prompted responses vs. telling me a spontaneous story. I then transcribe the child’s narrative verbatim and include all the pauses, mazes, linguistic reformulations, etc. This is particularly important for the purpose of determining the extent of the child’s word finding difficulties (if any) as well as in order to establish whether the child can retell a story with ease or if s/he struggles significantly during this task.

Here’s an example of what my transcription and analysis look like for first-grade students. Below narrative was produced by a 6-year-old student after I’ve read to her a script of  ‘Frog Where Are You?’ by Mercer Mayer.     Image result for frog where are youAnalysis: This student’s narrative was judged to be immature and decontextualized for her age.  The student’s strengths included the inclusion of all the relevant story grammar elements (for her age), some dialogue (e.g., “Frog! Where are you?”), as well as limited use of perspective taking (e.g., /mad/; /the boy checked that the dog was OK/, etc.). However, her narrative was very difficult to follow due to its limited coherence and cohesion.  The presence of grammatical, syntactic, and pragmatic errors, tangential story production, as well as abrupt and confusing shifts between settings and characters made it further confusing and difficult to follow.

With respect to microstructure, the student’s story was composed of numerous partially produced phrases and simple sentences, had limited temporal markers (e.g., then), and did not contain an adequate number of complex and compound sentences as is appropriate for a child her age (Paul, 1981). Throughout her narrative student inconsistently used anaphoric referencing. She was observed to overuse the pronoun ‘he’, which resulted in lack of clarity regarding which characters – the dog, the boy, or the turtle, she was referring to.  She also at times evidenced pronoun confusion (referred to the boy as ‘it’).

Image result for frog where are youThroughout her narrative, the student also evidenced a number of word finding difficulties manifested via word/phrase repetitions and revisions, use of fillers (e.g., “um”), and pauses, which made her story difficult for listeners to follow. Usage of invented vocabulary (e.g., stairpass) as well as target word substitutions (e.g., /roof/ vs. /cliff/) was also noted (German, 2005).

Summary: A 6-0-year-old student is expected to be at the True Narratives Level I (Hedberg & Westby, 1993), characterized by a well-developed plot, character development, clear sequencing of events, and consistent perspectives which focus around an incident in a story. Weaknesses in the area of narrative ability possess adverse impact on academic performance in the areas of oral language, reading, and written expression. Narrative weaknesses also significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014), which this student is currently displaying. In order to facilitate academic and social success in this area, therapeutic intervention is strongly recommended.

Please note that the above analysis is by no means exhaustive. Furthermore, there are numerous other ways one can analyze a narrative sample. Nevertheless, I hope you found the above example useful for your language assessment purposes. Stay tuned for another example of my narrative analysis, to be posted shortly. Meanwhile, feel free to share in the comments section of this post, how you perform narrative assessments and what materials you use for this purpose.

References:

Helpful Smart Speech Therapy Resources: 

 

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Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

In the past several years, I wrote a series of posts on the topic of improving clinical practices in speech-language pathology.  Some of these posts were based on my clinical experience as backed by research,  while others summarized key point from articles written by prominent colleagues in our field such as Dr. Alan KamhiDr.  David DeBonnisDr. Andrew Vermiglio, etc.

In the past, I have highlighted several articles from the 2014 LSHSS clinical forum entitled: Improving Clinical Practice. Today I would like to explicitly summarize another relevant article written by Dr. Wallach in 2014, entitled “Improving Clinical Practice: A School-Age and School-Based Perspective“, which discusses how to change the “persistence of traditional practices” in order to make our language interventions more functional and meaningful for students with language learning difficulties.

Image result for geraldine wallachDr. Wallach begins her article by describing 3  fairly typical to the schools’ scenarios.  In the first one,  a group of second graders with narrative retelling goals are working on a sequencing activity (“First the soup is on the counter, next it is opened, then it is cooked on the stove, last it is put in a bowl and ready to eat.”).

In the second scenario,  a group of fourth graders are working on following directions presented to them by the clinician (“Pick up the red triangle before you touch the large, green circle.”)

Image result for ambiguous newspaper headlinesIn  the third scenario,  a group of middle schoolers  are working on interpreting  newspaper headlines (“Jazz Helps Lakers Become Mellow in Victory.”)

Dr. Wallach then poses several overarching questions:

  • Do these goals make sense in the current context of research pertaining to language, learning, and literacy?
  • ‘Are the targets relevant to language and academic contexts beyond the “speech room” (i.e., are the choices, curriculum, and classroom relevant)?’
  • ‘Are they relevant to language learning in general?’
  • ‘Is the intervention’s focus encouraging performance (short-term learning that is context-bound) or long-term and context-independent learning?’ (p. 128)

She then delves deeper into where these goals come from as well as presents some suggestions regarding how these goals could be altered in order to make them more functional.

She begins by explaining that labeling SLP  provided school-based services as “speech” “creates artificial barriers, inaccurate perceptions, and inappropriate intervention recommendations that exacerbate an already complex situation, that is, meeting the language learning and literacy needs of students across a changing landscape of required knowledge and skills needed to succeed academically.” (128)

From there,  she explains why targets in the first two scenarios are inaccurate and not functional.  She explains that while working on improving narrative abilities is functional,  working on isolated sequencing abilities is not functional since in the context of her present scenario the child was not retelling an actual story. Furthermore, ‘the clinician’s focus on sequencing as an underlying skill comes from sources that are unknown’ and ‘the “transfer” to producing and comprehending temporal and causal narratives from the soup scenario is an assumption that research fails to support” (128) She adds, that  “Duke and Pearson (2008/2009) mirror these notions when they state that the “transfer [of taught skills and strategies] decreases as a function of distance from the original information domain” (p. 113).”    Then, of course, there is the usage of “expository text (i.e., a sequential text) rather than narrative text,”  further indicating that the goal is not functionally transferable.  The second graders are receiving a message that we are working on storytelling skills,  when in reality that is not what is taking place in the session.

To balance the above criticism, Dr. Wallach does describe a number of positive elements involved in what her fictional clinician in her scenario is doing: (e.g, using expository text knowledge, talking about language, etc.), but she also asks: (1) Is the activity developmentally appropriate? and (2) Are the metalinguistic task aspects too complex for children that age? (129).

Now, let’s move on to multiple step commands, a persistent intervention meme, created because our students have difficulty understanding instructions, paying attention in class, as well as processing and completing classroom assignments.

The problem is that the processing of multistep directions is influenced by a number of contextual, semantic, and linguistic factors.  By far, not all multistep directions are created equal. Some are far more contextually related and semantically constrained than others (e.g., “After you open the book, turn to page 120” vs. “Pick up the red triangle before you touch the large, green circle.”) (p. 129). Consequently, “following directions” is not a simple task of “memorizing the steps”, rather it is a complex process which involves activation of available semantic and syntactic knowledge, comprehension of sentences with a variety of clauses, as well as numerous other linguistic factors.

Unfortunately, the provision of decontextualized directions will not meaningfully assist the students with comprehension of school work and navigation of the classroom environment. As such, rather than teaching the students multiple step directions which will not meaningfully transfer to other settings it may be far more appropriate to teach the students how to request clarification from their speakers in order to break up complex instructions into manageable chunks of information.

In contrast, the goals and procedures in the 3rd scenario (see pgs. 127-128 for full details ) are actually supported by research in developmental disorders.  The SLP is helping students to be actively involved in language by activating their background knowledge, use new strategies, reduce competing resources, heighten the students’ metalinguistic abilities, as well as incorporating aspects of both language and literacy into sessions, making her intervention highly relevant to the curriculum.

Dr. Wallach then moves on to provide constructive suggestions regarding how intervention services can be improved in the school setting. This includes: “(a) creating intervention goals that are knowledge-based and help students connect known and new information; (b) balancing content knowledge and awareness of text structure in functional, authentic tasks that optimize long-term retention and transfer across grades and content-area subjects; and (c) matching students’ language goals and objectives to the “outside world” of curricular and classroom contexts.” (p. 130)

First, “research suggests that engaging students in prior knowledge activities increases the comprehension and retention of information” (p. 130). In other words, “when too much is new, comprehension and retention suffer; something has to “give” or be modified to facilitate learning” (p. 130).  She suggests using a familiar high-interest topic to teach a discrete amount of new information.  Here, the role of background knowledge is hugely important when it comes to learning. “Engaging students in prior knowledge activities that include questioning and other meaning-based strategies encourage them to use and express what they do know, talk about what they need to know and become more actively involved in interacting with spoken and written text (Wallach et al., 2014)” (p. 131).

To illustrate, Dr. Wallach provides an example from a ninth-grade science textbook, laden with complex information. She then explains how to “use of evidence-based strategies including self-questioning and clinician-led discussions to guide students” in better understanding the material via use of various frameworks (e.g., K-W-L) (p. 131). She also emphasizes how within a collaborative framework SLPs can focus on aspects of text structure to ask relevant questions about content.

From there she segues into a fifth-grade history text and explains that  “No kit or program from the hundreds that appear in ASHA Convention exhibit halls year after year will come to our rescue” (131), As such, SLPs need to teach their clients both macro (text organization) and micro (syntax, morphology, etc.) components of language so they could successfully navigate complex texts. A number of researchers (e.g., A. Kamhi, C. Scott, M. Nippold, B. Ehren, etc.) have highlighted the fact that our middle school and high school students lack the comprehension of complex morphosyntax. Hence, explicitly teaching it to out students will significantly improve both our clinical practice and their academic outcomes. Here, Dr. Wallach also recommends the work of “McKeown and her colleagues (e.g., Beck, McKeown, & Worthy, 1995McKeown et al., 2009McKeown, Beck, Sinatra, & Loxterman, 1992) when trying to understand the complex interaction between content and structure knowledge.” (p. 132)

After that Dr. Wallach segues into a discussion on how our clients’ language goals can be better aligned with the academic curricular demands. She states that SLPs need to delve deeper (or at all) into disciplinary literacy (teaching our students subject-specific comprehension and vocabulary). Here, collaboration with content-area teachers is very important. “For example, science involves many technical terms and definitions and requires clear and concise cause and effect thinking (Fang, 2004Halliday, 1993). “The noun phrases [in science texts] contain a large quantity of information that in more commonsense language of everyday life would require several sentences to express” (Fang, 2012, p. 24). ” (132). “Alternatively, social studies involves being able to put events into a context, comparing sources, and understanding the biases of the writer. Unlike science, authorship is important in history.” (132)

Dr. Wallach suggests a number of questions clinicians can ask selves about our students when determining therapy targets:

  1. Can they handle complex syntactic forms that are more common in written language than spoken language?
  2. Do they have an understanding of word derivations?
  3. Do our students know how to write a compare and contrast expository piece?
  4. Are they able to evaluate sources information?
  5. Do they use prior knowledge and experience to help them comprehend new information?

She then offers SLPs valuable ideas on how to create a thoughtful balance between general and subject-specific language targets (see pg 133 for complete details).

Dr. Wallach concludes her article with the following points.

  • Students with language learning disabilities are at a disadvantage in school due to having reduced/limited background knowledge and language proficiency as compared to typically developing peers. Hence “school-based SLPs must consider ways that students’ language abilities influence and interact with their academic success (Wallach et al., 2014). Our intervention should be seen as developing a set of language initiatives focused toward content-area learning (A. S. Bashir, personal communication, 2012; Wallach et al., 2009). ” 
  • Staying focused on the continuum of change across the grades is an important aspect of clinical practice in the school years. Likewise, as suggested by many authors, connecting our preschool endeavors to the horizon of school-age demands underpins our work over time
  • As we look to changes in service delivery models in schools including research that supports response-to-intervention (RtI) models (e.g., Wixson, Lipson, & Valencia, 2014), we can be optimistic that less relevant and nonfunctional practices will die natural deaths.” (pgs. 133-134)

There you have it! Numerous practical suggestions as well as functional clarifications from Dr. Wallach so SLPs can improve their treatment practices with school-aged children.  And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation.

They include:

References:

  • Beck, I. L., McKeown, M. G., & Worthy, J. (1995). Giving text a voice can improve students’ understanding. Reading Research Quarterly30, 220–238.
  • Duke, N. K., & Pearson, P. D. (2008/2009). Effective practices for developing reading comprehension. Journal of Education189, 107–122.
  • Fang, Z. (2004). Scientific literacy: A systematic functional linguistics perspective. Science Education89, 335–347. 
  • Fang, Z. (2012). Language correlates of disciplinary literacy. Topics in Language Disorders32, 19–34. 
  • Halliday, M. A. K. (1993). Some grammatical problems in scientific English. In Halliday, M. A. K., & Martin, J. R. (Eds.), Writing science: Literacy and discursive power (pp. 69–85). London, England: Falmer.
  • McKeown, M. G., Beck, I. L., & Blake, R. G. K. (2009). Rethinking reading comprehension instruction: A comparison of instruction for strategies and content approaches. Reading Research Quarterly44, 218–253. 
  • McKeown, M. G., Beck, I. L., Sinatra, G. M., & Loxterman, J. A. (1992). The contribution of prior knowledge and coherent text to comprehension. Reading Research Quarterly27, 79–93.
  • Wallach, G. P., Charlton, S. J., & Christie, J. (2009). Making a broader case for the narrow view? Where to begin? Language, Speech, and Hearing Services in Schools40, 201–211. 
  • Wallach, G.P. (2014). Improving clinical practice: A school-age and school-based perspective. Language, Speech, and Hearing Services in Schools, 45, 127-136
  • Wallach, G.P., Charlton, S., & Christie Bartholomew, J. (2014). The spoken-written comprehension connection: Constructive intervention strategies. In C.A. Stone, E.R. Silliman, B.J. Ehren, & G.P. Wallach (Eds). Handbook of language and literacy: Development and disorders (pp. 485-501). NY: Guilford Press.
  • Wixson, K. K., Lipson, M. Y., & Valencia, S. W. (2014). Response to intervention for teaching and learning in language and literacy. InStone, C. A., Silliman, E. R., Ehren, B. J., & Wallach, G. P. (Eds.), Handbook of language and literacy: Development and disorders (2nd ed., pp. 637–653). New York, NY: Guilford Press.

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

 

 

 

 

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Help, My Student has a Huge Score Discrepancy Between Tests and I Don’t Know Why?

Here’s a  familiar scenario to many SLPs. You’ve administered several standardized language tests to your student (e.g., CELF-5 & TILLS). You expected to see roughly similar scores across tests. Much to your surprise, you find that while your student attained somewhat average scores on one assessment, s/he had completely bombed the second assessment, and you have no idea why that happened.

So you go on social media and start crowdsourcing for information from a variety of SLPs located in a variety of states and countries in order to figure out what has happened and what you should do about this. Of course, the problem in such situations is that while some responses will be spot on, many will be utterly inappropriate. Luckily, the answer lies much closer than you think, in the actual technical manual of the administered tests.

So what is responsible for such as drastic discrepancy?  A few things actually. For starters, unless both tests were co-normed (used the same sample of test takers) be prepared to see disparate scores due to the ability levels of children in the normative groups of each test.  Another important factor involved in the score discrepancy is how accurately does the test differentiate disordered children from typical functioning ones.

Let’s compare two actual language tests to learn more. For the purpose of this exercise let us select The Clinical Evaluation of Language Fundamentals-5 (CELF-5) and the Test of Integrated Language and Literacy (TILLS).   The former is a very familiar entity to numerous SLPs, while the latter is just coming into its own, having been released in the market only several years ago.

Both tests share a number of similarities. Both were created to assess the language abilities of children and adolescents with suspected language disorders. Both assess aspects of language and literacy (albeit not to the same degree nor with the same level of thoroughness).  Both can be used for language disorder classification purposes, or can they?

Actually, my last statement is rather debatable.  A careful perusal of the CELF – 5 reveals that its normative sample of 3000 children included a whopping 23% of children with language-related disabilities. In fact, the folks from the Leaders Project did such an excellent and thorough job reviewing its psychometric properties rather than repeating that information, the readers can simply click here to review the limitations of the CELF – 5 straight on the Leaders Project website.  Furthermore, even the CELF – 5 developers themselves have stated that: “Based on CELF-5 sensitivity and specificity values, the optimal cut score to achieve the best balance is -1.33 (standard score of 80). Using a standard score of 80 as a cut score yields sensitivity and specificity values of .97.

In other words, obtaining a standard score of 80 on the CELF – 5 indicates that a child presents with a language disorder. Of course, as many SLPs already know, the eligibility criteria in the schools requires language scores far below that in order for the student to qualify to receive language therapy services.

In fact, the test’s authors are fully aware of that and acknowledge that in the same document. “Keep in mind that students who have language deficits may not obtain scores that qualify him or her for placement based on the program’s criteria for eligibility. You’ll need to plan how to address the student’s needs within the framework established by your program.”

But here is another issue – the CELF-5 sensitivity group included only a very small number of: “67 children ranging from 5;0 to 15;11”, whose only requirement was to score 1.5SDs < mean “on any standardized language test”.  As the Leaders Project reviewers point out: “This means that the 67 children in the sensitivity group could all have had severe disabilities. They might have multiple disabilities in addition to severe language disorders including severe intellectual disabilities or Autism Spectrum Disorder making it easy for a language disorder test to identify this group as having language disorders with extremely high accuracy. ” (pgs. 7-8)

Of course, this begs the question,  why would anyone continue to administer any test to students, if its administration A. Does not guarantee disorder identification B. Will not make the student eligible for language therapy despite demonstrated need?

The problem is that even though SLPs are mandated to use a variety of quantitative clinical observations and procedures in order to reliably qualify students for services, standardized tests still carry more value then they should.  Consequently,  it is important for SLPs to select the right test to make their job easier.

The TILLS is a far less known assessment than the CELF-5 yet in the few years it has been out on the market it really made its presence felt by being a solid assessment tool due to its valid and reliable psychometric properties. Again, the venerable Dr. Carol Westby had already done such an excellent job reviewing its psychometric properties that I will refer the readers to her review here, rather than repeating this information as it will not add anything new on this topic. The upshot of her review as follows: “The TILLS does not include children and adolescents with language/literacy impairments (LLIs) in the norming sample. Since the 1990s, nearly all language assessments have included children with LLIs in the norming sample. Doing so lowers overall scores, making it more difficult to use the assessment to identify students with LLIs. (pg. 11)”

Now, here many proponents of inclusion of children with language disorders in the normative sample will make a variation of the following claim: “You CANNOT diagnose a language impairment if children with language impairment were not included in the normative sample of that assessment!Here’s a major problem with such assertion. When a child is referred for a language assessment, we really have no way of knowing if this child has a language impairment until we actually finish testing them. We are in fact attempting to confirm or refute this fact, hopefully via the use of reliable and valid testing. However, if the normative sample includes many children with language and learning difficulties, this significantly affects the accuracy of our identification, since we are interested in comparing this child’s results to typically developing children and not the disordered ones, in order to learn if the child has a disorder in the first place.  As per Peña, Spaulding and Plante (2006), “the inclusion of children with disabilities may be at odds with the goal of classification, typically the primary function of the speech pathologist’s assessment. In fact, by including such children in the normative sample, we may be “shooting ourselves in the foot” in terms of testing for the purpose of identifying disorders.”(p. 248)

Then there’s a variation of this assertion, which I have seen in several Facebook groups: “Children with language disorders score at the low end of normal distribution“.  Once again such assertion is incorrect since Spaulding, Plante & Farinella (2006) have actually shown that on average, these kids will score at least 1.28 SDs below the mean, which is not the low average range of normal distribution by any means.  As per authors: “Specific data supporting the application of “low score” criteria for the identification of language impairment is not supported by the majority of current commercially available tests. However, alternate sources of data (sensitivity and specificity rates) that support accurate identification are available for a subset of the available tests.” (p. 61)

Now, let us get back to your child in question, who performed so differently on both of the administered tests. Given his clinically observed difficulties, you fully expected your testing to confirm it. But you are now more confused than before. Don’t be! Search the technical manual for information on the particular test’s sensitivity and specificity to look up the numbers.   Vance and Plante (1994) put forth the following criteria for accurate identification of a disorder (discriminant accuracy): “90% should be considered good discriminant accuracy; 80% to 89% should be considered fair. Below 80%, misidentifications occur at unacceptably high rates” and leading to “serious social consequences” of misidentified children. (p. 21)

Review the sensitivity and specificity of your test/s, take a look at the normative samples, see if anything unusual jumps out at you, which leads you to believe that the administered test may have some issues with assessing what it purports to assess. Then, after supplementing your standardized testing results with good quality clinical data (e.g., narrative samples, dynamic assessment tasks, etc.), consider creating a solidly referenced purchasing pitch to your administration to invest in more valid and reliable standardized tests.

Hope you find this information helpful in your quest to better serve the clients on your caseload. If you are interested in learning more regarding evidence-based assessment practices as well as psychometric properties of various standardized speech-language tests visit the SLPs for Evidence-Based Practice  group on Facebook learn more.

References:

 

 

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FREE Resources for Working with Russian Speaking Clients: Part II

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

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

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

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

Select Speech and Language Norms:

Image result for развитие речи детей

Select Parent Questionnaires (McArthur Bates Adapted in Russian):

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

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

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

Related Resources:

 

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It’s All Due to …Language: How Subtle Symptoms Can Cause Serious Academic Deficits

Scenario: Len is a 7-2-year-old, 2nd-grade student who struggles with reading and writing in the classroom. He is very bright and has a high average IQ, yet when he is speaking he frequently can’t get his point across to others due to excessive linguistic reformulations and word-finding difficulties. The problem is that Len passed all the typical educational and language testing with flying colors, receiving average scores across the board on various tests including the Woodcock-Johnson Fourth Edition (WJ-IV) and the Clinical Evaluation of Language Fundamentals-5 (CELF-5). Stranger still is the fact that he aced Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2), with flying colors, so he is not even eligible for a “dyslexia” diagnosis. Len is clearly struggling in the classroom with coherently expressing self, telling stories, understanding what he is reading, as well as putting his thoughts on paper. His parents have compiled impressively huge folders containing examples of his struggles. Yet because of his performance on the basic standardized assessment batteries, Len does not qualify for any functional assistance in the school setting, despite being virtually functionally illiterate in second grade.

The truth is that Len is quite a familiar figure to many SLPs, who at one time or another have encountered such a student and asked for guidance regarding the appropriate accommodations and services for him on various SLP-geared social media forums. But what makes Len such an enigma, one may inquire? Surely if the child had tangible deficits, wouldn’t standardized testing at least partially reveal them?

Well, it all depends really, on what type of testing was administered to Len in the first place. A few years ago I wrote a post entitled: “What Research Shows About the Functional Relevance of Standardized Language Tests“.  What researchers found is that there is a “lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores” (Betz et al, 2012, 141). Furthermore, they also found that the most frequently used tests were the comprehensive assessments including the Clinical Evaluation of Language Fundamentals and the Preschool Language Scale as well as one-word vocabulary tests such as the Peabody Picture Vocabulary Test”. Most damaging finding was the fact that: “frequently SLPs did not follow up the comprehensive standardized testing with domain-specific assessments (critical thinking, social communication, etc.) but instead used the vocabulary testing as a second measure”.(Betz et al, 2012, 140)

In other words, many SLPs only use the tests at hand rather than the RIGHT tests aimed at identifying the student’s specific deficits. But the problem doesn’t actually stop there. Due to the variation in psychometric properties of various tests, many children with language impairment are overlooked by standardized tests by receiving scores within the average range or not receiving low enough scores to qualify for services.

Thus, “the clinical consequence is that a child who truly has a language impairment has a roughly equal chance of being correctly or incorrectly identified, depending on the test that he or she is given.” Furthermore, “even if a child is diagnosed accurately as language impaired at one point in time, future diagnoses may lead to the false perception that the child has recovered, depending on the test(s) that he or she has been given (Spaulding, Plante & Farinella, 2006, 69).”

There’s of course yet another factor affecting our hypothetical client and that is his relatively young age. This is especially evident with many educational and language testing for children in the 5-7 age group. Because the bar is set so low, concept-wise for these age-groups, many children with moderate language and literacy deficits can pass these tests with flying colors, only to be flagged by them literally two years later and be identified with deficits, far too late in the game.  Coupled with the fact that many SLPs do not utilize non-standardized measures to supplement their assessments, Len is in a pretty serious predicament.

But what if there was a do-over? What could we do differently for Len to rectify this situation? For starters, we need to pay careful attention to his deficits profile in order to choose appropriate tests to evaluate his areas of needs. The above can be accomplished via a number of ways. The SLP can interview Len’s teacher and his caregiver/s in order to obtain a summary of his pressing deficits. Depending on the extent of the reported deficits the SLP can also provide them with a referral checklist to mark off the most significant areas of need.

In Len’s case, we already have a pretty good idea regarding what’s going on. We know that he passed basic language and educational testing, so in the words of Dr. Geraldine Wallach, we need to keep “peeling the onion” via the administration of more sensitive tests to tap into Len’s reported areas of deficits which include: word-retrieval, narrative production, as well as reading and writing.

For that purpose, Len is a good candidate for the administration of the Test of Integrated Language and Literacy (TILLS), which was developed to identify language and literacy disorders, has good psychometric properties, and contains subtests for assessment of relevant skills such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school-age children.

Given Len’s reported history of narrative production deficits, Len is also a good candidate for the administration of the Social Language Development Test Elementary (SLDTE). Here’s why. Research indicates that narrative weaknesses significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014). As such, it’s not just children with Autism Spectrum Disorders who present with impaired narrative abilities. Many children with developmental language impairment (DLD) (#devlangdis) can present with significant narrative deficits affecting their social and academic functioning, which means that their social communication abilities need to be tested to confirm/rule out presence of these difficulties.

However, standardized tests are not enough, since even the best-standardized tests have significant limitations. As such, several non-standardized assessments in the areas of narrative production, reading, and writing, may be recommended for Len to meaningfully supplement his testing.

Let’s begin with an informal narrative assessment which provides detailed information regarding microstructural and macrostructural aspects of storytelling as well as child’s thought processes and socio-emotional functioning. My nonstandardized narrative assessments are based on the book elicitation recommendations from the SALT website. For 2nd graders, I use the book by Helen Lester entitled Pookins Gets Her Way. I first read the story to the child, then cover up the words and ask the child to retell the story based on pictures. I read the story first because: “the model narrative presents the events, plot structure, and words that the narrator is to retell, which allows more reliable scoring than a generated story that can go in many directions” (Allen et al, 2012, p. 207).

As the child is retelling his story I digitally record him using the Voice Memos application on my iPhone, for a later transcription and thorough analysis.  During storytelling, I only use the prompts: ‘What else can you tell me?’ and ‘Can you tell me more?’ to elicit additional information. I try not to prompt the child excessively since I am interested in cataloging all of his narrative-based deficits. After I transcribe the sample, I analyze it and make sure that I include the transcription and a detailed write-up in the body of my report, so parents and professionals can see and understand the nature of the child’s errors/weaknesses.

Now we are ready to move on to a brief nonstandardized reading assessment. For this purpose, I often use the books from the Continental Press series entitled: Reading for Comprehension, which contains books for grades 1-8.  After I confirm with either the parent or the child’s teacher that the selected passage is reflective of the complexity of work presented in the classroom for his grade level, I ask the child to read the text.  As the child is reading, I calculate the correct number of words he reads per minute as well as what type of errors the child is exhibiting during reading.  Then I ask the child to state the main idea of the text, summarize its key points as well as define select text embedded vocabulary words and answer a few, verbally presented reading comprehension questions. After that, I provide the child with accompanying 5 multiple choice question worksheet and ask the child to complete it. I analyze my results in order to determine whether I have accurately captured the child’s reading profile.

Finally, if any additional information is needed, I administer a nonstandardized writing assessment, which I base on the Common Core State Standards for 2nd grade. For this task, I provide a student with a writing prompt common for second grade and give him a period of 15-20 minutes to generate a writing sample. I then analyze the writing sample with respect to contextual conventions (punctuation, capitalization, grammar, and syntax) as well as story composition (overall coherence and cohesion of the written sample).

The above relatively short assessment battery (2 standardized tests and 3 informal assessment tasks) which takes approximately 2-2.5 hours to administer, allows me to create a comprehensive profile of the child’s language and literacy strengths and needs. It also allows me to generate targeted goals in order to begin effective and meaningful remediation of the child’s deficits.

Children like Len will, unfortunately, remain unidentified unless they are administered more sensitive tasks to better understand their subtle pattern of deficits. Consequently, to ensure that they do not fall through the cracks of our educational system due to misguided overreliance on a limited number of standardized assessments, it is very important that professionals select the right assessments, rather than the assessments at hand, in order to accurately determine the child’s areas of needs.

References:

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Making Our Interventions Count or What’s Research Got To Do With It?

Two years ago I wrote a blog post entitled: “What’s Memes Got To Do With It?” which summarized key points of Dr. Alan G. Kamhi’s 2004 article: “A Meme’s Eye View of Speech-Language Pathology“. It delved into answering the following question: “Why do some terms, labels, ideas, and constructs [in our field] prevail whereas others fail to gain acceptance?”.

Today I would like to reference another article by Dr. Kamhi written in 2014, entitled “Improving Clinical Practices for Children With Language and Learning Disorders“.

This article was written to address the gaps between research and clinical practice with respect to the implementation of EBP for intervention purposes.

Dr. Kamhi begins the article by posing 10 True or False questions for his readers:

  1. Learning is easier than generalization.
  2. Instruction that is constant and predictable is more effective than instruction that varies the conditions of learning and practice.
  3. Focused stimulation (massed practice) is a more effective teaching strategy than varied stimulation (distributed practice).
  4. The more feedback, the better.
  5. Repeated reading of passages is the best way to learn text information.
  6. More therapy is always better.
  7. The most effective language and literacy interventions target processing limitations rather than knowledge deficits.
  8. Telegraphic utterances (e.g., push ball, mommy sock) should not be provided as input for children with limited language.
  9. Appropriate language goals include increasing levels of mean length of utterance (MLU) and targeting Brown’s (1973) 14 grammatical morphemes.
  10. Sequencing is an important skill for narrative competence.

Guess what? Only statement 8 of the above quiz is True! Every other statement from the above is FALSE!

Now, let’s talk about why that is!

First up is the concept of learning vs. generalization. Here Dr. Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful. He explains that when we are talking about generalization – what children truly have a difficulty with is “transferring narrow limited rules to new situations“. “Children with language and learning problems will have difficulty acquiring broad-based rules and modifying these rules once acquired, and they also will be more vulnerable to performance demands on speech production and comprehension (Kamhi, 1988)” (93). After all, it is not “reasonable to expect children to use language targets consistently after a brief period of intervention” and while we hope that “language intervention [is] designed to lead children with language disorders to acquire broad-based language rules” it is a hugely difficult task to undertake and execute.

Next, Dr. Kamhi addresses the issue of instructional factors, specifically the importance of “varying conditions of instruction and practice“.  Here, he addresses the fact that while contextualized instruction is highly beneficial to learners unless we inject variability and modify various aspects of instruction including context, composition, duration, etc., we ran the risk of limiting our students’ long-term outcomes.

After that, Dr. Kamhi addresses the concept of distributed practice (spacing of intervention) and how important it is for teaching children with language disorders. He points out that a number of recent studies have found that “spacing and distribution of teaching episodes have more of an impact on treatment outcomes than treatment intensity” (94).

He also advocates reducing evaluative feedback to learners to “enhance long-term retention and generalization of motor skills“. While he cites research from studies pertaining to speech production, he adds that language learning could also benefit from this practice as it would reduce conversational disruptions and tunning out on the part of the student.

From there he addresses the limitations of repetition for specific tasks (e.g., text rereading). He emphasizes how important it is for students to recall and retrieve text rather than repeatedly reread it (even without correction), as the latter results in a lack of comprehension/retention of read information.

After that, he discusses treatment intensity. Here he emphasizes the fact that higher dose of instruction will not necessarily result in better therapy outcomes due to the research on the effects of “learning plateaus and threshold effects in language and literacy” (95). We have seen research on this with respect to joint book reading, vocabulary words exposure, etc. As such, at a certain point in time increased intensity may actually result in decreased treatment benefits.

His next point against processing interventions is very near and dear to my heart. Those of you familiar with my blog know that I have devoted a substantial number of posts pertaining to the lack of validity of CAPD diagnosis (as a standalone entity) and urged clinicians to provide language based vs. specific auditory interventions which lack treatment utility. Here, Dr. Kamhi makes a great point that: “Interventions that target processing skills are particularly appealing because they offer the promise of improving language and learning deficits without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (95) The problem is that we have numerous studies on the topic of improvement of isolated skills (e.g., auditory skills, working memory, slow processing, etc.) which clearly indicate lack of effectiveness of these interventions.  As such, “practitioners should be highly skeptical of interventions that promise quick fixes for language and learning disabilities” (96).

Now let us move on to language and particularly the models we provide to our clients to encourage greater verbal output. Research indicates that when clinicians are attempting to expand children’s utterances, they need to provide well-formed language models. Studies show that children select strong input when its surrounded by weaker input (the surrounding weaker syllables make stronger syllables stand out).  As such, clinicians should expand upon/comment on what clients are saying with grammatically complete models vs. telegraphic productions.

From there lets us take a look at Dr. Kamhi’s recommendations for grammar and syntax. Grammatical development goes much further than addressing Brown’s morphemes in therapy and calling it a day. As such, it is important to understand that children with developmental language disorders (DLD) (#DevLang) do not have difficulty acquiring all morphemes. Rather studies have shown that they have difficulty learning grammatical morphemes that reflect tense and agreement  (e.g., third-person singular, past tense, auxiliaries, copulas, etc.). As such, use of measures developed by (e.g., Tense Marker Total & Productivity Score) can yield helpful information regarding which grammatical structures to target in therapy.

With respect to syntax, Dr. Kamhi notes that many clinicians erroneously believe that complex syntax should be targeted when children are much older. The Common Core State Standards do not help this cause further, since according to the CCSS complex syntax should be targeted 2-3 grades, which is far too late. Typically developing children begin developing complex syntax around 2 years of age and begin readily producing it around 3 years of age. As such, clinicians should begin targeting complex syntax in preschool years and not wait until the children have mastered all morphemes and clauses (97)

Finally, Dr. Kamhi wraps up his article by offering suggestions regarding prioritizing intervention goals. Here, he explains that goal prioritization is affected by

  • clinician experience and competencies
  • the degree of collaboration with other professionals
  • type of service delivery model
  • client/student factors

He provides a hypothetical case scenario in which the teaching responsibilities are divvied up between three professionals, with SLP in charge of targeting narrative discourse. Here, he explains that targeting narratives does not involve targeting sequencing abilities. “The ability to understand and recall events in a story or script depends on conceptual understanding of the topic and attentional/memory abilities, not sequencing ability.”  He emphasizes that sequencing is not a distinct cognitive process that requires isolated treatment. Yet many SLPs “continue to believe that  sequencing is a distinct processing skill that needs to be assessed and treated.” (99)

Dr. Kamhi supports the above point by providing an example of two passages. One, which describes a random order of events, and another which follows a logical order of events. He then points out that the randomly ordered story relies exclusively on attention and memory in terms of “sequencing”, while the second story reduces demands on memory due to its logical flow of events. As such, he points out that retelling deficits seemingly related to sequencing, tend to be actually due to “limitations in attention, working memory, and/or conceptual knowledge“. Hence, instead of targeting sequencing abilities in therapy, SLPs should instead use contextualized language intervention to target aspects of narrative development (macro and microstructural elements).

Furthermore, here it is also important to note that the “sequencing fallacy” affects more than just narratives. It is very prevalent in the intervention process in the form of the ubiquitous “following directions” goal/s. Many clinicians readily create this goal for their clients due to their belief that it will result in functional therapeutic language gains. However, when one really begins to deconstruct this goal, one will realize that it involves a number of discrete abilities including: memory, attention, concept knowledge, inferencing, etc.  Consequently, targeting the above goal will not result in any functional gains for the students (their memory abilities will not magically improve as a result of it). Instead, targeting specific language and conceptual goals  (e.g., answering questions, producing complex sentences, etc.) and increasing the students’ overall listening comprehension and verbal expression will result in improvements in the areas of attention, memory, and processing, including their ability to follow complex directions.

There you have it! Ten practical suggestions from Dr. Kamhi ready for immediate implementation! And for more information, I highly recommend reading the other articles in the same clinical forum, all of which possess highly practical and relevant ideas for therapeutic implementation. They include:

References:

Kamhi, A. (2014). Improving clinical practices for children with language and learning disorders.  Language, Speech, and Hearing Services in Schools, 45(2), 92-103

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SLPs for Evidence-Based Practice