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Smart Speech Therapy Black Friday Sale!

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New Products for the 2017 Academic School Year for SLPs

Image result for back to schoolSeptember is quickly approaching and  school-based speech language pathologists (SLPs) are preparing to go back to work. Many of them are looking to update their arsenal of speech and language materials for the upcoming academic school year.

With that in mind, I wanted to update my readers regarding all the new products I have recently created with a focus on assessment and treatment in speech language pathology.

My most recent product Assessment of Adolescents with Language and Literacy Impairments in Speech Language Pathology  is a 130-slide pdf download which discusses how to effectively select assessment materials in order to conduct comprehensive evaluations of adolescents with suspected language and literacy disorders. It contains embedded links to ALL the books and research articles used in the development of this product.

Effective Reading Instruction Strategies for Intellectually Impaired Students is a 50-slide downloadable presentation in pdf format which describes how speech-language pathologists (SLPs) trained in assessment and intervention of literacy disorders (reading, spelling, and writing) can teach phonological awareness, phonics, as well as reading fluency skills to children with mild-moderate intellectual disabilities. It reviews the research on reading interventions conducted with children with intellectual disabilities, lists components of effective reading instruction as well as explains how to incorporate components of reading instruction into language therapy sessions.

Dysgraphia Checklist for School-Aged Children helps to identify the students’ specific written language deficits who may require further assessment and treatment services to improve their written abilities.

Processing Disorders: Controversial Aspects of Diagnosis and Treatment is a 28-slide downloadable pdf presentation which provides an introduction to processing disorders.  It describes the diversity of ‘APD’ symptoms as well as explains the current controversies pertaining to the validity of the ‘APD’ diagnosis.  It also discusses how the label “processing difficulties” often masks true language and learning deficits in students which require appropriate language and literacy assessment and targeted intervention services.

Checklist for Identification of Speech Language Disorders in Bilingual and Multicultural Children was created to assist Speech Language Pathologists (SLPs) and Teachers in the decision-making process of how to appropriately identify bilingual and multicultural children who present with speech-language delay/deficits (vs. a language difference), for the purpose of initiating a formal speech-language-literacy evaluation.  The goal is to ensure that educational professionals are appropriately identifying bilingual children for assessment and service provision due to legitimate speech language deficits/concerns, and are not over-identifying students because they speak multiple languages or because they come from low socioeconomic backgrounds.

Comprehensive Assessment and Treatment of Literacy Disorders in Speech-Language Pathology is a 125 slide presentation which describes how speech-language pathologists can effectively assess and treat children with literacy disorders, (reading, spelling, and writing deficits including dyslexia) from preschool through adolescence.  It explains the impact of language disorders on literacy development, lists formal and informal assessment instruments and procedures, as well as describes the importance of assessing higher order language skills for literacy purposes. It reviews components of effective reading instruction including phonological awareness, orthographic knowledge, vocabulary awareness,  morphological awareness, as well as reading fluency and comprehension. Finally, it provides recommendations on how components of effective reading instruction can be cohesively integrated into speech-language therapy sessions in order to improve literacy abilities of children with language disorders and learning disabilities.

Improving critical thinking via picture booksImproving Critical Thinking Skills via Picture Books in Children with Language Disorders is a partial 30-slide presentation which discusses effective instructional strategies for teaching language disordered children critical thinking skills via the use of picture books utilizing both the Original (1956) and Revised (2001) Bloom’s Taxonomy: Cognitive Domain which encompasses the (R) categories of remembering, understanding, applying, analyzing, evaluating and creating.

from wordless books to reading From Wordless Picture Books to Reading Instruction: Effective Strategies for SLPs Working with Intellectually Impaired Students is a full 92 slide presentation which discusses how to address the development of critical thinking skills through a variety of picture books  utilizing the framework outlined in Bloom’s Taxonomy: Cognitive Domain which encompasses the categories of knowledge, comprehension, application, analysis, synthesis, and evaluation in children with intellectual impairments. It shares a number of similarities with the above product as it also reviews components of effective reading instruction for children with language and intellectual disabilities as well as provides recommendations on how to integrate reading instruction effectively into speech-language therapy sessions.

Best Practices in Bilingual LiteracyBest Practices in Bilingual Literacy Assessments and Interventions is a 105 slide presentation which focuses on how bilingual speech-language pathologists (SLPs) can effectively assess and intervene with simultaneously bilingual and multicultural children (with stronger academic English language skills) diagnosed with linguistically-based literacy impairments. Topics include components of effective literacy assessments for simultaneously bilingual children (with stronger English abilities), best instructional literacy practices, translanguaging support strategies, critical questions relevant to the provision of effective interventions, as well as use of accommodations, modifications and compensatory strategies for improvement of bilingual students’ performance in social and academic settings.

Comprehensive Literacy Checklist For School-Aged Children was created to assist Speech Language Pathologists (SLPs) in the decision-making process of how to identify deficit areas and select assessment instruments to prioritize a literacy assessment for school aged children. The goal is to eliminate administration of unnecessary or irrelevant tests and focus on the administration of instruments directly targeting the specific areas of difficulty that the student presents with.

You can find these and other products in my online store (HERE). Wishing all of you a highly successful and rewarding school year!

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Treatment of Children with “APD”: What SLPs Need to Know

Free stock photo of people, woman, cute, playingIn recent years there has been an increase in research on the subject of diagnosis and treatment of Auditory Processing Disorders (APD), formerly known as Central Auditory Processing Disorders or CAPD.

More and more studies in the fields of audiology and speech-language pathology began confirming the lack of validity of APD as a standalone (or useful) diagnosis. To illustrate, in June 2015, the American Journal of Audiology published an article by David DeBonis entitled: “It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children.” In this article, DeBonis pointed out numerous inconsistencies involved in APD testing and concluded that “routine use of APD test protocols cannot be supported” and that [APD] “intervention needs to be contextualized and functional” (DeBonis, 2015, p. 124)

Image result for time to rethink quotesFurthermore, in April 2017, an article entitled: “AAA (2010) CAPD clinical practice guidelines: need for an update” (also written by DeBonnis) concluded that the “AAA CAPD guidance document will need to be updated and re-conceptualised in order to provide meaningful guidance for clinicians” due to the fact that the “AAA document … does not reflect the current literature, fails to help clinicians understand for whom auditory processing testing and intervention would be most useful, includes contradictory suggestions which reduce clarity and appears to avoid conclusions that might cast the CAPD construct in a negative light. It also does not include input from diverse affected groups. All of these reduce the document’s credibility.” 

Image result for systematic reviewIn April 2016, de Wit and colleagues published a systematic review in the Journal of Speech, Language, and Hearing ResearchThey reviewed research studies which described the characteristics of APD in children to determine whether these characteristics merited a label of a distinct clinical disorder vs. being representative of other disorders.  After a search of 6 databases, they chose 48 studies which satisfied appropriate inclusion criteria. Unfortunately, they unearthed only one study with strong methodological quality. Even more disappointing was that the children in these studies 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” (de Wit et al., 2016, p. 384).  In other words, none of the reviewed studies had conclusively proven that APD was a distinct clinical disorder.  Instead, these studies showed that the children diagnosed with APD exhibited language-based deficits. In other words, the diagnosis of APD did not reveal any new information regarding the child beyond the fact that s/he is in great need of a comprehensive language assessment in order to determine which language-based interventions s/he would optimally benefit from.

Now, it is important to reiterate that students diagnosed with “APD” present with legitimate symptomology (e.g., difficulty processing language, difficulty organizing narratives, difficulty decoding text, etc.). However, all the research to date indicates that these symptoms are indicative of broader language-based deficits, which require targeted language/literacy-based interventions rather than recommendations for specific prescriptive programs (e.g., CAPDOTS, Fast ForWord, etc.) or mere in-school accommodations.

Image result for dig deeper quotesUnfortunately, on numerous occasions when the students do receive the diagnosis of APDthe testing does not “dig further,” which leads to many of them not receiving appropriate comprehensive language-literacy assessments.  Furthermore, APD then becomes the “primary” diagnosis for the student, which places SLPs in situations in which they must address inappropriate therapeutic targets based on an audiologist’s recommendations.  Even worse, in many of these situations, the diagnosis of APD limits the provision of appropriate language-based services to the student.

Since the APD controversy has been going on for years with no end in sight despite the mounting evidence pointing to the lack of its validity, we know that SLPs will continue to have students on their caseloads diagnosed with APD. Thus, the aim of today’s post is to offer some constructive suggestions for SLPs who are asked to assess and treat students with “confirmed” or suspected APD.

The first suggestion comes directly from Dr. Alan Kamhi, who states: “Do not assume that a child who has been diagnosed with APD needs to be treated any differently than children who have been diagnosed with language and learning disabilities” (Kamhi, 2011, p. 270).  In other words, if one carefully analyzes the child’s so-called processing issues, one will quickly realize that those issues are not related to the processing of auditory input  (auditory domain) since the child is not processing tones, hoots, or clicks, etc. but rather has difficulty processing speech and language (language domain).

If a student with confirmed or suspected APD is referred to an SLP, it is important, to begin with formal and informal assessments of language and literacy knowledge and skills. (details HERE)   SLPs need to “consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, language knowledge, conceptual abilities, attention, and motivation (Kamhi & Wallach, 2012).

Image result for language goalsAfter performing a comprehensive assessment, SLPs need to formulate language goals based on determined areas of weaknesses. Please note that a systematic review by Fey and colleagues (2011) found no compelling evidence that auditory interventions provided any unique benefit to auditory, language, or academic outcomes for children with diagnoses of (C)APD or language disorder. As such it’s important to avoid formulating goals focused on targeting isolated processing abilities like auditory discrimination, auditory sequencing, recognizing speech in noise, etc., because these processing abilities have not been shown to improve language and literacy skills (Fey et al., 2011; Kamhi, 2011).

Instead, SLPs need to target we need to focus on the language underpinnings of the above skills and turn them into language and literacy goals. For example, if the child has difficulty recognizing speech in noise, improve the child’s knowledge and access to specific vocabulary words.  This will help the child detect the word when the auditory information is degraded.  Child presents with phonemic awareness deficits? Figure out where in the hierarchy of phonemic awareness their strengths and weaknesses lie and formulate goals based on the remaining areas in need of mastery.  Received a description of the child’s deficits from the audiologist in an accompanying report? Turn them into language goals as well!  Turn “prosodic deficits” or difficulty understanding the intent of verbal messages into “listening for details and main ideas in stories” goals.   In other words, figure out the language correlate to the ‘auditory processing’ deficit and replace it.

Image result for quackeryIt is easy to understand the appeal of using dubious practices which promise a quick fix for our student’s “APD deficits” instead of labor-intensive language therapy sessions. But one must also keep something else in mind as well:   Acquiring higher order language abilities takes a significant period of time, especially for those students whose skills and abilities are significantly below age-matched peers.

APD Summary 

  1. There is still no compelling evidence that APD is a stand-alone diagnosis with clear diagnostic criteria.
  2. There is still no compelling evidence that auditory deficits are a “significant risk factor for  language or academic performance.”
  3. 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).
  4. APD deficits are language based deficits which accompany a host of developmental conditions ranging from developmental language disorders to learning disabilities, etc.
  5. SLPs should perform comprehensive language and literacy assessments of children diagnosed with APD.
  6. SLPs should target   literacy goals.
  7. 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).
  8. SLPs should be wary of any prescriptive programs offering APD “interventions” and instead focus on improving children’s abilities for functional communication including listening, speaking, reading, and writing (see Wallach, 2014: Improving Clinical Practice: A School-Age and School-Based Perspective).  This article  “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.”

There you have it!  Students diagnosed with APD are best served by targeting the language and literacy problems that are affecting their performance in school. 

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C/APD Update: New Developments on an Old Controversy

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:

  1. The clinical entity must possess an unambiguous definition (Sydenham, 1676; FDA, 2000)
  2. It must represent a homogeneous patient group (Sydenham, 1676; Guttentag, 1949, 1950; FDA, 2000)
  3. It must represent a perceived limitation (Guttentag, 1949)
  4. 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 ratheron improvements on complex listening and academic tasks“. (p.373) As such,

  1. “This limited definition of effectiveness leads to statements about the impact of certain interventions that can be misinterpreted at best and possibly misleading.”
  2. “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 asThe 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.

Conclusions:

  • 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!

References:

(arranged in chronological order of citation in the blog post):

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New Product Giveaway: Comprehensive Literacy Checklist For School-Aged Children

I wanted to start the new year right by giving away a few copies of a new checklist I recently created entitled: “Comprehensive Literacy Checklist For School-Aged Children“.

It was created to assist Speech Language Pathologists (SLPs) in the decision-making process of how to identify deficit areas and select assessment instruments to prioritize a literacy assessment for school aged children.

The goal is to eliminate administration of unnecessary or irrelevant tests and focus on the administration of instruments directly targeting the specific areas of difficulty that the student presents with.

*For the purpose of this product, the term “literacy checklist” rather than “dyslexia checklist” is used throughout this document to refer to any deficits in the areas of reading, writing, and spelling that the child may present with in order to identify any possible difficulties the child may present with, in the areas of literacy as well as language.

This checklist can be used for multiple purposes.

1. To identify areas of deficits the child presents with for targeted assessment purposes

2. To highlight areas of strengths (rather than deficits only) the child presents with pre or post intervention

3. To highlight residual deficits for intervention purpose in children already receiving therapy services without further reassessment

Checklist Contents:

  • Page 1 Title
  • Page 2 Directions
  • Pages 3-9 Checklist
  • Page 10 Select Tests of Reading, Spelling, and Writing for School-Aged Children
  • Pages 11-12 Helpful Smart Speech Therapy Materials

Checklist Areas:

  1. AT RISK FAMILY HISTORY
  2. AT RISK DEVELOPMENTAL HISTORY
  3. BEHAVIORAL MANIFESTATIONS 
  4. LEARNING DEFICITS   
    1. Memory for Sequences
    2. Vocabulary Knowledge
    3. Narrative Production
    4. Phonological Awareness
    5. Phonics
    6. Morphological Awareness
    7. Reading Fluency
    8. Reading Comprehension
    9. Spelling
    10. Writing Conventions
    11. Writing Composition 
    12. Handwriting

You can find this product in my online store HERE.

Would you like to check it out in action? I’ll be giving away two copies of the checklist in a Rafflecopter Giveaway to two winners.  So enter today to win your own copy!

a Rafflecopter giveaway

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Review of the Test of Integrated Language and Literacy (TILLS)

The Test of Integrated Language & Literacy Skills (TILLS) is an assessment of oral and written language abilities in students 6–18 years of age. Published in the Fall 2015, it is  unique in the way that it is aimed to thoroughly assess skills  such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school age children.   As I have been using this test since the time it was published,  I wanted to take an opportunity today to share just a few of my impressions of this assessment.

               

First, a little background on why I chose to purchase this test  so shortly after I had purchased the Clinical Evaluation of Language Fundamentals – 5 (CELF-5).   Soon after I started using the CELF-5  I noticed that  it tended to considerably overinflate my students’ scores  on a variety of its subtests.  In fact,  I noticed that unless a student had a fairly severe degree of impairment,  the majority of his/her scores  came out either low/slightly below average (click for more info on why this was happening HERE, HEREor HERE). Consequently,  I was excited to hear regarding TILLS development, almost simultaneously through ASHA as well as SPELL-Links ListServe.   I was particularly happy  because I knew some of this test’s developers (e.g., Dr. Elena Plante, Dr. Nickola Nelson) have published solid research in the areas of  psychometrics and literacy respectively.

According to the TILLS developers it has been standardized for 3 purposes:

  • to identify language and literacy disorders
  • to document patterns of relative strengths and weaknesses
  • to track changes in language and literacy skills over time

The testing subtests can be administered in isolation (with the exception of a few) or in its entirety.  The administration of all the 15 subtests may take approximately an hour and a half, while the administration of the core subtests typically takes ~45 mins).

Please note that there are 5 subtests that should not be administered to students 6;0-6;5 years of age because many typically developing students are still mastering the required skills.

  • Subtest 5 – Nonword Spelling
  • Subtest 7 – Reading Comprehension
  • Subtest 10 – Nonword Reading
  • Subtest 11 – Reading Fluency
  • Subtest 12 – Written Expression

However,  if needed, there are several tests of early reading and writing abilities which are available for assessment of children under 6:5 years of age with suspected literacy deficits (e.g., TERA-3: Test of Early Reading Ability–Third Edition; Test of Early Written Language, Third Edition-TEWL-3, etc.).

Let’s move on to take a deeper look at its subtests. Please note that for the purposes of this review all images came directly from and are the property of Brookes Publishing Co (clicking on each of the below images will take you directly to their source).

TILLS-subtest-1-vocabulary-awareness1. Vocabulary Awareness (VA) (description above) requires students to display considerable linguistic and cognitive flexibility in order to earn an average score.    It works great in teasing out students with weak vocabulary knowledge and use,   as well as students who are unable to  quickly and effectively analyze  words  for deeper meaning and come up with effective definitions of all possible word associations. Be mindful of the fact that  even though the words are presented to the students in written format in the stimulus book, the examiner is still expected to read  all the words to the students. Consequently,  students with good vocabulary knowledge  and strong oral language abilities  can still pass this subtest  despite the presence of significant reading weaknesses. Recommendation:  I suggest informally  checking the student’s  word reading abilities  by asking them to read of all the words, before reading all the word choices to them.   This way  you can informally document any word misreadings  made by the student even in the presence of an average subtest score.

TIILLS-subtest-2-phonemic-awareness

2. The Phonemic Awareness (PA) subtest (description above) requires students to  isolate and delete initial sounds in words of increasing complexity.  While this subtest does not require sound isolation and deletion in various word positions, similar to tests such as the CTOPP-2: Comprehensive Test of Phonological Processing–Second Edition  or the The Phonological Awareness Test 2 (PAT 2)  it is still a highly useful and reliable measure of  phonemic awareness (as one of many precursors to reading fluency success).  This is especially because after the initial directions are given, the student is expected to remember to isolate the initial sounds in words without any prompting from the examiner.  Thus,  this task also  indirectly tests the students’ executive function abilities in addition to their phonemic awareness skills.

TILLS-subtest-3-story-retelling

3. The Story Retelling (SR) subtest (description above) requires students to do just that retell a story. Be mindful of the fact that the presented stories have reduced complexity. Thus, unless the students possess  significant retelling deficits, the above subtest  may not capture their true retelling abilities. Recommendation:  Consider supplementing this subtest  with informal narrative measures. For younger children (kindergarten and first grade) I recommend using wordless picture books to perform a dynamic assessment of their retelling abilities following a clinician’s narrative model (e.g., HERE).  For early elementary aged children (grades 2 and up), I recommend using picture books, which are first read to and then retold by the students with the benefit of pictorial but not written support. Finally, for upper elementary aged children (grades 4 and up), it may be helpful for the students to retell a book or a movie seen recently (or liked significantly) by them without the benefit of visual support all together (e.g., HERE).

TILLS-subtest-4-nonword-repetition

4. The Nonword Repetition (NR) subtest (description above) requires students to repeat nonsense words of increasing length and complexity. Weaknesses in the area of nonword repetition have consistently been associated with language impairments and learning disabilities due to the task’s heavy reliance on phonological segmentation as well as phonological and lexical knowledge (Leclercq, Maillart, Majerus, 2013). Thus, both monolingual and simultaneously bilingual children with language and literacy impairments will be observed to present with patterns of segment substitutions (subtle substitutions of sounds and syllables in presented nonsense words) as well as segment deletions of nonword sequences more than 2-3 or 3-4 syllables in length (depending on the child’s age).

TILLS-subtest-5-nonword-spelling

5. The Nonword Spelling (NS) subtest (description above) requires the students to spell nonwords from the Nonword Repetition (NR) subtest. Consequently, the Nonword Repetition (NR) subtest needs to be administered prior to the administration of this subtest in the same assessment session.  In contrast to the real-word spelling tasks,  students cannot memorize the spelling  of the presented words,  which are still bound by  orthographic and phonotactic constraints of the English language.   While this is a highly useful subtest,  is important to note that simultaneously bilingual children may present with decreased scores due to vowel errors.   Consequently,  it is important to analyze subtest results in order to determine whether dialectal differences rather than a presence of an actual disorder is responsible for the error patterns.

TILLS-subtest-6-listening-comprehension

6. The  Listening Comprehension (LC) subtest (description above) requires the students to listen to short stories  and then definitively answer story questions via available answer choices, which include: “Yes”, “No’, and “Maybe”. This subtest also indirectly measures the students’ metalinguistic awareness skills as they are needed to detect when the text does not provide sufficient information to answer a particular question definitively (e.g., “Maybe” response may be called for).  Be mindful of the fact that because the students are not expected to provide sentential responses  to questions it may be important to supplement subtest administration with another listening comprehension assessment. Tests such as the Listening Comprehension Test-2 (LCT-2), the Listening Comprehension Test-Adolescent (LCT-A),  or the Executive Function Test-Elementary (EFT-E)  may be useful  if  language processing and listening comprehension deficits are suspected or reported by parents or teachers. This is particularly important  to do with students who may be ‘good guessers’ but who are also reported to present with word-finding difficulties at sentence and discourse levels. 

TILLS-subtest-7-reading-comprehension

7. The Reading Comprehension (RC) subtest (description above) requires the students to  read short story and answer story questions in “Yes”, “No’, and “Maybe”  format.   This subtest is not stand alone and must be administered immediately following the administration the Listening Comprehension subtest. The student is asked to read the first story out loud in order to determine whether s/he can proceed with taking this subtest or discontinue due to being an emergent reader. The criterion for administration of the subtest is making 7 errors during the reading of the first story and its accompanying questions. Unfortunately,  in my clinical experience this subtest  is not always accurate at identifying children with reading-based deficits.

While I find it terrific for students with severe-profound reading deficits and/or below average IQ, a number of my students with average IQ and moderately impaired reading skills managed to pass it via a combination of guessing and luck despite being observed to misread aloud between 40-60% of the presented words. Be mindful of the fact that typically  such students may have up to 5-6  errors during the reading of the first story. Thus, according to administration guidelines these students will be allowed to proceed and take this subtest.  They will then continue to make text misreadings  during each story presentation (you will know that by asking them to read each story aloud vs. silently).   However,  because the response mode is in definitive (“Yes”, “No’, and “Maybe”) vs. open ended question format,  a number of these students  will earn average scores by being successful guessers. Recommendation:  I highly recommend supplementing the administration of this subtest with grade level (or below grade level) texts (see HERE and/or HERE),  to assess the student’s reading comprehension informally.

I present a full  one page text to the students and ask them to read it to me in its entirety.   I audio/video record  the student’s reading for further analysis (see Reading Fluency section below).   After the  completion of the story I ask  the student questions with a focus on main idea comprehension and vocabulary definitions.   I also ask questions pertaining to story details.   Depending on the student’s age  I may ask them  abstract/ factual text questions with and without text access.  Overall, I find that informal administration of grade level (or even below grade-level) texts coupled with the administration of standardized reading tests provides me with a significantly better understanding of the student’s reading comprehension abilities rather than administration of standardized reading tests alone.

TILLS-subtest-8-following-directions

8. The Following Directions (FD) subtest (description above) measures the student’s ability to execute directions of increasing length and complexity.  It measures the student’s short-term, immediate and working memory, as well as their language comprehension.  What is interesting about the administration of this subtest is that the graphic symbols (e.g., objects, shapes, letter and numbers etc.) the student is asked to modify remain covered as the instructions are given (to prevent visual rehearsal). After being presented with the oral instruction the students are expected to move the card covering the stimuli and then to executive the visual-spatial, directional, sequential, and logical if–then the instructions  by marking them on the response form.  The fact that the visual stimuli remains covered until the last moment increases the demands on the student’s memory and comprehension.  The subtest was created to simulate teacher’s use of procedural language (giving directions) in classroom setting (as per developers).

TILLS-subtest-9-delayed-story-retelling

9. The Delayed Story Retelling (DSR) subtest (description above) needs to be administered to the students during the same session as the Story Retelling (SR) subtest, approximately 20 minutes after the SR subtest administration.  Despite the relatively short passage of time between both subtests, it is considered to be a measure of long-term memory as related to narrative retelling of reduced complexity. Here, the examiner can compare student’s performance to determine whether the student did better or worse on either of these measures (e.g., recalled more information after a period of time passed vs. immediately after being read the story).  However, as mentioned previously, some students may recall this previously presented story fairly accurately and as a result may obtain an average score despite a history of teacher/parent reported  long-term memory limitations.  Consequently, it may be important for the examiner to supplement the administration of this subtest with a recall of a movie/book recently seen/read by the student (a few days ago) in order to compare both performances and note any weaknesses/limitations.

TILLS-subtest-10-nonword-reading

10. The Nonword Reading (NR) subtest (description above) requires students to decode nonsense words of increasing length and complexity. What I love about this subtest is that the students are unable to effectively guess words (as many tend to routinely do when presented with real words). Consequently, the presentation of this subtest will tease out which students have good letter/sound correspondence abilities as well as solid orthographic, morphological and phonological awareness skills and which ones only memorized sight words and are now having difficulty decoding unfamiliar words as a result.      TILLS-subtest-11-reading-fluency

11. The Reading Fluency (RF) subtest (description above) requires students to efficiently read facts which make up simple stories fluently and correctly.  Here are the key to attaining an average score is accuracy and automaticity.  In contrast to the previous subtest, the words are now presented in meaningful simple syntactic contexts.

It is important to note that the Reading Fluency subtest of the TILLS has a negatively skewed distribution. As per authors, “a large number of typically developing students do extremely well on this subtest and a much smaller number of students do quite poorly.”

Thus, “the mean is to the left of the mode” (see publisher’s image below). This is why a student could earn an average standard score (near the mean) and a low percentile rank when true percentiles are used rather than NCE percentiles (Normal Curve Equivalent). Tills Q&A – Negative Skew

Consequently under certain conditions (See HERE) the percentile rank (vs. the NCE percentile) will be a more accurate representation of the student’s ability on this subtest.

Indeed, due to the reduced complexity of the presented words some students (especially younger elementary aged) may obtain average scores and still present with serious reading fluency deficits.  

I frequently see that in students with average IQ and go to long-term memory, who by second and third grades have managed to memorize an admirable number of sight words due to which their deficits in the areas of reading appeared to be minimized.  Recommendation: If you suspect that your student belongs to the above category I highly recommend supplementing this subtest with an informal measure of reading fluency.  This can be done by presenting to the student a grade level text (I find science and social studies texts particularly useful for this purpose) and asking them to read several paragraphs from it (see HERE and/or HERE).

As the students are reading  I calculate their reading fluency by counting the number of words they read per minute.  I find it very useful as it allows me to better understand their reading profile (e.g, fast/inaccurate reader, slow/inaccurate reader, slow accurate reader, fast/accurate reader).   As the student is reading I note their pauses, misreadings, word-attack skills and the like. Then, I write a summary comparing the students reading fluency on both standardized and informal assessment measures in order to document students strengths and limitations.

TILLS-subtest-12-written-expression

12. The Written Expression (WE) subtest (description above) needs to be administered to the students immediately after the administration of the Reading Fluency (RF) subtest because the student is expected to integrate a series of facts presented in the RF subtest into their writing sample. There are 4 stories in total for the 4 different age groups.

The examiner needs to show the student a different story which integrates simple facts into a coherent narrative. After the examiner reads that simple story to the students s/he is expected to tell the students that the story is  okay, but “sounds kind of “choppy.” They then need to show the student an example of how they could put the facts together in a way that sounds more interesting and less choppy  by combining sentences (see below). Finally, the examiner will ask the students to rewrite the story presented to them in a similar manner (e.g, “less choppy and more interesting.”)

tills

After the student finishes his/her story, the examiner will analyze it and generate the following scores: a discourse score, a sentence score, and a word score. Detailed instructions as well as the Examiner’s Practice Workbook are provided to assist with scoring as it takes a bit of training as well as trial and error to complete it, especially if the examiners are not familiar with certain procedures (e.g., calculating T-units).

Full disclosure: Because the above subtest is still essentially sentence combining, I have only used this subtest a handful of times with my students. Typically when I’ve used it in the past, most of my students fell in two categories: those who failed it completely by either copying text word  for word, failing to generate any written output etc. or those who passed it with flying colors but still presented with notable written output deficits. Consequently, I’ve replaced Written Expression subtest administration with the administration of written standardized tests, which I supplement with an informal grade level expository, persuasive, or narrative writing samples.

Having said that many clinicians may not have the access to other standardized written assessments, or lack the time to administer entire standardized written measures (which may frequently take between 60 to 90 minutes of administration time). Consequently, in the absence of other standardized writing assessments, this subtest can be effectively used to gauge the student’s basic writing abilities, and if needed effectively supplemented by informal writing measures (mentioned above).

TILLS-subtest-13-social-communication

13. The Social Communication (SC) subtest (description above) assesses the students’ ability to understand vocabulary associated with communicative intentions in social situations. It requires students to comprehend how people with certain characteristics might respond in social situations by formulating responses which fit the social contexts of those situations. Essentially students become actors who need to act out particular scenes while viewing select words presented to them.

Full disclosure: Similar to my infrequent administration of the Written Expression subtest, I have also administered this subtest very infrequently to students.  Here is why.

I am an SLP who works full-time in a psychiatric hospital with children diagnosed with significant psychiatric impairments and concomitant language and literacy deficits.  As a result, a significant portion of my job involves comprehensive social communication assessments to catalog my students’ significant deficits in this area. Yet, past administration of this subtest showed me that number of my students can pass this subtest quite easily despite presenting with notable and easily evidenced social communication deficits. Consequently, I prefer the administration of comprehensive social communication testing when working with children in my hospital based program or in my private practice, where I perform independent comprehensive evaluations of language and literacy (IEEs).

Again, as I’ve previously mentioned many clinicians may not have the access to other standardized social communication assessments, or lack the time to administer entire standardized written measures. Consequently, in the absence of other social communication assessments, this subtest can be used to get a baseline of the student’s basic social communication abilities, and then be supplemented with informal social communication measures such as the Informal Social Thinking Dynamic Assessment Protocol (ISTDAP) or observational social pragmatic checklists

TILLS-subtest-14-digit-span-forward

14.  The Digit Span Forward (DSF) subtest (description above) is a relatively isolated  measure  of short term and verbal working memory ( it minimizes demands on other aspects of language such as syntax or vocabulary).

TILLS-subtest-15-digit-span-backward

15.  The Digit Span Backward (DSB) subtest (description above) assesses the student’s working memory and requires the student to mentally manipulate the presented stimuli in reverse order. It allows examiner to observe the strategies (e.g. verbal rehearsal, visual imagery, etc.) the students are using to aid themselves in the process.  Please note that the Digit Span Forward subtest must be administered immediately before the administration of this subtest.

SLPs who have used tests such as the Clinical Evaluation of Language Fundamentals – 5 (CELF-5) or the Test of Auditory Processing Skills – Third Edition (TAPS-3) should be highly familiar with both subtests as they are fairly standard measures of certain aspects of memory across the board.

To continue, in addition to the presence of subtests which assess the students literacy abilities, the TILLS also possesses a number of interesting features.

For starters, the TILLS Easy Score, which allows the examiners to use their scoring online. It is incredibly easy and effective. After clicking on the link and filling out the preliminary demographic information, all the examiner needs to do is to plug in this subtest raw scores, the system does the rest. After the raw scores are plugged in, the system will generate a PDF document with all the data which includes (but is not limited to) standard scores, percentile ranks, as well as a variety of composite and core scores. The examiner can then save the PDF on their device (laptop, PC, tablet etc.) for further analysis.

The there is the quadrant model. According to the TILLS sampler (HERE)  “it allows the examiners to assess and compare students’ language-literacy skills at the sound/word level and the sentence/ discourse level across the four oral and written modalities—listening, speaking, reading, and writing” and then create “meaningful profiles of oral and written language skills that will help you understand the strengths and needs of individual students and communicate about them in a meaningful way with teachers, parents, and students. (pg. 21)”

tills quadrant model

Then there is the Student Language Scale (SLS) which is a one page checklist parents,  teachers (and even students) can fill out to informally identify language and literacy based strengths and weaknesses. It  allows for meaningful input from multiple sources regarding the students performance (as per IDEA 2004) and can be used not just with TILLS but with other tests or in even isolation (as per developers).

Furthermore according to the developers, because the normative sample included several special needs populations, the TILLS can be used with students diagnosed with ASD,  deaf or hard of hearing (see caveat), as well as intellectual disabilities (as long as they are functioning age 6 and above developmentally).

According to the developers the TILLS is aligned with Common Core Standards and can be administered as frequently as two times a year for progress monitoring (min of 6 mos post 1st administration).

With respect to bilingualism examiners can use it with caution with simultaneous English learners but not with sequential English learners (see further explanations HERE).   Translations of TILLS are definitely not allowed as they will undermine test validity and reliability.

So there you have it these are just some of my very few impressions regarding this test.  Now to some of you may notice that I spend a significant amount of time pointing out some of the tests limitations. However, it is very important to note that we have research that indicates that there is no such thing as a “perfect standardized test” (see HERE for more information).   All standardized tests have their limitations

Having said that, I think that TILLS is a PHENOMENAL addition to the standardized testing market, as it TRULY appears to assess not just language but also literacy abilities of the students on our caseloads.

That’s all from me; however, before signing off I’d like to provide you with more resources and information, which can be reviewed in reference to TILLS.  For starters, take a look at Brookes Publishing TILLS resources.  These include (but are not limited to) TILLS FAQ, TILLS Easy-Score, TILLS Correction Document, as well as 3 FREE TILLS Webinars.   There’s also a Facebook Page dedicated exclusively to TILLS updates (HERE).

But that’s not all. Dr. Nelson and her colleagues have been tirelessly lecturing about the TILLS for a number of years, and many of their past lectures and presentations are available on the ASHA website as well as on the web (e.g., HERE, HERE, HERE, etc). Take a look at them as they contain far more in-depth information regarding the development and implementation of this groundbreaking assessment.

Disclaimer:  I did not receive a complimentary copy of this assessment for review nor have I received any encouragement or compensation from either Brookes Publishing  or any of the TILLS developers to write it.  All images of this test are direct property of Brookes Publishing (when clicked on all the images direct the user to the Brookes Publishing website) and were used in this post for illustrative purposes only.

References: 

Leclercq A, Maillart C, Majerus S. (2013) Nonword repetition problems in children with SLI: A deficit in accessing long-term linguistic representations? Topics in Language Disorders. 33 (3) 238-254.

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If It’s NOT CAPD Then Where do SLPs Go From There?

Image result for processingIn July 2015 I wrote a blog post entitled: “Why (C) APD Diagnosis is NOT Valid!” citing the latest research literature to explain that the controversial diagnosis of (C)APD tends to

a) detract from understanding that the child presents with legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development

b) may result in the above deficits not getting adequately addressed due to the provision of controversial APD treatments

To CLARIFY, I was NOT trying to disprove that the processing deficits exhibited by the children diagnosed with “(C)APD” were not REAL. Rather I was trying to point out that these processing deficits are of neurolinguistic origin and as such need to be addressed from a linguistic rather than ‘auditory’ standpoint.

In other words, if one carefully analyzes the child’s so-called processing issues, one will quickly realize that those issues are not related to the processing of auditory input  (auditory domain) since the child is not processing tones, hoots, or clicks, etc. but rather has difficulty processing speech and language (linguistic domain).

Let us review two major APD Models: The Buffalo Model (Katz) and the Bellis/Ferre Model, to support the above stance.

iStock_000009897175XSmall-1-300x300

The Buffalo Model by Jack Katz, PhD contains 4 major categories:

1. The Decoding Category – refers to the ability to quickly and accurately process speech, most importantly at the phonemic level (Since this involves speech sounds then this has nothing to do with the processing of auditory stimuli. In other words deficits in this area are of linguistic nature and the highly correlated with reading deficits characterized by weak/deficient phonemic awareness abilities/poor emergent reading abilities).

Here are a few examples of so-called “decoding” deficits:

  • Difficulty with processing what is heard accurately and quickly; tends to respond more slowly (indicative of weak language abilities)
  • Problems keeping up with the flow of communication and running discourse (indicative of weak language abilities)
  • Problems processing at a phonemic level (e.g, can’t blend ‘t,’ ‘u’ and ‘b’ together to make the word ‘tub’) (indicative of phonemic awareness deficits)
  • Trouble reading and spelling (reading and writing deficits rather then APD)
  • Receptive language problems and impairments in discrimination, closure abilities and temporal resolution (this one just explains itself)

2. Tolerance-Fading Memory (TFM) Category – refers to two skills that are often found together: “tolerance” – understanding speech in noise (processing of language) and “fading memory” – auditory short-term or working memory (memory= higher level cognitive skills vs. a pure auditory entity).

Here are a few examples of given of tolerance-fading memory deficits:

  1. Difficulty blocking out background noise so child’s performance suffers in a noisy classroom environment, may be labeled as distractible (clearly describes the child with poor language comprehension)
  2. Linked to poor reading comprehension, oral and written expression, poor short-term memory (in other words describes a learning disability)

3. Integration category 

  • difficulty bringing in information from different modalities, such as receiving auditory and visual information at the same time; these children are often labeled as learning disabled or even dyslexic (this one just explains itself)
  • They may be poor readers, have trouble with spelling, and exhibit difficulty with multimodal tasks (clearly indicative of reading and writing deficits or students which will often get classified in the schools with specific learning disability)

4. Organization –disorganized thinking; sequencing errors (This appears to be indicative of the social communication / executive function deficits, as well as word-retrieval deficits)

Another major APD model is the Bellis/Ferre Model, which divides the above four categories into the following subtypes:

  • Primary subtype
  1. Auditory decoding – listening difficulties in noisy environments
  2. Integration deficit – problems with tasks requiring both cerebral hemispheres to cooperate
  3. Prosodic deficits- difficulty understanding the intent of verbal messages
  • Secondary
  1. Associative deficits- receptive language disorder
  2. Output organization deficits- attention and/or executive function disorder- might also be caused by an auditory efferent dysfunction

Similar to the Buffalo model, the Bellis/Ferre Model, describes deficits of linguistic versus auditory nature many of which are characteristic of a learning disability.

testing

Consequently, if an SLP is referred a student with confirmed or suspected (C)APD, the first thing they should do is to administer a comprehensive battery of testing to determine the scope of the student’s linguistic deficits. To test general language abilities, consider using the Test of Integrated Language & Literacy Skills (TILLS) (Review HERE). But SLPs shouldn’t just stop there! They need to dig deeper to make sure that the following major areas of language are assessed:

The above list doesn’t even reference assessment of Reading, Writing, and Spelling, all areas which play a crucial role in academic language as any deficits displayed in those areas may also present as CAPD symptoms.  If literacy testing is not performed, it is still important for SLPs to review and seriously consider the results of learning evaluations in order to see the whole child and not just their limited functioning in select areas of oral language comprehension, expression, and use.

It is very important for SLPs to understand that without a comprehensive language and literacy assessment of deficit areas it is very difficult to adequately address the student’s linguistically-based deficits! Thus, if testing shortcuts are taken then the referral of students diagnosed with the (C)APD will not cease, and SLPs will continue to be in the dark regarding which goals should be addressed with these students in therapy.

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Professional Consultation Services for Speech Language Pathologists

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

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

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

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

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

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

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

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

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

Below is the recent professional consultation testimonial.

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

Tatyana,

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

Last year an esteemed colleague, Dr. Roseberry-McKibbin posed this question in our Bilingual SLPs Facebook Group:  “Is anyone working on morphological awareness in therapy with ELLs (English Language Learners) with language disorders?”

Her question got me thinking: “How much time do I spend on treating morphological awareness in therapy with monolingual and bilingual language disordered clients?” The answer did not make me happy!

So what is morphological awareness and why is it important to address when treating monolingual and bilingual  language impaired students?

Morphemes are the smallest units of language that carry meaning. They can be free (stand alone words such as ‘fair’, ‘toy’, or ‘pretty’) or bound (containing prefixes and suffixes that change word meanings – ‘unfair’ or ‘prettier’).

Morphological awareness refers to a ‘‘conscious awareness of the morphemic structure of words and the ability to reflect on and manipulate that structure’’ (Carlisle, 1995, p. 194). Also referred to as “the study of word structure” (Carlisle, 2004), it is an ability to recognize, understand, and use affixes or word parts (prefixes, suffixes, etc) that “carry significance” when speaking as well as during reading tasks. It is a hugely important skill for building vocabulary, reading fluency and comprehension as well as spelling (Apel & Lawrence, 2011; Carlisle, 2000; Binder & Borecki, 2007; Green, 2009). 

So why is teaching morphological awareness important? Let’s take a look at some research.

Goodwin and Ahn (2010) found morphological awareness instruction to be particularly effective for children with speech, language, and/or literacy deficits. After reviewing 22 studies Bowers et al. (2010) found the most lasting effect of morphological instruction was on readers in early elementary school who struggled with literacy.

Morphological awareness instruction mediates and facilitates vocabulary acquisition leading to improved reading comprehension abilities (Bowers & Kirby, 2010; Carlisle, 2003, 2010; Guo, Roehrig, & Williams, 2011; Tong, Deacon, Kirby, Cain, & Parilla, 2011).

Unfortunately as important morphological instruction is for vocabulary building, reading fluency, reading comprehension, and spelling, it is often overlooked during the school years until it’s way too late. For example, traditionally morphological instruction only beings in late middle school or high school but research actually found that in order to be effective one should actually begin teaching it as early as first grade (Apel & Lawrence, 2011).

So now that we know that we need to target morphological instruction very early in children with language deficits, let’s talk a little bit regarding how morphological awareness can be assessed in language impaired learners.

When it comes to standardized testing, both the Test of Language Development: Intermediate – Fourth Edition (TOLD-I:4) and the Test of Adolescent and Adult Language–Fourth Edition (TOAL-4) have subtests which assess morphology as well as word derivations. However if you do not own either of these tests you can easily create non-standardized tasks to assess  morphological awareness.

Apel, Diehm, & Apel (2013) recommend multiple measures which include:  phonological awareness tasks, word level reading tasks, as well as reading comprehension tasks.

Below are direct examples of tasks from their study:

MATs

One can test morphological awareness via production or decomposition tasks. In a production task a student is asked to supply a missing word, given the root morpheme (e.g., ‘‘Sing. He is a great _____.’’ Correct response: singer).  A decomposition task asks the student to identify the correct root of a given derivation or inflection. (e.g., ‘‘Walker. How slow can she _____?’’ Correct response: walk).

Another way to test morphological awareness is through completing analogy tasks since it involves both  decomposition and production components (provide a missing word based on the presented pattern—crawl: crawled:: fly: ______ (flew).

Still another way to test morphological awareness with older students is through deconstruction tasks: Tell me what ____ word means? How do you know? (The student must explain the meaning of individual morphemes).

Finding the affix: Does the word ______ have smaller parts?

So what are the components of effective morphological instruction you might ask?

Below is an example of a ‘Morphological Awareness Intervention With Kindergarteners and First and Second Grade Students From Low SES Homes’ performed by Apel & Diehm, 2013:

Apel and Diem 2011

Here are more ways in which this can be accomplished with older children:

  • Find the root word in a longer word
  • Fix the affix (an additional element placed at the beginning or end of a root, stem, or word, or in the body of a word, to modify its meaning)
    • Affixes at the beginning of words are called “prefixes”
    • Affixes at the end of words are called “suffixes
  • Word sorts to recognize word families based on morphology or orthography
  • Explicit instruction of syllable types to recognize orthographical patterns
  • Word manipulation through blending and segmenting morphemes to further solidify patterns

Now that you know about the importance of morphological awareness, will you be incorporating it into your speech language sessions? I’d love to know!

Until then, Happy Speeching!

References:

  • Apel, K., & Diehm, E. (2013). Morphological awareness intervention with kindergarteners and first and second grade students from low SES homes: A small efficacy study. Journal of Learning Disabilities.
  • Apel, K., & Lawrence, J. (2011). Contributions of morphological awareness skills to word-level reading and spelling in first-grade children with and without speech sound disorder. Journal of Speech, Language & Hearing Research, 54, 1312–1327.
  • Apel, K., Brimo, D., Diehm, E., & Apel, L. (2013). Morphological awareness intervention with kindergarteners and first and second grade students from low SES homes: A feasibility study. Language, Speech, and Hearing Services in Schools, 44, 161-173.
  • Binder, K. & Borecki, C. (2007). The use of phonological, orthographic, and contextualinformation during reading: a comparison of adults who are learning to read and skilled adult readers. Reading and Writing, 21, 843-858.
  • Bowers, P.N., Kirby, J.R., Deacon, H.S. (2010). The effects of morphological instruction on literacy skills: A systematic review of the literature. Review of Educational Research, 80, 144-179.
  • Carlisle, J. F. (1995). Morphological awareness and early reading achievement. In L. B. Feldman (Ed.), Morphological aspects of language processing (pp. 189–209). Hillsdale, NJ: Erlbaum.
  • Carlisle, J. F. (2000). Awareness of the structure and meaning of morphologically complex words: Impact on reading. Reading and Writing: An Interdisciplinary Journal,12,169-190.
  • Carlisle, J. F. (2004). Morphological processes that influence learning to read. In C. A. Stone, E. R. Silliman, B. J. Ehren, & K. Apel (Eds.), Handbook of language and literacy. NY: Guilford Press.
  • Carlisle, J. F. (2010). An integrative review of the effects of instruction in morphological awareness on literacy achievement. Reading Research Quarterly, 45(4), 464-487.
  • Goodwin, A.P. & Ahn, S. (2010). Annals of Dyslexia, 60, 183-208.
  • Green, L. (2009). Morphology and literacy: Getting our heads in the game. Language, Speech, and Hearing Services in the schools, 40, 283-285.
  • Green, L., & Wolter, J.A. (2011, November). Morphological Awareness Intervention: Techniques for Promoting Language and Literacy Success. A symposium presentation at the annual American Speech Language Hearing Association, San Diego, CA.
  • Guo, Y., Roehrig, A. D., & Williams, R. S. (2011). The relation of morphological awareness and syntactic awareness to adults’ reading comprehension: Is vocabulary knowledge a mediating variable? Journal of Literacy Research, 43, 159-183.
  • Tong, X., Deacon, S. H., Kirby, J. R., Cain, K., & Parrila, R. (2011). Morphological awareness: A key to understanding poor reading comprehension in English. Journal of Educational Psychology103 (3), 523-534.
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Why (C) APD Diagnosis is NOT Valid!

Today’s post will make a number of people quite angry and is intended to be controversial!  Why? Because controversy promotes critical thinking, broadens perspectives, allows to acquire better knowledge of the construct in question as well as ultimately guides better decision making on the part of the parties in question. So why the lengthy disclaimer? Because today via the use of the latest research publications, I would like discuss the fact that the diagnosis of Auditory Processing Disorder (APD) or what some may know as Central Auditory Processing Disorder (CAPD) is NOT valid!

Here are just a few reasons why:

  1. There is a strong desire for the (C)APD label on the part of those encountering processing difficulties, yet once the label is given no direct/specific auditory interventions are provided by the audiologist. Subsequent to the diagnosis, confusion ensues regarding the type, frequency, and duration of service provision (typically performed by the SLP) as well as what those services should actually constitute 
  2. Recommendations for training deficits specific areas such as working memory, auditory discrimination, auditory sequencing, etc., do not functionally transfer into practice and fail to create generalization affect
  3. Recommendations for specific costly auditory training programs such Auditory Integration Training (AIT), The Listening Program (TLP), Fast ForWord® (FFW) at the exclusion of all others, without the provision of a detailed breakdown of the child’s deficit areas often cause an incursion of unnecessary expenses for parents and professionals and are found to be INEFFECTIVE or limitedly effective in the long run
  4. General audiological recommendations for accommodations (e.g., FM systems, etc.) are frequently unnecessary, and may actually exacerbate the isolation effect while in no way alleviating the student’s deficits, which require direct and targeted intervention
  5. Auditory deficits don’t cause speech, language, and academic learning difficulties
  6. Numerous non-linguistic based disorders can be misdiagnosed as (C)APD without differential diagnosis
  7. (C)APD testing is hugely influenced by non-auditory factors grounded in higher order cognitive and linguistic processes
  8. Presently there’s no no clear performance criteria to make the (C)APD diagnosis
  9. The diagnosis of (C)APD is appealing because it presents a more attractive explanation than the diagnoses of language and learning disabilities for children with processing deficits
  10. The diagnosis of (C)APD may often detract from identifying legitimate language based deficits in the areas of comprehension, expression, social communication and literacy development, as the result of which these areas will not get adequate therapeutic attention by relevant professionals

A few words on (C)APD popularity, well sort of:

(C)APD  is currently rampantly diagnosed in the United States, Australia and New Zealand, and is even beginning to be diagnosed in the United Kingdom (Dawes & Bishop, 2009). However, presently, (C)APD is not a mainstream diagnostic classifications in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) nor is part of an actual educational classification in United States.  Already many of you can see the beginnings of the controversy.  If this diagnoses is so popular and so prevalent why is that major psychological and educational governing bodies such as American Psychiatric Association and the US Department of Education still do not officially recognize it?

(C)APD symptomology:

A. Student presents with difficulty processing information efficiently

  • Requires increased processing time to respond to questions
  • Presents like s/he are ignoring the speaker
  • May request frequent repetition of presented information from speakers
  • Difficulty following long sentences
  • Difficulty keeping up with class discussions in group settings
  • Poor listening abilities under noisy conditions may be interpreted as “distractibility”

B. Student has difficulty maintaining attention on presented tasks

  • Frequent loss of focus
  • Difficulty completing assignments on their own

C. Student has poor short term memory – difficulty remembering instructions and directions or verbally presented information

D.Student has difficulty with phonemic awareness, reading and spelling

  • Poor ability to recognize and produce rhyming words
  • Poor segmentation abilities (separation of sentences, syllables and sounds)
  • Poor sound manipulation abilities (isolation, deletion, substitution, blending, etc)
  • Poor sound letter identification abilities
  • Poor vowel recognition abilities
  • Poor decoding
  • Poor comprehension
  • Spelling errors
  • Limited/disorganized writing

E. The combination of above factors may result in generalized deficits across the board, affecting the child’s social and academic performance:

  • Poor reading comprehension
  • Poor oral and written expression
  • Disorganized thinking (e.g., disjointed narrative production)
  • Sequencing errors (recalling/retelling information in order, following recipes, etc)
  • Poor message interpretation
  • Difficulty making inferences
  • Misinterpreting the meaning of abstract information

I do not know what you see when you read the above description but to me those are the classical signs of a language impairment which has turned into a learning disability masking under the ambiguous label of  (C)APD. 

That is exactly what Dawes & Bishop, stated in 2009, when they asserted that “a child who is regarded as having a specific learning disability by one group of experts may be given an APD diagnosis by another.” They concluded that: “APD, as currently diagnosed, is not a coherent category, but that rather than abandoning the construct, we need to develop improved methods for assessment and diagnosis, with a focus on interdisciplinary evaluation“.

Let us now deconstruct each of the above statements with the assistance of direct quotes from current research.

1. (C)APD – what is it good for? Child goes to an audiologist and receives an ambiguous battery of (C)APD  testing with unclear qualification criteria (more on that below). There are some abnormal findings, so the audiologist states that the child has (C)APD, recommends accommodations and modifications, services in the form of speech language therapy with a focus on auditory training (more below) and/or some form of program similar to Fast ForWord®, and doesn’t see the child again for some time (maybe even years).  Since the child is now being seen by an SLP, who by the way frequently has no idea what to do with that child based on the ambiguous audiological findings, what exactly did the diagnosis of (C) APD just accomplish?

2. Processing Skills Training – Say What? In 2011 Fey and colleagues  (many notable audiologists and speech language pathologists) conducted a systematic review of  25 journal articles on the efficacy of interventions for school-age children with auditory processing disorder (C)APD. Their review found no compelling evidence that auditory interventions provided any unique benefit to auditory, language, or academic outcomes for children with diagnoses of (C)APD or language disorder.

Presently there is no valid evidence that targeting specific processing skills such as auditory discrimination, auditory sequencing, phonological memory, working memory, or rapid serial naming actually improves children’s ‘auditory processing’, language or reading abilities (Fey et al., 2011).

To illustrate further, Melby-Lervåg & Hulme, 2013 performed a meta analysis  of 23 working memory training studies. They found no evidence that memory training was an effective intervention for children with ADHD or dyslexia as it did not lead to better performance outside of the tasks presented within the memory tests. They concluded: “In the light of such evidence, it seems very difficult to justify the use of working memory training programs in relation to the treatment of reading and language disorders.” Further adding: “Our findings also cast strong doubt on claims that working memory training is effective in improving cognitive ability and scholastic attainment.” (Melby-Lervåg, 2013, p. 282).

3. The trouble with prescriptive programs.  (C)APD assessments often yield recommendations for a number of specific costly prescriptive programs such as AIT, FFW, etc.. As humans we are “attracted to interventions that promise relatively rapid improvements in language and academic skills. Interventions that target processing abilities are appealing because they promise significant improvements in language and reading without having to directly target the specific knowledge and skills required to be a proficient speaker, listener, reader, and writer.” (Kamhi and Wallach, 2012)

These programs claim to improve the child’s processing abilities through music, phonics, hearing distortions, etc. When such recommendations are made parents and professionals are urged to carefully review evidence-based research supported information regarding these prescribed programs in order to determine their effectiveness. Presently, there’s no research to support the use of any of these programs with children presenting with processing difficulties. 

Let’s take a look at Fast ForWord®, which is a highly costly program frequently recommended for children with auditory processing deficits. It is designed to help children’s reading and spoken language by training their memory, attention, processing, and sequencing by training 3 to 5 days per week, for 8 to 12 weeks. However, systematic reviews found no sign of a reliable effect of Fast ForWord® on reading or on expressive or receptive spoken language. 

Now some of you may legitimately tell me: “How dare you? I’ve tried it with my child and seen great gains”. And that is terrific! However, it is important to note that ANY intervention is better than NO intervention! And there is currently no scientific proof out there that this program works better than other programs aimed directly at improving the children’s reading abilities and listening skills.  Furthermore, if the child needs assistance with reading rather than spending the money  on Fast ForWord® it would be far more effective to select a systematic Orton-Gillingham (OG) (or similar) reading based program to teach her/him reading!

4. The dreaded FM system! FM systems have become an almost automatic recommendation for children diagnosed with (C)APD but are they actually effective?

Here is what one notable audiologist had to say in the subject. An FM system brings the speaker’s voice via the mic to the listener via loudspeakers or earphones through an amplifier. Only personal systems appropriate for children with TRUE APD-based auditory distractibility problems (understanding speech in the presence of background noise)”.  However, when he did his testing he found that only ~25% of children with (C)APD had issues with hearing speech in noise, the other ~75% didn’t. 

Guess what… a recent meta-analysis showed? Lemos et, al, 2009 did a systematic literature review of articles recommending the use of FM systems for APD. They concluded that: “Strong scientific evidence supporting the use of personal FM systems for APD intervention was not found. Since such device is frequently recommended for the treatment of APD, it becomes essential to carry out studies with high scientific evidence that could safely guide clinical decision making on this subject.

5. (C)APD diagnosis does NOT Language Disorder Make. “There little evidence that auditory perceptual impairments (not referring to hearing deficits) are a significant risk factor for language and academic performance (e.g., Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009)” (Kamhi, 2011, p. 265).  

  • Watson et al., 2003 found that measures of auditory processing (NOT hearing) had no impact on children’s reading or language abilities in Grades 1 through 4.
  • Sharma, Purdy, and Kelly (2009)  found that having auditory processing difficulties did not increase the likelihood that a child would have a language or reading disorder.
  • Hazan et al., 2009; Ramus et al., 2006) found that despite poor phonological processing abilities, individuals with dyslexia perform within normal limits on measures of speech perception. 

(From Kamhi, 2011, p. 268)

6. Are you sure it’s (C)APD?

—Without a careful differential diagnosis, numerous non-linguistic based medical, psychiatric neurological, psychological, and cognitive conditions can be misdiagnosed as (C)APD including (but not limited):

  • —Respiratory Disorders
    • —Adenoid hypertrophy, asthma, allergic rhinitis
  • —Metabolic/Endocrine Disorders
    • —Diabetes  hypo/hyperthyroidism
  • —Hematological Disorders
    • —Anemia
  • —Immunological Disorders
    • —Acquired and congenital immune problems
  • —Cardiac Disorders
    • —Congenital and acquired heart disease, syncopy
  • —Digestive  Disorders
    • —Irritable bowel syndrome, GERD
  • —Neurological Disorders
    • —Traumatic Brain Injuries, Tumors, Encephalopathy
  • Genetic Disorders
    • —Fragile X Syndrome
  • —Toxin Exposure
    • —Lead, Mercury, Drug Exposure
  • —Infections and Infestations
    • —Yeast overgrowth , intestinal worms/parasites
  • —Sleep Disorders
    • Sleep Apnea
  • —Mental Health Disorders
    • —Trauma, Anxiety, mood disorders, adjustment disorders
  • ——Sensory Processing Disorders
    • —Vision, hearing, auditory, tactile
  • —Acquired Disorders
    • —FASD

7. (C)APD testing is NOT so PURE 

(C)APD testing does not simply consists of pure tone audiometry and is heavily comprised of higher order linguistic and cognitive tasks. Testing requires that the listeners attend to given directions, remember and label the presented auditory sequences, etc, in other words participate in tasks aimed to task their linguistic system and executive functions  (DeBonis, 2015)

So what does the research show?

  • Wallach (2011) has indicated that  (C) APD ‘symptomology’ “reflects broader underlying problems in language comprehension and metalinguistic awareness.
  • Dawes and Bishop (2009)  compared children with a CAPD to children diagnosed with dyslexia and found similar attention, reading, and language deficits in both groups.
  •  Kelly et al. (2009)  found that 76% of a sample of 68 children with suspected auditory processing disorder also had language impairment with 53% demonstrating decreased auditory attention and 59% demonstrated decreased auditory memory.
  • Ferguson et al. (2011)  concluded that “the current labels of CAPD and SLI [specific language impairment] may, for all practical purposes, be indistinguishable” (p. 225).

(From DeBonis, 2015 pgs. 126-127)

8. What to Test and How to do it – That IS the Question? 

“Despite lofty claims to the contrary, there is no clear consensus concerning the battery of tests that lead to a diagnosis of CAPD.”  (Burkard, 2009, p. vii) Presently, neither the American Academy of Audiology nor the American Speech Language Hearing Association have a clear criteria on what testing to administer, how many standard deviations the client has to be in order to qualify, as well as even who is a good candidate for (C)APD testing.  (DeBonis, 2015 pg. 125)

As such, presently children diagnosed with (C)APD are diagnosed purely in an arbitrary fashion rather than based on a specific widely accepted standard.  To illustrate W. J. Wilson and Arnott (2013) found that “in a sample of records of 150 school-aged children who had completed at least four CAPD tests, rates of diagnosis ranged from 7.3% to 96% depending on the criteria used” (DeBonis, 2015 pg. 125). Are you “processing” what I am saying? 

9. Looking for the “Right” Label 

As an SLP, I frequently hear the following statement from parents: “We were searching for what was wrong with our child for such a long time; we are so happy that we were finally able to identify that it’s (C)APD.

The above comment is certainly understandable.  After all (C)APD sounds manageable!  The appeal to it is that presumably if the child undergoes specific auditory interventions to improve deficit areas, s/he will get better and all the problems will go away.  In contrast, finding out that the child’s processing difficulties are the result of linguistic deficits in the areas of listening, speaking, reading, and writing can be incredibly overwhelming especially because what we know about the nature of language impairments and that is that more often than not they turn into lifelong learning disabilities.

Some parents and professionals may disagree.  They might point out that many children with (C)APD test just fine on generalized language testing and only present with isolated deficits in the areas of attention, memory, as well as phonological processing. Yet here is the problem! General language testing in the form of administration of tests such as the CELF-5 or the CASL does not complete language assessment make!

The same children who test ‘just fine’ on these assessments often test quite poorly on the measures of social communication, executive function, as well as reading.  In other words if the professionals dig deep enough they often find out that something which outwardly presents as (C)APD is part of much broader language related issues, which require relevant intervention services. This leads me to my final point below.

10. Missing the Big Picture

“The primacy given to auditory processing abilities has resulted at times in neglect of other cognitive factors” (Cowan et al. 2009, p. 192). Focusing on the diagnosis of (C)APD obscures REAL, language-based deficits in children in question. It forces SLPs to address erroneous therapeutic targets based on AuD recommendations. It makes us ignore the BIG Picture and  “Consider non-auditory reasons for listening and comprehension difficulties, such as limitations in working memory, language knowledge, conceptual abilities, attention, and motivation and consequently targeting language, literacy, and knowledge-based goals in therapy.” —(Kamhi &Wallach, 2012)

Conclusion:

So what will happen next? Well, I can tell you with certainty that the controversy will certainly not end here!  Presently, not only is that there is a fierce academic debate between speech language pathologist and audiologists but there is also a raging debate among audiologists themselves!  This controversy will continue for many years among some highly educated people.  And SLPs? Well, we will continue seeing numerous children diagnosed with (C)APD.  Except, I do hope something will change and that is our collective outlook on how we view ambiguously defined and assessed disorders such as (C)APD.

I sincerely hope that we do not blindly defer to other professions and reject current valid research regarding this controversial diagnosis without first spending some time reflecting and critically reviewing these findings in order to better assist us with making informed and educated decisions regarding our clients’ plan of care.

Click HERE to read the second part of this post, which describes how SLPs SHOULD assess and treat children diagnosed by audiologists with (C)APD

References:

  • Burkard, R. (2009). Foreword. In A. Cacace & D. McFarland (Eds.), Controversies in central auditory processing disorder (pp. vii-viii). San Diego, CA: Plural.
  • Cowan, J., Rosen, S., & Moore, D. (2009). Putting the auditory back into auditory processing disorder in children. In Cacace, A., & McFarland, D. (Eds.),Controversies in central auditory processing disorder(pp. 187–197). San Diego, CA: Plural Publishing.
  • Dawes, P., & Bishop, D. (2009). Auditiory processing disorder in relation to developmental disorders of language, communication and attention: A review and critique. International Journal of Language and Communication Disorders, 44, 440–465.
  • 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.
  • Ferguson, M. A., Hall, R. L., Moore, D. R., & Riley, A. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54, 211–227.
  • 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.
  • 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
  • Kamhi, A. G. (2011). What speech-language pathologists need to know about auditory processing disorder. Language, Speech, and Hearing Services in Schools, 42, 265–272.
  • Kamhi, A & Wallach, G (2012) What Speech-Language Pathologists Need to Know about Auditory Processing Disorders. ASHA Convention Presentation. Atlanta, GA.
  • Kelly, A. S., Purdy, S. C., & Sharma, M. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research, 53, 706–722.
  • Lemos IC, Jacob RT, Gejao MG, et al. (2009) Frequency modulation (FM) system in auditory processing disorder: An evidence-based practice? Pró-Fono Produtos Especializados para Fonoaudiologia Ltda. 21(3):243-248.
  • Melby-Lervåg, M., & Hulme, C. (2013). Is working memory training effective? A meta-analytic review. Developmental Psychology, 49, 270–291.
  • Ramus, F., White, S., Frith, U. (2006). Weighing the evidence between competing theories of dyslexia.Developmental Science. 9 265–269
  • Sharma, M., Purdy, S. C., Kelly, A. S. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research. 52 706–722
  • Wallach, G. P. (2011). Peeling the onion of auditory processing disorder: A language/curricular-based perspective. Language, Speech, and Hearing Services in Schools, 42, 273–285.
  • 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.
  • Wilson, W. J., & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research, 56, 63–70.