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Test Review: Clinical Assessment of Pragmatics (CAPs)

Today due to popular demand I am reviewing the Clinical Assessment of Pragmatics (CAPs) for children and young adults ages 7 – 18, developed by the Lavi Institute. Readers of this blog are familiar with the fact that I specialize in working with children diagnosed with psychiatric impairments and behavioral and emotional difficulties. They are also aware that I am constantly on the lookout for good quality social communication assessments due to a notorious dearth of good quality instruments in this area of language.

I must admit when I first learned about the existence of CAPs in May 2018, I was definitely interested but quite cautious. Many standardized tests assessing pragmatics and social language contain notable psychometric limitations due to the inclusion of children with social and pragmatic difficulties into the normative sample. This, in turn, tends to overinflate test scores and produce false negatives (a belief that the child does not possess a social communication impairment due to receiving average scores on the test).  Furthermore, tests of pragmatics such as Test of Pragmatic Language -2 (TOPL-2) tend to primarily assess the child’s knowledge of rules of politeness and knowing the right thing to say under a particular set of circumstances and as such are of limited value when it comes to gauging the child’s ability to truly assume perspectives and adequately showcase social cognitive abilities.

The CAPs is a unique test as compared to others with a similar purpose, due to the fact that the testing administration (which can take between 45-60 mins) is conducted exclusively via videos. The CAPs consists of 6 subtests and 3 indices.

Subtests (You can read up more on the comparison of the CAPs subtests HERE ):

Instrumental Performance Appraisal (IPA) subtest (Awareness of Basic Social Routines) is a relatively straightforward subtest which examines the student’s ability to be polite in basic social contexts. The student is asked to first identify “if anything went wrong in the presented scenario?” After that, the student is asked to explain, what went wrong and how s/he knows? Targeted structures include greeting and closure, making requests, responding to gratitude, requesting help, answering phone calls, asking for directions, asking permission, etc.  Goals: can the student discern between appropriate and inappropriate language and then provide a verbal rationale in a coherent and cohesive manner.

Score types: (2) correct identification of problem or lack of thereof + correct justification; (1) correct identification but incorrect rationale; (0) incorrect identification.

Social Context Appraisal (SCA) subtest (Reading Context Cues) requires the student to engage in effective perspective taking (assume mutual vs. individual perspectives) by identifying sarcasm, irony, and figurative language in the presented video scenarios. The student is then asked to provide a coherent and cohesive verbal explanation and effectively justify own response.

Score types: (3) correct identification of the problem or lack of thereof + identification of idiom or sarcasm + reference to both characters actions; (2) correct identification of the problem or lack of thereof + identification of idiom or sarcasm + reference to one character’s actions; (1) correct identification of the problem or lack of thereof but an inability to verbalize the problem in the situation; (0) for incorrect identification.

Paralinguistic Decoding (PD) subtest (Reading Nonverbal Cues) assesses the students’ ability to notice and interpret micro-expressions and nonverbal language.  The aim of this subtest is to have the students grasp what went wrong vs. well in the presented videos, assume mutual perspectives,  as well as verbally justify their responses providing adequate and relevant details.

Score types: (3) correct identification of the problem or lack of thereof + explanation of situation + reference to both characters facial expressions and tone of voices; (2) correct identification of the problem or lack of thereof + explanation of situation  + reference to one character’s facial expression and tone of voice  (1) correct identification of the problem or lack of thereof but an inability to explain actions and/or nonverbal body language; (0) for incorrect identification.

Instrumental Performance (IP) subtest (Use of Social Routine Language) assesses the student’s ability to use rules of politeness (e.g., make requests, respond to gratitude, answer phone calls, etc.) by providing adequately supportive responses using first-person perspectives relevant to various social situations.

Score types: (2) appropriate introduction + use of supportive statements; (1) appropriate introduction without the use of supportive statements; (0) inappropriate intent of message or use of impolite language 

Affective Expression (AE) subtest (Expressing Emotions) assesses the student’s ability to effectively display empathy, gratitude, praise, apology, etc., towards affected peers in the video scenario. It requires the usage of relevant facial expressions, tone of voice, as well as stating appropriately supportive comments.

Score types: (2) expresses empathy, praise, apology, gratitude, etc. along with supportive statements +appropriate facial and prosodic affect; (1) expresses empathy, praise, apology, gratitude, etc. + appropriate facial and prosodic affect without relevant supportive statements;   (0) provides an approrpiate response but lacks adequate prosody and affect, or message contains inappropriate intent 

Paralinguistic Signals (PS) subtest (Using Nonverbal Cues)assesses the student’s ability to appropriately use facial expressions, gestures, and prosody (act out vs. recognize and interpret facial expression and gestures). This includes showing appropriate expression of empathy, frustration, alarm, excitement, gratitude, etc., exhibiting relevant inflection in prosody as well as showing appropriate to the situation facial expression (vs. having inappropriate message intent, be monotone, have flat affect, etc.)

Score types: (2) appropriately expresses urgency, empathy apology, etc. +exhibits inflections in prosody and shows relevant facial expressions; (1) appropriately expresses urgency, empathy apology, etc. +exhibits inflections in prosody without showing relevant facial expressions  (0)   inappropriate intent of message or monotone prosody. 

Indices (information regarding the student’s pragmatic proficiency):

  1. Pragmatic Judgement (Sum of IPA, SCA & PD scaled scores)
  2. Pragmatic Performance (Sum of IP, AE & PS scaled scores)
  3. Paralinguistic (Sum of PD, AE & PS scaled scores)

Based on the administration of this test the following goals can be formulated for remediation purposes:

Long Term Goal: Student will improve pragmatic abilities for social and academic purposes

Short-Term Objectives: 

  1. The student will verbally identify instances of politeness or impoliteness in presented social routines
  2. The student will provide relevant justifications explaining which aspects of the presented scenarios were appropriate vs. inappropriate
  3. The student will verbally identify sarcasm, irony, and figurative language in presented social scenarios
  4. The student will effectively explain sarcasm, irony, and figurative language in presented social scenarios
  5. The student will verbally interpret micro-expressions and nonverbal body language  (e.g., they feel disgusted; the girl is smirking, the man’s hands are crossed, etc.)
  6. The student will effectively use rules of politeness and provide adequately supportive responses using first-person perspectives pertaining to various aspects of social scenarios
  7. The student will display a range of emotional expressions via the use of relevant facial expressions, tone of voice when providing supporting responses
  8. The student will state appropriately supportive comments regarding relevant social scenarios
  9. The student will use a range of facial expressions, gestures, and relevant prosody pertinent to the provided social scenarios

Furthermore, this test comes with a Contextualized Assessment of Pragmatics Checklist as well as a downloadable  Free Report Template.

Multiple videos posted by the Lavi Institute showcasing individual subtest administration can be accessed by clicking on the above-highlighted links as well as on YouTube.

Psychometrics: the normative sample consisted of 914 individuals out of which 137 (or 15%)  included individuals with atypical language development: ASD: N-18; SLI: N-27; Other (Learning Disabilities): N-92.

Excellent Sensitivity and Specificity Cut Scores (at 1, 1.5 & 2 SD) for clients with ASD ONLY:

Impressions:  To date, I have used this assessment with only 3 students. As such, expect multiple updates of this post as I continue to document how well it suited to identify children with social communication difficulties. Below are my preliminary impressions on how well this test is suited for children with varying pragmatic profiles.

A. Initial Assessment: 8-3-year-old male diagnosed with Autism

The CAPs had captured the student’s display of pragmatic deficits extremely well.  It was able to highlight the student’s relative strengths as well as pervasive pragmatic needs.  Based on the results of the CAPs, I was able to generate relevant pragmatic goals to target with this student in therapy.

B.  Yearly Reassessment: 8-11-year-old diagnosed with Anxiety:

I definitely had some trepidation about how well the CAPs will be able to capture this student’s pragmatic difficulties. This student was initially assessed via the Social Language Development Test-Elementary (SLDTE), which did show deficits in the areas of making inferences, interpersonal negotiation, as well as multiple interpretations of social situations. However, subsequent to his assessment that student did exceptionally well in treatment and had improved exponentially. While I knew that the student was not done with the treatment quite yet, I wasn’t certain if the CAPs was capable of picking up his subtle social pragmatic difficulties. Much to my surprise, the CAPs was effective in highlighting my student’s difficulties on a number of subtests including those pertaining to the effective reading and use of context and nonverbal cues, comprehension  and interpretation of irony and sarcasm, effective support of peers via a variety of statements relevant to social situations (coherent and cohesive sentence formulation given relevant details), as well as use of relevant prosody, facial expressions, tone of voice, and nonverbal cues.

C. Initial Assessment: 11-year-old student with suspected language and literacy deficits 

This was definitely the trickiest assessment subject from my small sample. Based on the collected data I suspected the student had social communication deficits, however, given his relative strengths in a variety of areas and that the fact that no one had previously brought it up, I truly did not anticipate that CAPs will effectively and accurately identify his pragmatic needs. As expected, the student did quite well on that “easier” subtests of the CAPs: (IPA, IP, and AE). However, I was very pleasantly surprised that the CAPs had accurately picked up on the fact that the student presented with difficulty reading both context and nonverbal cues as well as using nonverbal cues to effectively answer the presented questions.

Summary: While my sample of subjects has been quite small to date, I fully intend to continue using the CAPs with students of varying ages with varying diagnoses in order to continue refining profile of students who will significantly benefit from CAPs administration for assessment and reassessment purposes.

MISC:

Current Cost $149

Where to purchase: Effective 1/7/19 on the WPS Publishing website

There you have it! These are my impressions of using the CAPs in my settings. How about you? Have you used this test with any of your students to date? If yes, what are some strengths and limitations you are noticing?

 

 

 

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Speech, Language, and Literacy Fun with Karma Wilson’s “Bear” Books

In my previous posts, I’ve shared my thoughts about picture books being an excellent source of materials for assessment and treatment purposes. They can serve as narrative elicitation aids for children of various ages and intellectual abilities, ranging from pre-K through fourth grade.  They are also incredibly effective treatment aids for addressing a variety of speech, language, and literacy goals that extend far beyond narrative production.

In the past, I’ve shared several posts regarding how to incorporate both fiction and nonfiction picture books into contextual language intervention sessions, with the most recent posts describing how I incorporate Helen Lester‘s as well as Julia Cook‘s picture books into therapy sessions.

Today I wanted to share how I implement books by Karma Wilson into my treatment sessions with preschool, kindergarten aged, as well as early elementary aged children.

Though these books are intended for younger children (3-8 years; pre-K-3rd grade), older children (~10 years of age) with significant language and learning difficulties and/or intellectual disabilities can significantly benefit from reading/listening to them and enjoy working with them as well.

Much like Helen Lester’s books, Karma Wilson’s books possess tremendous versatility with respect to what goals can be targeted via their use.

Themes:

  • Ms. Wilson’s books are terrific for discussing a variety of seasonal events and happenings.
    • Bear Feels Sick’, ‘Bear Feels Scared’ and ‘Bear Says Thanks‘ take place in the fall.
    • Bear Can’t Sleep’, ‘Bear Stays Up’, and ‘Bear Snores On‘ take place in the winter.
    • Bear’s New Friend’ and Bear’s Loose Tooth‘ take place in the Spring and Summer.
  • They are great for discussing illness and visits to the dentist (‘Bear Feels Sick’ and Bear’s Loose Tooth’), hibernation ( ‘Bear Snores On‘), holidays such as Thanksgiving and Christmas (‘Bear Says Thanks‘ and ‘Bear Stays Up‘).
  • They are also great for select social themes such as feeling frightened and making new friends (‘Bear Feels Scared’ and ‘Bear’s New Friend’).
  • Finally, ‘Bear Wants More‘ is great for working on nutrition as well as on making healthy food choices, in addition to reviewing a variety of food groups as well as food categories.

Speech Production: Bear books are terrific for the production of a variety of sounds in words in sentences including /r/ in all books, /s/ (‘Bear Feels Sick’, ‘Bear Feels Scared’), /th/ (‘Bear Says Thanks‘ ), etc.

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

  • Select Highlights:Vocabulary: For the ages/grades that there’ve written for (3-8 years; pre-K-3rd grade), Ms. Wilson’s books are laden with a wealth of sophisticated vocabulary words such as vale, crooked, trail, lumbers, prowl, howl, spooks, wails, dimmer, squeaks, lair, roam, perch, prepare, trembles, longs, flounce, squawk, cluster, etc. (From the ‘Bear Feels Scared’ book)
  • Social Communication: ‘Bear’s New Friend’, ‘Bear’s Loose Tooth’, and ‘Bear Says Thanks’ are especially terrific for addressing a variety of social themes such as rules of politeness, making new friends (and accepting them for who they are), as well as helping out friends in difficult circumstances.

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

  • Select Highlights:
    • Phonics: Students can practice reading words containing a variety of syllable shapes as well as decode low-frequency words containing a variety of consonantal clusters (From the ‘Bear Feels Sick’ book: achy, autumn, stuffed, sneezes, heap, wheezes, whiffs, mutters, mumbles, moans, broth, squeezes, whispers, cloth, gopher, coax, herbs, smidgen, fuss, fret, etc. 
    • Morphology: There’s a terrific opportunity to introduce a discussion on simple affixes when using Ms. Wilson’s books to discuss how for example, select suffixes (e.g., –s, -ly, ‘ed, etc.) can change root words.  (From the ‘Bear Stays Up’ book: soundly, stays, gathered, etc.) 
    • Spelling: There is a terrific opportunity for children to practice spelling numerous spelling patterns to solidify their spelling abilities. From the ‘Bear’s New Friend’ book:  -00-, -ee-, -ea-,-oo-, -oe-, -ou-, -le, -ff-, -mm-, -tt-, etc.

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

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

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

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

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

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

Here is a sampling of verbal prompts I provide to the students with a focus on Critical Thinking Image result for bear says thanks

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

Here is a small sampling of verbal prompts I provide to the students with a focus on Social Communication and Social Cognition 

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

At times, I also use select Free TPT resources to supplement my sessions with book-related visuals as related materials.

There you have it! Just a few of the reasons why I really like using Karma Wilson’s books for language and literacy treatment purposes with younger children. How about you? Do you use any of her books for treatment purposes? If yes, comment below which ones you use and why do you use them?

References:

Helpful Related Smart Speech Therapy Resources: 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

Helpful Related Smart Speech Therapy Resources: 

 

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

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

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

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

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

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

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

Now, let’s talk about why that is!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

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Phonological Awareness Screening App Review: ProPA

pro-pa-img1Summer is in full swing and for many SLPs that means a welcome break from work. However, for me, it’s business as usual, since my program is year around, and we have just started our extended school year program.

Of course, even my program is a bit light on activities during the summer. There are lots of field trips, creative and imaginative play, as well as less focus on academics as compared to during the school year. However, I’m also highly cognizant of summer learning loss, which is the phenomena characterized by the loss of academic skills and knowledge over the course of summer holidays.

Image result for summer learning loss

According to Cooper et al, 1996, while generally, typical students lose about one month of learning, there is actually a significant degree of variability of loss based on SES. According to Cooper’s study, low-income students lose approximately two months of achievement. Furthermore, ethnic minorities, twice-exceptional students (2xE), as well as students with language disorders tend to be disproportionately affected (Graham et al, 2011;  Kim & Guryan, 2010; Kim, 2004). Finally, it is important to note that according to research, summer loss is particularly prominent in the area of literacy (Graham et al, 2011).

So this summer I have been busy screening the phonological awareness abilities (PA) of an influx of new students (our program enrolls quite a few students during the ESY), as well as rescreening PA abilities of students already on my caseload, who have been receiving services in this area for the past few months.

Why do I intensively focus on phonological awareness (PA)? Because PA is a precursor to emergent reading. It helps children to manipulate sounds in words (see Age of Aquisition of PA Skills). Children need to attain PA mastery (along with a host of a few literacy-related skills) in order to become good readers.

When children exhibit poor PA skills for their age it is a red flag for reading disabilities. Thus it is very important to assess the child’s PA abilities in order to determine their proficiency in this area.

While there are a number of comprehensive tests available in this area, for the purposes of my screening I prefer to use the ProPA app by Smarty Ears.

pro-pa-img14

The Profile of Phonological Awareness (Pro-PA) is an informal phonological awareness screening. According to the developers on average it takes approximately 10 to 20 minutes to administer based on the child’s age and skill levels. In my particular setting (outpatient school based in a psychiatric hospital) it takes approximately 30 minutes to administer to students on the individual basis. It is by no means a comprehensive tool such as the CTOPP-2 or the PAT-2, as there are not enough trials, complexity or PA categories to qualify for a full-blown informal assessment. However, it is a highly useful measure for a quick determination of the students’ strengths and weaknesses with respect to their phonological awareness abilities. Given its current retail price of $29.99 on iTunes, it is a relatively affordable phonological awareness screening option, as the app allows its users to store data, and generates a two-page report at the completion of the screening.

The Pro-PA assesses six different skill areas:

  • Rhyming
    • Identification
    • Production
  • Blending
    • Syllables
    • Sounds
  • Sound Isolation
    • Initial
    • Final
    • Medial
  • Segmentation
    • Words in sentences
    • Syllables in words
    • Sounds in words
    • Words with consonant clusters
  • Deletion
    • Syllables
    • Sounds
    • Words with consonant clusters
  • Substitution
    • Sounds in initial position of words
    • Sounds in final position of words

pro-pa-img21After the completion of the screening, the app generates a two-page report which describes the students’ abilities as:

  • Achieved (80%+ accuracy)
  • Not achieved (0-50% accuracy)
  • Emerging (~50-79% accuracy)

The above is perfect for quickly tracking progress or for generating phonological awareness goals to target the students’ phonological awareness weaknesses. While the report can certainly be provided as an attachment to parents and teachers, I usually tend to summarize its findings in my own reports for the purpose of brevity. Below is one example of what that looks like:

pro-pa-img29The Profile of Phonological Awareness (Pro-PA), an informal phonological awareness screening was administered to “Justine” in May 2017 to further determine the extent of her phonological awareness strengths and weaknesses.

On the Pro-PA, “Justine” evidenced strengths (80-100% accuracy) in the areas of rhyme identification, initial and final sound isolation in words, syllable segmentation, as well as substitution of sounds in initial position in words.

She also evidenced emerging abilities (~60-66% accuracy) in the areas of syllable and sound blending in words, as well as sound segmentation in CVC words,

However, Pro-PA assessment also revealed weaknesses (inability to perform) in the areas of: rhyme production, isolation of medial sounds in words, segmentation of words, segmentation of sounds in words with consonant blends,deletion of first sounds,  consonant clusters, as well as substitution of sounds in final position in words. Continuation of therapeutic intervention is recommended in order to improve “Justine’s” abilities in these phonological awareness areas.

Now you know how I quickly screen and rescreen my students’ phonological awareness abilities, I’d love to hear from you! What screening instruments are you using (free or paid) to assess your students’ phonological awareness abilities? Do you feel that they are more or less comprehensive/convenient than ProPA?

References:

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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. 

Related Posts:

 

 

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Review and Giveaway: Test of Semantic Reasoning (TOSR)

Today I am reviewing a new receptive vocabulary measure for students 7-17 years of age, entitled the Test of Semantic Reasoning (TOSR) created by Beth Lawrence, MA, CCC-SLP  and Deena Seifert, MS, CCC-SLP, available via Academic Therapy Publications.

The TOSR assesses the student’s semantic reasoning skills or the ability to nonverbally identify vocabulary via image analysis and retrieve it from one’s lexicon.

According to the authors, the TOSR assesses “breadth (the number of lexical entries one has) and depth (the extent of semantic representation for each known word) of vocabulary knowledge without taxing expressive language skills”.

The test was normed on 1117 students ranging from 7 through 17 years of age with the norming sample including such diagnoses as learning disabilities, language impairments, ADHD, and autism. This fact is important because the manual did indicate how the above students were identified. According to Peña, Spaulding and Plante (2006), the inclusion of children with disabilities in the normative sample can negatively affect the test’s discriminant accuracy (separate typically developing from disordered children) by lowering the mean score, which may limit the test’s ability to diagnose children with mild disabilities.

TOSR administration takes approximately 20 minutes or so, although it can take a little longer or shorter depending on the child’s level of knowledge.  It is relatively straightforward. You start at the age-based point and then calculate a basal and a ceiling. For a basal rule, if the child missed any of the first 3 items, the examiner must go backward until the child retains 3 correct responses in a row. To attain a ceiling, test administration can be discontinued after the student makes 6 out of 8 incorrect responses.

Test administration is as follows. Students are presented with 4 images and told 4 words which accompany the images. The examiner asks the question: “Which word goes with all four pictures? The words are…

Students then must select the single word from a choice of four that best represents the multiple contexts of the word represented by all the images.

According to the authors, this assessment can provide “information on children and adolescents basic receptive vocabulary knowledge, as well as their higher order thinking and reasoning in the semantic domain.”

My impressions:

During the time I had this test I’ve administered it to 6 students on my caseload with documented history of language disorders and learning disabilities. Interestingly all students with the exception of one had passed it with flying colors. 4 out of 6 received standard scores solidly in the average range of functioning including a recently added to the caseload student with significant word-finding deficits. Another student with moderate intellectual disability scored in the low average range (18th percentile). Finally, my last student scored very poorly (1st%); however, in addition to being a multicultural speaker he also had a significant language disorder. He was actually tested for a purpose of a comparison with the others to see what it takes not to pass the test if you will.

I was surprised to see several children with documented vocabulary knowledge deficits to pass this test. Furthermore, when I informally used the test and asked them to identify select vocabulary words expressively or in sentences, very few of the children could actually accomplish these tasks successfully. As such it is important for clinicians to be aware of the above finding since receptive knowledge given multiple choices of responses does not constitute spontaneous word retrieval. 

Consequently, I caution SLPs from using the TOSR as an isolated vocabulary measure to qualify/disqualify children for services, and encourage them to add an informal expressive administration of this measure in words in sentences to get further informal information regarding their students’ expressive knowledge base.

I also caution test administration to Culturally and Linguistically Diverse (CLD)  students (who are being tested for the first time vs. retesting of CLD students with confirmed language disorders) due to increased potential for linguistic and cultural bias, which may result in test answers being marked incorrect due lack of relevant receptive vocabulary knowledge (in the absence of actual disorder).

Final Thoughts:

I think that SLPs can use this test as a replacement for the Receptive One-Word Picture Vocabulary Test-4 (ROWPVT-4) effectively, as it does provide them with more information regarding the student’s reasoning and receptive vocabulary abilities.  I think this test may be helpful to use with children with word-finding deficits in order to tease out a lack of knowledge vs. a retrieval issue.

You can find this assessment for purchase on the ATP website HERE. Finally, due to the generosity of one of its creators, Deena Seifert, MS, CCC-SLP, you can enter my Rafflecopter giveaway below for a chance to win your own copy!

Disclaimer:  I did receive a complimentary copy of this assessment for review from the publisher. Furthermore, the test creators will be mailing a copy of the test to one Rafflecopter winner. However, all the opinions expressed in this post are my own and are not influenced by the publisher or test developers.

References:

Peña ED, Spaulding TJ, and Plante E. ( 2006) The composition of normative groups and diagnostic decision-making: Shooting ourselves in the foot. American Journal of Speech-Language Pathology 15: 24754

  a Rafflecopter giveaway

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What do Narratives and Pediatric Psychiatric Impairments Have in Common?

High comorbidity between language and psychiatric disorders has been well documented (Beitchman, Cohen, Konstantaras, & Tannock, 1996; Cohen, Barwick, Horodezky, Vallence, & Im, 1998; Toppelberg & Shapiro, 2000). However, a lesser known fact is that there’s also a significant under-diagnosis of language impairments in children with psychiatric disorders.

In late 90’s, a study by Cohen, Barwick, Horodezky, Vallance, & Im (1998) found that 40% of children between the ages of 7 and 14 referred solely for psychiatric problems had a language impairment that had not been previously suspected.

Several decades later not much has changed. Hollo, Wehby, & Oliver (2014) did a meta-analysis of 22 studies, which reported results of language assessments in children with emotional and behavioral disturbances, EBD, with no prior history of language impairment (LI). They found that more than 80% of these children displayed below average language performance on standardized assessments (1–2 SD below the mean on a single measure) and 46.5% of these children qualified for criteria of moderate-severe LI (>2 SD below the mean on a single measure).

The above illustrates that children with psychiatric impairments often spend years “under the radar” without the recognition from medical and educational professionals that they present with difficulty adequately comprehending and expressing language. This is particularly damaging because good language development is critically important in order for psychotherapy and cognitive-behavioral therapies to be effective for the child. Without relevant speech-language intervention services, psychotherapy referrals are rendered virtually useless, since those children who lack adequate linguistic abilities would not make meaningful therapeutic gains even after spending years in psychotherapy.

Narrative abilities are “highly relevant for the child psychiatry population as means for both psychotherapeutic evaluation (Emde, Wolf, & Oppenheim, 2003) and intervention (Angus & McLeod, 2004; Chaika, 2000; Gardner, 1993)”.  That is why it is crucial that language impairments be “identified, taken into account, and remediated (Losh & Capps, 2003)” (Pearce, et al, 2014, p. 245).

Over a two-year period, Pearce and colleagues (2014) assessed 48 children, 6–12 years old who were admitted: “for a four-week diagnostic period to the Child Psychiatry Inpatient Unit in a children’s hospital”. The children selected for the study had a minimum IQ of 85, had passed a hearing test and did not present with any acute psychotic symptoms (e.g., delusions, hallucinations, etc.). The children were administered the core subtests of The Clinical Evaluation of Language Fundamentals–4 (CELF-4) as well as the Test of Narrative Language (TNL).

Study results found that:

  1. “The mean scores for less complex core language production and comprehension were in the average range”, whereas the mean narrative-production scores on the TNL were in the clinical range. In other words: “These children perhaps had acquired foundational language skills sufficient for functional communication and produced verbal output at a rate and complexity not noticeably different from their peers, particularly with the overlay of social or emotional disturbance, yet had impaired discourse skills difficult to detect in the typical psychiatric interview, psychotherapy session, or classroom setting” (Pearce, et al, 2014, p. 253).
  2. The study also found a significant correlation between narratives and social skills (but not between core language and social skills). That is because, in contrast to general language tests, which assess basic constructs such as vocabulary and grammar and often require single word responses, storytelling involves a number of higher order skills such as sequencing, emotion processing, perspective taking, pragmatic presupposition, gauging the listener’s level of interest, etc., which children with psychiatric impairments understandably lack.
  3. Consequently, the authors concluded that: “More than half the children in our complex population not previously diagnosed with language impairment were identified as having impaired language when higher-level discourse skills, measured by narrative ability, were tested in addition to core language abilities.”(Pearce, et al, 2014, p. 257)

Additionally, it is important to note that the above study utilized two fairly basic language measures and was still able to attain very significant results. It is strongly speculated that if the study was conducted in the present and utilized a general language test such as the Test of Integrated Language and Literacy the results would have been even more dramatic and the impairment would have extended to language abilities as well as narratives.

So the takeaway messages are as follows:

  1. Do not assume that children who present with challenging behaviors are merely “acting out” and present with intact language abilities. Assess them in order to confirm/rule out a language disorder (and make a relevant psychiatric referral if needed).
  2. Do not assume that children with emotional and behavioral disturbances are ONLY behaviorally/psychiatrically impaired and have average language abilities. Consequently, perform necessary testing in order to confirm/rule out the presence of concomitant language disorder.
  3. General language tests such do NOT directly test children’s narrative abilities or social language skills. Thus, many children can attain average scores on these tests yet still present with pervasive higher order language deficits, so more sensitive testing IS NEEDED
  4. Don’t ascribe linguistic deficits to externalizing symptomology (e.g., impulsivity, anxiety, inattention, challenging behaviors, etc.)  when the cause of it may in actuality be an undiagnosed language impairment. Perform a thorough assessment of higher-order linguistic abilities to ensure that the child receives the best possible care in order to optimally function in social and academic settings.

Helpful Resources:

References:

  • Angus, L. E., & McLeod, J. (Eds.) (2004). The handbook of narrative and psychotherapy. London, UK: Sage Publications
  • Beitchman, J., Cohen, N., Konstantareas, M., & Tannock, R. (Eds.) (1996). Language, learning and behaviour disorders: Developmental, biological and clinical perspectives. Cambridge, NY: Cambridge University Press.
  • Chaika, E. (2000). Linguistics, pragmatics and psychotherapy. London, UK: Whurr Publishers
  • Cohen, N., Barwick, M., Horodezky, N., Vallance, D., & Im, N. (1998). Language, achievement, and cognitive processing in psychiatrically disturbed children with previously identified and unsuspected language impairments. Journal of Child Psychology and Psychiatry, 39, 865–877.
  • Cohen, N., & Horodezky, N. (1998). Prevalence of language impairments in psychiatrically referred children at different ages: Preschool to adolescence [Letter to the editor]. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 461–262.
  • Emde, R., Wolf, D., & Oppenheim, D. (Eds.) (2003). Revealing the inner worlds of young children—The MacArthur story stem battery. New York, NY: Oxford University Press.
  • Gardner, R. (1993). Storytelling in psychotherapy with children. London, UK: Jason Aronson.
  • Hollo, A., Wehby, J. H., & Oliver, R. O.  (2014). Unsuspected language deficits in children with emotional and behavioral disorders: A meta-analysis. Exceptional Children, Vol. 80, No. 2, pp. 169-186.
  • Losh, M., & Capps, L. (2003). Narrative ability in high-functioning children with autism or Asperger’s syndrome. Journal of Autism and Developmental Disorders, 33, 239–251.
  • Pearce, P. et al. (2014). Use of narratives to assess language disorders in an inpatient pediatric psychiatric population. Clin Child Psychol Psychiatry, 19(2) 244-259.
  • Toppelberg, C., & Shapiro, T. (2000). Language disorders: A 10-year research update review. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 143–152.
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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):

Related Posts:

 

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Review and Giveaway of Strategies by Numbers (by SPELL-Links)

SPELL-Links Strategies By The Numbers

Today I am reviewing a fairly recently released (2014) book from the Learning By Design, Inc. team entitled SPELL-Links Strategies by Numbers.   This 57 page instructional guide was created to support the implementation of the SPELL-Links to Reading and Writing Word Study Curriculum as well as to help students “use the SPELL-Links strategies anytime in any setting.’ (p. iii) Its purpose is to enable students to strategize their way to writing and reading rather than overrelying on memorization techniques.

SPELL-Links Strategies by Numbers contains in-depth explanations of SPELL-Links’ 14 strategies for spelling and reading, detailed instructions on how to teach the strategies during writing and reading activities, as well as helpful ideas for supporting students as they further acquire literacy skills.  It can be used by a wide array of professionals including classroom teachers, speech-language pathologists, reading improvement teachers, learning disabilities teachers, aides, tutors, as well as parents for teaching word study lessons or as carryover and practice during reading and writing tasks.

The author includes a list of key terms used in the book as well as a guide with instructional icons screen-shot-2016-09-24-at-10-57-10-amscreen-shot-2016-09-24-at-10-56-46-am

The goal of the 14 strategies listed in the book is to build vocabulary, improve spelling, word decoding, reading fluency, and reading comprehension as well as improve students’ writing skills. While each strategy is presented in isolation under its own section, the end result is for students to fully integrate and apply multiple strategies when reading or writing.

Here’s the list of the 14 strategies in order of appearance as applied to spelling and reading:

  1. Sound It Out
  2. Check the Order
  3. Catch the Beat
  4. Listen Up
  5. A Little Stress Will Help This Mess
  6. No Fouls
  7. Play By the Rules
  8. Use Rhyme This Time
  9. Spell What You Mean and Mean What You Spell
  10. Be Smart About Word Parts
  11. Build on the Base
  12. Invite the Relatives
  13. Fix the Funny Stuff
  14. Look It Up

Each strategy includes highly detailed implementation instructions with students including pictorial support as well as both instructor and student guidance for practice at various levels during writing and reading tasks.  At the end of the book all the strategies are succinctly summarized in handy table, which is also provided to the user separately as a double sided one page insert printed on reinforced paper to be used as a guide when the book is not handy.

There are a number of things I like about the book. Firstly, of course it is based on the latest research in reading, writing, and spelling. Secondly, clinicians can use it the absence  of SPELL-Links to Reading and Writing Word Study Curriculum since the author’s purpose was to have the students  “use the SPELL-Links strategies anytime in any setting.’ (p. iii).  Thirdly, I love the fact that the book is based on the connectionist research model, which views spelling and reading as a “dynamic interplay of phonological, orthographic, and semantic knowledge.” (iii). Consequently, the listed strategies focus on simultaneously developing and strengthening phonological, orthographic, semantic and morphological knowledge during reading and writing tasks.

You can find this book for purchase on the Learning By Design, Inc. Store HERE. Finally, due to the generosity of Jan Wasowicz  PhD the book’s author, you can enter my Rafflecopter giveaway below for a chance to win your own copy!

 

 

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