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Posted on March 6, 2018January 5, 2022 by Tatyana Elleseff — 4 Comments

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

Image result for effective intervention 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:

Learning is easier than generalization.
Instruction that is constant and predictable is more effective than instruction that varies the conditions of learning and practice.
Focused stimulation (massed practice) is a more effective teaching strategy than varied stimulation (distributed practice).
The more feedback, the better.
Repeated reading of passages is the best way to learn text information.
More therapy is always better.
The most effective language and literacy interventions target processing limitations rather than knowledge deficits.
Telegraphic utterances (e.g., push ball, mommy sock) should not be provided as input for children with limited language.
Appropriate language goals include increasing levels of mean length of utterance (MLU) and targeting Brown’s (1973) 14 grammatical morphemes.
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 Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful.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 Hadley & Holt, 2006; Hadley & Short, 2005 (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

Posted on February 25, 2018January 5, 2022 by Tatyana Elleseff — Leave a comment

It’s a Fairy Tale (Well, Almost) Therapy!

I’ve always loved fairy tales! Much like Audrey Hepburn “If I’m honest I have to tell you I still read fairy-tales and I like them best of all.” Not to compare myself with Einstein (sadly in any way, sigh) but “When I examine myself and my methods of thought, I come to the conclusion that the gift of fantasy has meant more to me than any talent for abstract, positive thinking.”

It was the very first genre I’ve read when I’ve learned how to read. In fact, I love fairy tales so much that I actually took a course on fairy tales in college (yes they teach that!) and even wrote some of my own (though they were primarily satirical in nature).

So it was a given that I would use fairy tales as a vehicle to teach speech and language goals to the children on my caseload (and I am not talking only preschoolers either). Continue reading It’s a Fairy Tale (Well, Almost) Therapy!

Posted on December 30, 2017January 5, 2022 by Tatyana Elleseff — 1 Comment

What Should be Driving Our Treatment?

Today I want to talk treatment. That thing that we need to plan for as we are doing our assessments. But are we starting our treatments the right way? The answer may surprise you. I often see SLPs phrasing questions regarding treatment the following way: “I have a student diagnosed with ____ (insert disorder here). What is everyone using (program/app/materials) during therapy sessions to address ___ diagnosis?”

Of course, the answer is never that simple. Just because a child has a diagnosis of a social communication disorder, word-finding deficits, or a reading disability does not automatically indicate to the treating clinician, which ‘cookie cutter’ materials and programs are best suited for the child in question. Only a profile of strengths and needs based on a comprehensive language and literacy testing can address this in an adequate and targeted manner.

To illustrate, reading intervention is a much debated and controversial topic nowadays. Everywhere you turn there’s a barrage of advice for clinicians and parents regarding which program/approach to use. Barton, Wilson, OG… the well-intentioned advice just keeps on coming. The problem is that without knowing the child’s specific deficit areas, the application of the above approaches is quite frankly … pointless.

There could be endless variations of how deficits manifest in poor readers. Is it aspects of phonological awareness, phonics, morphology, etc. What combination of deficits is preventing the child from becoming a good reader?

Let’s a take a look at an example, below. It’s the CTOPP-2 results of a 7-6-year-old female with a documented history of extensive reading difficulties and a significant family history of reading disabilities in the family.

Results of the Comprehensive Test of Phonological Processing-2 (CTOPP-2)

Subtests	Scaled Scores	Percentile Ranks	Description
Elision (EL)	7	16	Below Average
Blending Words (BW)	13	84	Above Average
Phoneme Isolation (PI)	6	9	Below Average
Memory for Digits (MD)	8	25	Average
Nonword Repetition (NR)	8	25	Average
Rapid Digit Naming (RD)	10	50	Average
Rapid Letter Naming (RL)	11	63	Average
Blending Nonwords (BN)	8	25	Average
Segmenting Nonwords (SN)	8	25	Average

However, the results of her CTOPP-2 testing clearly indicate that phonological awareness, despite two areas of mild weaknesses, is not really a significant problem for this child. So let’s look at the student’s reading fluency results.

Reading Fluency: “LG’s reading fluency during this task was judged to be significantly affected by excessive speed, inappropriate pausing, word misreadings, choppy prosody, as well as inefficient word attack skills. While she was able to limitedly utilize the phonetic spelling of unfamiliar words (e.g., __) provided to her in parenthesis next to the word (which she initially misread as ‘__’), she exhibited limited use of metalinguistic strategies (e.g., pre-scanning sentences to aid text comprehension, self-correcting to ensure that the read words made sense in the context of the sentence, etc.), when reading the provided passage. To illustrate, during the reading of the text, LG was observed to frequently (at least 3 times) lose her place and skip entire lines of text without any attempts at self-correction. At times she was observed to read the same word a number of different ways (e.g., read ‘soup’ as ‘soup’ then as ‘soap’, ‘roots’ as ‘roofs’ then as ‘roots’, etc.) without attempting to self-correct. LG’s oral reading rate was also observed to be impaired for her age/grade levels. Her prosody was significantly adversely affected due to lack of adequate pausing for punctuation marks (e.g., periods, commas, etc.). Instead, she paused during text reading only when he could not decode select words in the text. Though, LG was able to read 70 words per minute, which was judged to be grossly commensurate with grade-level, out of these 70 words she skipped 2 entire lines of text, invented an entire line of text, as well as made 4 decoding errors and 6 inappropriate pauses.”

So now we know that despite quite decent phonological awareness abilities, this student presents with quite poor sound-letter correspondence skills and will definitely benefit from explicit phonics instruction addressing the above deficit areas. But that is only the beginning! By looking at the analysis of specific misreadings we next need to determine what other literacy areas need to be addressed. For the sake of brevity, I can specify that further analysis of this child reading abilities revealed that reading comprehension, orthographic knowledge, as well as morphological awareness were definitely areas that also required targeted remediation. The assessment also revealed that the child presented with poor spelling and writing abilities, which also needed to be addressed in the context of therapy.

Now, what if I also told you that this child had already been receiving private, Orton-Gillingham reading instruction for a period of 2 years, 1x per week, at the time the above assessment took place? Would you change your mind about the program in question?

Well, the answer is again not so simple! OG is a fine program, but as you can see from the above example it has definite limitations and is not an exclusive fit for this child, or for any child for that matter. Furthermore, a solidly-trained in literacy clinician DOES NOT need to rely on just one program to address literacy deficits. They simply need solid knowledge of typical and atypical language and literacy development/milestones and know how to create a targeted treatment hierarchy in order to deliver effective intervention services. But for that, they need to first, thoughtfully, construct assessment-based treatment goals by carefully taking into the consideration the child’s strengths and needs.

So let’s stop asking which approach/program we should use and start asking about the child’s profile of strengths and needs in order to create accurate language and literacy goals based on solid evidence and scientifically-guided treatment practices.

Helpful Resources Pertaining to Reading:

Earle, G. A., Sayeski, K. L (2017) Systematic Instruction in Phoneme-Grapheme Correspondence for Students With Reading Disabilities. Intervention in School and Clinic. Vol. 52(5) 262–269
The Florida Center for Reading Research (FCRR)
Hasbrouck, J. & Tindal, G. A. (2006). Oral reading fluency norms: A valuable assessment tool for reading teachers. The Reading Teacher. 59(7), 636-644.
O’Connor, R (2017) Reading Fluency and Students With Reading Disabilities: How Fast Is Fast Enough to Promote Reading Comprehension? Journal of Learning Disabilities
Tolman, C (2005) Working Smarter, Not Harder: What Teachers of Reading Need to Know and Be Able to Teach IDA Perspectives pp. 15-23.
Toste et al (2016) Reading Big Words: Instructional Practices to Promote Multisyllabic Word Reading Fluency Intervention in School and Clinic pp. 1–9
Zipoli, R (2017) Unraveling-Difficult-Sentences: Strategies to Support Reading Comprehension. Intervention in School and Clinic, Vol. 52(4) 218–227. Intervention in School and Clinic, Vol. 52(4) 218–227

Posted on December 26, 2017January 5, 2022 by Tatyana Elleseff — Leave a comment

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Posted on August 15, 2017March 12, 2022 by Tatyana Elleseff — Leave a comment

New Products for the 2017 Academic School Year for SLPs

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

With that in mind, I wanted to update my readers regarding all the new products I have recently created with a focus on assessment and treatment in speech language pathology. Continue reading New Products for the 2017 Academic School Year for SLPs

Posted on August 3, 2017January 5, 2022 by Tatyana Elleseff — Leave a comment

Early Intervention Part V: Assessing Feeding and Swallowing in Children Under Three

General speech and language assessments of children under 3 years of age.
Assessments of toddlers with suspected motor speech disorders
Assessments of children ~16-18 months of age
Assessments of Social Pragmatic Abilities of Children Under 3

Today I’d like to talk about the assessment of feeding abilities of children under 3 years of age. Just to be clear, in my post, I am not offering tips on the assessment of medically fragile or neurologically impaired children with complex swallowing and feeding disorders such as severe food selectivity. Rather, I am offering suggestions for routine orofacial and feeding assessments of young children with normal swallowing but slightly immature feeding abilities.

First, let take a look at what the typical feeding development looks like in children 0-3 years of age. For this, I really like to use a resource from Dr. Joan Arvedson entitled: Developmental milestones and feeding skills birth to 36 months from her article Swallowing and feeding in infants and young children which was published online in 2006.

Age (months)	Development/posture	Feeding/oral sensorimotor
Source: Adapted from Arvedson and Brodsky (pp. 62–67).
Birth to 4–6	Neck and trunk with balanced flexor and extensor tone Visual fixation and tracking Learning to control body against gravity Sitting with support near 6 months Rolling over Brings hands to mouth	Nipple feeding, breast, or bottle Hand on bottle during feeding (2–4 months) Maintains semiflexed posture during feeding Promotion of infant–parent interaction
6–9 (transition feeding)	Sitting independently for short time Self-oral stimulation (mouthing hands and toys) Extended reach with pincer grasp Visual interest in small objects Object permanence Stranger anxiety Crawling on belly, creeping on all fours	Feeding more upright position Spoon feeding for thin, smooth puree Suckle pattern initially Suckle suck Both hands to hold bottle Finger feeding introduced Vertical munching of easily dissolvable solids Preference for parents to feed
9–12	Pulling to stand Cruising along furniture First steps by 12 months Assisting with spoon; some become independent Refining pincer grasp	Cup drinking Eats lumpy, mashed food Finger feeding for easily dissolvable solids Chewing includes rotary jaw action
12–18	Refining all gross and fine motor skills Walking independently Climbing stairs Running Grasping and releasing with precision	Self-feeding: grasps spoon with whole hand Holding cup with 2 hands Drinking with 4–5 consecutive swallows Holding and tipping bottle
>18–24	Improving equilibrium with refinement of upper extremity coordination. Increasing attention and persistence in play activities Parallel or imitative play Independence from parents Using tools	Swallowing with lip closure Self-feeding predominates Chewing broad range of food Up–down tongue movements precise
24–36	Refining skills Jumping in place Pedaling tricycle Using scissors	Circulatory jaw rotations Chewing with lips closed One-handed cup holding and open cup drinking with no spilling Using fingers to fill spoon Eating wide range of solid food Total self-feeding, using fork

Now, let’s discuss the importance of examining the child’s facial features and oral structures. During these examinations it is important to document anything out of the ordinary noted in the child’s facial features or oral cavity.

Facial dysmorphia, signs of asymmetry indicative of paresis, unusual spots, nodules, openings, growths, etc, all need to be documented. Note the condition of the child’s mouth. Is there excessive tooth decay? Do you see an unusual absence of teeth? Is there an unusual bite (open, cross, etc.), unusual voice or a cough, in the absence of a documented illness? Here’s an example from a write up on a 2-8-year-old male toddler, below:

Facial observations revealed dysmorphic features: microcephaly (small head circumference), anteriorly rotated ears (wide set), and medially deviated, inward set eyes. A presence of mild-moderate hypotonicity (low tone) of the face [and trunk] was also noted. FA presented with mostly closed mouth posture and appropriate oral postural control at rest but moderate drooling (drool fell on clothes vs. touching chin only) was noted during speech tasks and during play. It’s important to note that the latter might be primarily behavioral in origin since FA was also observed to engage in “drool play” – gathering oral secretions at lip level then slowly and deliberately expelling them in a thin stream from his mouth and onto his shirt.

Articulatory structures including lips, tongue, hard palate and velum appeared to be unremarkable and are adequate for speech purposes. FA’s dentition was adequate for speech purposes as well. Oral motor function was appropriate for lingual lateralization, labial retraction, volitional pucker and lingual elevation. Lingual depression was not achieved. Diadochokinesis for sequential and alternate movements was unremarkable. Overall, FA’s oral structures and function presented to be adequate for speech production purposes.

FA’s prosody, pitch, and loudness were within normal limits for age and gender. No clinical dysfluencies were present during the evaluation. Vocal quality was remarkable for intermittent hoarseness which tended to decrease (clear up) as speech output increased and may be largely due to a cold (he presented with a runny nose during the assessment). Vocal quality should continue to be monitored during therapy sessions for indications of persistent hoarseness in the absence of a cold.

From there I typically segue into a discussion of the child’s feeding and swallowing abilities. Below is an excerpt discussing the strengths and needs of an 18-month-old internationally adopted female.

“During the assessment concerns presented regarding AK’s feeding abilities only. No swallowing concerns were reported or observed during the assessment. As per the parental report, at the age of 18 months, AK is still drinking from the bottle and consuming only puréed foods, which is significantly delayed for a child her age. AK’s feeding skills were assessed at snack time via indirect observation and select direct food administration. The following foods and liquids were presented to AK during the assessment: 2 oz of yogurt, 18 cheerios, 4 banana and 2 apple bites, and 40 ml of water (via cup and straw). AK was observed to accept all of the above foods and liquids readily when offered.

Spoon Stripping and Mouth Closure: During the yogurt presentation, AK’s spoon stripping abilities and mouth closure were deemed good (adequate) when fed by a caregiver and fair when AK fed self (incomplete food stripping from the spoon was observed due to only partial mouth closure). According to parental report, AK’s spoon stripping abilities have improved in recent months. Ms. K was observed to present spoon upwardly in AK’s mouth and hold it still until AK placed her lips firmly around the spoon and initiated spoon stripping. Since this strategy is working adequately for all parties in question no further recommendations regarding spoon feeding are necessary at this time. Skill monitoring is recommended on an ongoing basis for further refinement.

Biting and Chewing Abilities on Solids and Semi-Solids: AK’s chewing abilities were judged to be immature at this time for both solid (e.g., Cheerios) and semi-solid foods (e.g., banana). AK was observed to feed self Cheerios from a plate (1 at a time). She placed a cheerio laterally on lower right molars and attempted to grind it. When the cheerio was presented to AK midline she was observed to anteriorly munch it, or mash it against the hard palate. Notably, when too many cheerios were presented to her, rather than grasping and consuming them AK began to bang on a plate with both hands and throw the cheerios around the room.

During feeding, the most difficulty was observed with biting and chewing solid and semisolid fruit (e.g., apple and banana pieces). When presented with a banana, AK manifested moderate difficulties biting off an adequately sized piece (she bit off too much). Consequently, due to the fact that she was unable to adequately chew on a piece that large, manual extraction of food from the oral cavity was initiated due to choking concerns. It is important to note that during all food presentations AK did not display a diagonal rotary chew, which is below age expectancy for a child her age. Feeding strengths noted during today’s assessment included complete mouth closure (including lack of drooling and anterior food loss) during assisted spoon and finger foods feeding.

Cup and Straw Drinking: AK was also observed to drink 40 mls of water from a cup given parental assistance. Minor anterior spillage was intermittently noted during liquid intake. It is recommended that the parents modify cup presentation by providing AK with a plastic cup with two handles on each side, which would improve her ability to grasp and maintain hold on cup while drinking.

Straw drinking trials were attempted during the assessment as it is a skill which typically emerges between 8-9 months of age and solidifies around 12-13 months of age (Hunt et al, 2000). When AK was presented with a shortened straw placed in cup, she was initially able to create enough intraoral pressure to suck in a small amount of liquid. However, AK quickly lost the momentum and began to tentatively chew on the presented straw as which point the trial was discontinued.

Based on the feeding assessment AK presented with mildly decreased abilities in the oral phase of feeding. It is recommended that she receive feeding therapy with a focus on refining her feeding abilities.”

I follow the above, with a summary of evaluation impressions, recommendations, as well as suggested therapy goals. Finally, I conclude my report with a statement regarding the child’s prognosis (e.g., excellent, good, fair, etc.) as well as list potential maintaining factors affecting the duration of therapy provision.

So what about you? How do you assess the feeding and swallowing of abilities of children under 3 on your caseload? What foods, tasks, and procedures do you use?

Posted on July 20, 2017November 23, 2022 by Tatyana Elleseff — 16 Comments

The Importance of Narrative Assessments in Speech Language Pathology (Revised)

As SLPs we routinely administer a variety of testing batteries in order to assess our students’ speech-language abilities. Grammar, syntax, vocabulary, and sentence formulation get frequent and thorough attention. But how about narrative production? Does it get its fair share of attention when the clinicians are looking to determine the extent of the child’s language deficits? I was so curious about what the clinicians across the country were doing that in 2013, I created a survey and posted a link to it in several SLP-related FB groups. I wanted to find out how many SLPs were performing narrative assessments, in which settings, and with which populations. From those who were performing these assessments, I wanted to know what type of assessments were they using and how they were recording and documenting their findings. Since the purpose of this survey was non-research based (I wasn’t planning on submitting a research manuscript with my findings), I only analyzed the first 100 responses (the rest were very similar in nature) which came my way, in order to get the general flavor of current trends among clinicians, when it came to narrative assessments. Here’s a brief overview of my [limited] findings. Continue reading The Importance of Narrative Assessments in Speech Language Pathology (Revised)

Posted on July 13, 2017January 5, 2022 by Tatyana Elleseff — 3 Comments

Early Intervention Evaluations PART III: Assessing Children Under 2 Years of Age

In this post, I am continuing my series of articles on speech and language assessments of children under 3 years of age. My first installment in this series offered suggestions regarding what information to include in general speech-language assessments for this age group, while my second post specifically discussed assessments of toddlers with suspected motor speech disorders.

Today, I’d like to describe what information I tend to include in reports for children ~16-18 months of age. As I mentioned in my previous posts, the bulk of children I assess under the age of 3, are typically aged 30 months or older. However, a relatively small number of children are brought in for an assessment around an 18-month mark, which is the age group that I would like to discuss today.

Typically, these children are brought in due to a lack of or minimal speech-language production. Interestingly enough, based on the feedback of colleagues, this group is surprisingly hard to report on. While all SLPs will readily state that 18-month-old children are expected to have a verbal vocabulary of at least 50 words and begin to combine them into two-word utterances (e.g., ‘daddy eat’). When prompted: “Well, what else should my child be capable of?” many SLPs draw a blank regarding what else to say to parents on the spot.

Image result for assessment As mentioned in my previous post on assessment of children under 3, the following sections should be an integral part of every early intervention speech-language assessment:

Background History
Language Development and Use (Free Questionnaires)
Adaptive Behavior
Play Assessment (Westby, 2000) (Westby Play Scale-Revised Link)
Auditory Function
Oral Motor Exam
Feeding and Swallowing
Vocal Parameters
Fluency and Resonance
Articulation and Phonology
- Phonetic inventory
- Phonotactic Repertoire
- Speech intelligibility
- Phonological Processes Analysis (Independent and Relational)
Receptive Language
Expressive Language
Social Emotional Development
Pragmatic Language
Impressions
Recommendations
Suggested Therapy Goals
References (if pertinent to a particular report)

In my two previous posts, I’ve also offered examples of select section write-ups (e.g., receptive, expressive phonology, etc.). Below a would like to offer a few more for this age group. Below is an example of a write-up on an 18-month-old bilingual child with a very limited verbal output.

RECEPTIVE LANGUAGE:

L’s receptive language skills were solid at 8 months of age (as per clinical observations and REEL-3 findings) which is significantly below age-expectancy for a child her age (18 months). During the assessment L received credit for appropriately reacting to prohibitive verbalizations (e.g., “No”, “Stop”), attending to speaker when her name was spoken, performing a routine activity upon request (when combined with gestures), looking at familiar object when named, finding the aforementioned familiar object when not in sight, as well as pointing to select body parts on Mrs. L and self (though identification on self was limited). L is also reported to be able to respond to yes/no questions by head nods and shakes.

However, during the assessment L was unable to consistently follow 1 and 2 step directions without gestural cues, understand and perform simple actions per clinician’s request, select objects from a group of 3-5 items given a verbal command, select familiar puzzle pieces from a visual field of 2 choices, understand simple ‘wh questions (e.g., “what?”, “where?”), point to objects or pictures when named, identify simple pictures of objects in book, or display the knowledge and understanding of age appropriate content, function and early concept words (in either Russian or English) as is appropriate for a child her age.

EXPRESSIVE LANGUAGE and ARTICULATION

L’s expressive language skills were judged to be solid at 7 months of age (as per clinical observations and REEL-3 findings), which is significantly below age-expectancy for a child her age (18 months). L was observed to spontaneously use proto-imperative gestures (eye gaze, reaching, and leading [by hand]), vocalizations, as well waving for the following language functions: requesting, rejecting, regulating own environment as well as providing closure (waving goodbye).

L’s spontaneous vocalizations consisted primarily of reduplicated babbling (with a limited range of phonemes) which is significantly below age-expectancy for a child her age (see below for developmental norms). During the assessment, L was observed to frequently vocalize “da-da-da”. However, it was unclear whether she was vocalizing to request objects (in Russian “dai” means “give”) due to the fact that she was not observed to consistently vocalize the above solely when requesting items. Additionally, L was not observed to engage in reciprocal babbling or syllable/word imitation during today’s assessment, which is a concern for a child her age. When the examiner attempted to engage L in structured imitation tasks by offering and subsequently denying a toy of interest until L attempted to imitate the desired sound, L became easily frustrated and initiated tantrum behavior. During the assessment, L was not observed to imitate any new sounds trialed with her by the examiner.

During today’s assessment, L’s primary means of communication consisted of eye gaze, reaching, crying, gestures, as well as sound and syllable vocalizations. L’s phonetic inventory consisted of the following consonant sounds: plosives (/p/, /b/ as reported by Mrs. L), alveolars (/t/, /d/ as reported and observed), fricative (/v/ as observed), velar (/g/ as observed), as well as nasal (/n/, and /m/ as observed). L was also observed to produce two vowels /a/ and a pharyngeal /u/. L’s phonotactic repertoire was primarily restricted to reported CV(C-consonant; V-vowel) and VCV syllable shapes, which is significantly reduced for a child her age.

According to developmental norms, a child of L’s age (18 months) is expected to produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000). During this time the child’s vocabulary size increases to 50+ words at which point children begin to combine these words to produce simple phrases and sentences (as per Russian and English developmental norms). Additionally, an, 18 months old child is expected to begin monitoring and repairing own utterances, adjusting speech to different listeners, as well as practicing sounds, words, and early sentences. (Clark, adapted by Owens, 2015)

Based on the above guidelines L’s receptive and expressive language, as well as articulation abilities, are judged to be significantly below age expectancy at this time. Speech and language therapy is strongly recommended in order to improve L’s speech and language skills.

Typically when the assessed young children exhibit very limited comprehension and expression, I tend to provide their caregivers with a list of developmental expectations for that specific age group (given the range of a few months) along with recommendations of communication facilitation. Below is an example of such a list, pulled a variety of resources.

Developmental Milestones expected of a 16-18 months old toddler:

Attention/Gaze:

Make frequent spontaneous eye contact with adults during interactions
Turn head to look towards the new voice, when another person begins to talk
Make 3-point gaze shifts by 1. looking at a toy in hand, 2. then at an adult, 3. then back to the toy
Make 4-point gaze shifts if more than one person is in the room – by looking from a toy in hand to one person, then the other person, then back to the toy,
Spontaneously attend to book, activity for 2-3+ minutes without redirection

Reaching and Gestures:

Show objects in hand to an adult (without actually giving them)
Push away items that aren’t wanted
Engage in give and take games when holding objects with an adult
Imitate simple gestures such as clapping hands or waving bye-bye
Hand an object to an adult to ask for help with it
Shake head “no?”

Play Skills/Routines:

Attempt to actively explore toys (e.g., push or spin parts of toys, turn toys over, roll them back and forth)
Repeat interesting actions with toys (e.g., make a toy produce an unusual noise, then attempt to make the noise again)
Imitate simple play activities (adult bangs two blocks together, then child imitates)
Use objects on daily basis (e.g., when given a spoon or cup the child attempts to feed himself. When putting on clothes the child begins to lift his arms in anticipation of a shirt going on.)

Receptive (Listening Skills):

Consistently follow 1 and 2 step directions without gestural cues
Understand and perform simple actions per request (“sit down” or “come here”) without gestures
Select objects from a group of 3 items given a verbal command
Select familiar puzzle pieces from a visual field of 2 choices
Understand simple ‘wh questions (e.g., “what?”, “where?”)
Point to objects or pictures when named
Spontaneously and consistently identify simple pictures of objects in book
Stop momentarily what he is doing if an adult says “no” in a firm voice
Identify 2-3 common everyday objects or body parts when asked

Expressive (Speaking Skills):

Produce a wide variety of consonants (e.g., [b, d, m, n, h, w] in initial and [t, h, s] in final position of words) as well as most vowels. (Robb, & Bleile,(1994); Selby, Robb & Gilbert, 2000).
Have a vocabulary size nearing 50 words (e.g., 35-40)
Imitate adult words or vocalizations
Attempt to practice sounds and words (Clark, adapted by Owens, 2015)
Appropriately label familiar objects (foods, toys, animals)

Materials to use with the child to promote language and play:

Bubbles
Cause and effect toys
Toys with a variety of textures (soft toys, plastic toys, cardboard blocks, ridged balls)
Toys with multiple actions
Toys with special effects: lights, sounds, movement (push and go vehicles)
Building and linking toys
Toys with multiple parts
Balls, cars and trucks, animals, dolls
Puzzles
Pop-up picture books
Toys the child demonstrates an interest in (parents should advise)

Strategies:

Reduce distractions (noise, clutter etc)
Provide one on one interaction in a structured space (e.g., sitting at the play table or sitting on parent’s lap) to improve attention
Offer favorite activities and toys of interest initially before branching out to new materials
Offer favorite foods/toys as reinforcers to continue working
Offer choices of two toys, then remove one toy and focus interaction with one toy of interest
Try to prolong attention to toy for several minutes at a time
Change activities frequently, HOWEVER, repeat same activities in cycles over and over again during home practice in order to solidify skills
Label objects and actions in the child’s immediate environment
Use brief but loud utterances (2-3 words not more) to gain attention and understanding
Frequently repeat words in order to ensure understanding of what is said/expected of child
Use combination of gestures, signs, words, and pictures to teach new concepts
Do not force child to speak if he doesn’t want to rather attempt to facilitate production of gestures/sounds (e.g., use “hand over hand” to show child the desired gesture such as pointing/waving/motioning in order to reduce his/her frustration
Use play activities as much as possible to improve child’s ability to follow directions and comprehend language
- Doll House (with Little People)
- Garage
- Farm, etc

Core vocabulary categories for listening and speaking:

Favorite and familiar toys and objects
Names of people in the child’s life as well as his own name
Pets
Favorite or familiar foods
Clothing
Body parts
Names of daily activities and actions (go, fall, drink, eat, walk, wash, open)
Recurrence (more)
Names of places (bed, outside)
Safety words (hot, no, stop, dangerous, hurt, don’t touch, yuck, wait)
Condition words (boo-boo, sick/hurt, mad, happy)
Early pronouns (me, mine)
Social words (hi, bye, please, sorry)
Early concepts: in, off, on, out, big, hot, one, up, down, yucky, wet, all done)
Yes/no

Select References:

Owens, R. E. (2015). Language development: An introduction (9th ed.). Boston, MA: Allyn & Bacon.
Rescorla, L. (1989). The Language Development Survey: A screening tool for delayed language in toddlers. Journal of Speech and Hearing Disorders, 54, 587–599.
Rescorla, L., Hadicke-Wiley, M., & Escarce, E. (1993). Epidemiological investigation of expressive language delay
at age two. First Language, 13, 5–22.
Robb, M. P., & Bleile, K. M. (1994). Consonant inventories of young children from 8 to 25 months. Clinical Linguistics and Phonetics, 8, 295-320.
Selby, J. C., Robb, M. P., & Gilbert, H. R. (2000). Normal vowel articulations between 15 and 36 months of age. Clinical Linguistics and Phonetics, 14, 255-266.

Click HERE for the Early Intervention Evaluations PART IV: Assessing Pragmatic Abilities of Children Under 3

Stay Tuned for the next installment in this series:

Early Intervention Evaluations PART V: Assessing Feeding and Swallowing in Children Under Two

Posted on July 11, 2017May 16, 2022 by Tatyana Elleseff — 4 Comments

Improving Executive Function Skills of Language Impaired Students with Hedbanz

Those of you who have previously read my blog know that I rarely use children’s games to address language goals. However, over the summer I have been working on improving executive function abilities (EFs) of some of the language impaired students on my caseload. As such, I found select children’s games to be highly beneficial for improving language-based executive function abilities.

For those of you who are only vaguely familiar with this concept, executive functions are higher level cognitive processes involved in the inhibition of thought, action, and emotion, which located in the prefrontal cortex of the frontal lobe of the brain. The development of executive functions begins in early infancy; but it can be easily disrupted by a number of adverse environmental and organic experiences (e.g., psychosocial deprivation, trauma). Furthermore, research in this area indicates that the children with language impairments present with executive function weaknesses which require remediation.

EF components include working memory, inhibitory control, planning, and set-shifting.

Working memory
- Ability to store and manipulate information in mind over brief periods of time
Inhibitory control
- Suppressing responses that are not relevant to the task
Set-shifting
- Ability to shift behavior in response to changes in tasks or environment

Simply put, EFs contribute to the child’s ability to sustain attention, ignore distractions, and succeed in academic settings. By now some of you must be wondering: “So what does Hedbanz have to do with any of it?”

Well, Hedbanz is a quick-paced multiplayer (2-6 people) game of “What Am I?” for children ages 7 and up. Players get 3 chips and wear a “picture card” in their headband. They need to ask questions in rapid succession to figure out what they are. “Am I fruit?” “Am I a dessert?” “Am I sports equipment?” When they figure it out, they get rid of a chip. The first player to get rid of all three chips wins.

The game sounds deceptively simple. Yet if any SLPs or parents have ever played that game with their language impaired students/children as they would be quick to note how extraordinarily difficult it is for the children to figure out what their card is. Interestingly, in my clinical experience, I’ve noticed that it’s not just moderately language impaired children who present with difficulty playing this game. Even my bright, average intelligence teens, who have passed vocabulary and semantic flexibility testing (such as the WORD Test 2-Adolescent or the Vocabulary Awareness subtest of the Test of Integrated Language and Literacy ) significantly struggle with their language organization when playing this game.

So what makes Hedbanz so challenging for language impaired students? Primarily, it’s the involvement and coordination of the multiple executive functions during the game. In order to play Hedbanz effectively and effortlessly, the following EF involvement is needed:

Task Initiation
- Students with executive function impairments will often “freeze up” and as a result may have difficulty initiating the asking of questions in the game because many will not know what kind of questions to ask, even after extensive explanations and elaborations by the therapist.
Organization
- Students with executive function impairments will present with difficulty organizing their questions by meaningful categories and as a result will frequently lose their track of thought in the game.
Working Memory
- This executive function requires the student to keep key information in mind as well as keep track of whatever questions they have already asked.
Flexible Thinking
- This executive function requires the student to consider a situation from multiple angles in order to figure out the quickest and most effective way of arriving at a solution. During the game, students may present with difficulty flexibly generating enough organizational categories in order to be effective participants.
Impulse Control
- Many students with difficulties in this area may blurt out an inappropriate category or in an appropriate question without thinking it through first.
  - They may also present with difficulty set-shifting. To illustrate, one of my 13-year-old students with ASD, kept repeating the same question when it was his turn, despite the fact that he was informed by myself as well as other players of the answer previously.
Emotional Control
- This executive function will help students with keeping their emotions in check when the game becomes too frustrating. Many students of difficulties in this area will begin reacting behaviorally when things don’t go their way and they are unable to figure out what their card is quickly enough. As a result, they may have difficulty mentally regrouping and reorganizing their questions when something goes wrong in the game.
Self-Monitoring
- This executive function allows the students to figure out how well or how poorly they are doing in the game. Students with poor insight into own abilities may present with difficulty understanding that they are doing poorly and may require explicit instruction in order to change their question types.
Planning and Prioritizing
- Students with poor abilities in this area will present with difficulty prioritizing their questions during the game.

Consequently, all of the above executive functions can be addressed via language-based goals. However, before I cover that, I’d like to review some of my session procedures first.

Typically, long before game initiation, I use the cards from the game to prep the students by teaching them how to categorize and classify presented information so they effectively and efficiently play the game.

Rather than using the “tip cards”, I explain to the students how to categorize information effectively.

This, in turn, becomes a great opportunity for teaching students relevant vocabulary words, which can be extended far beyond playing the game.

I begin the session by explaining to the students that pretty much everything can be roughly divided into two categories animate (living) or inanimate (nonliving) things. I explain that humans, animals, as well as plants belong to the category of living things, while everything else belongs to the category of inanimate objects. I further divide the category of inanimate things into naturally existing and man-made items. I explain to the students that the naturally existing category includes bodies of water, landmarks, as well as things in space (moon, stars, sky, sun, etc.). In contrast, things constructed in factories or made by people would be example of man-made objects (e.g., building, aircraft, etc.)

When I’m confident that the students understand my general explanations, we move on to discuss further refinement of these broad categories. If a student determines that their card belongs to the category of living things, we discuss how from there the student can further determine whether they are an animal, a plant, or a human. If a student determined that their card belongs to the animal category, we discuss how we can narrow down the options of figuring out what animal is depicted on their card by asking questions regarding their habitat (“Am I a jungle animal?”), and classification (“Am I a reptile?”). From there, discussion of attributes prominently comes into play. We discuss shapes, sizes, colors, accessories, etc., until the student is able to confidently figure out which animal is depicted on their card.

In contrast, if the student’s card belongs to the inanimate category of man-made objects, we further subcategorize the information by the object’s location (“Am I found outside or inside?”; “Am I found in ___ room of the house?”, etc.), utility (“Can I be used for ___?”), as well as attributes (e.g., size, shape, color, etc.)

Thus, in addition to improving the students’ semantic flexibility skills (production of definitions, synonyms, attributes, etc.) the game teaches the students to organize and compartmentalize information in order to effectively and efficiently arrive at a conclusion in the most time expedient fashion.

Now, we are ready to discuss what type of EF language-based goals, SLPs can target by simply playing this game.

1. Initiation: Student will initiate questioning during an activity in __ number of instances per 30-minute session given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

2. Planning: Given a specific routine, student will verbally state the order of steps needed to complete it with __% accuracy given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

3. Working Memory: Student will repeat clinician provided verbal instructions pertaining to the presented activity, prior to its initiation, with 80% accuracy given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

4. Flexible Thinking: Following a training by the clinician, student will generate at least __ questions needed for task completion (e.g., winning the game) with __% accuracy given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

5. Organization: Student will use predetermined written/visual cues during an activity to assist self with organization of information (e.g., questions to ask) with __% accuracy given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

6. Impulse Control: During the presented activity the student will curb blurting out inappropriate responses (by silently counting to 3 prior to providing his response) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

7. Emotional Control: When upset, student will verbalize his/her frustration (vs. behavioral activing out) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

8. Self-Monitoring: Following the completion of an activity (e.g., game) student will provide insight into own strengths and weaknesses during the activity (recap) by verbally naming the instances in which s/he did well, and instances in which s/he struggled with __% accuracy given (maximal, moderate, minimal) type of ___ (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

There you have it. This one simple game doesn’t just target a plethora of typical expressive language goals. It can effectively target and improve language-based executive function goals as well. Considering the fact that it sells for approximately $12 on Amazon.com, that’s a pretty useful therapy material to have in one’s clinical tool repertoire. For fancier versions, clinicians can use “Jeepers Peepers” photo card sets sold by Super Duper Inc. Strapped for cash, due to highly limited budget? You can find plenty of free materials online if you simply input “Hedbanz cards” in your search query on Google. So have a little fun in therapy, while your students learn something valuable in the process and play Hedbanz today!

Related Smart Speech Therapy Resources:

Posted on June 25, 2017January 5, 2022 by Tatyana Elleseff — 4 Comments

Early Intervention Evaluations PART II: Assessing Suspected Motor Speech Disorders in Children Under 3

In my previous post on this topic, I brought up concerns regarding the paucity of useful information in EI SLP reports for children under 3 years of age and made some constructive suggestions of how that could be rectified. In 2013, I had written about another significant concern, which involved neurodevelopmental pediatricians (rather than SLPs), diagnosing Childhood Apraxia of Speech (CAS), without the adequate level of training and knowledge regarding motor speech disorders. Today, I wanted to combine both topics and delve deeper into another area of EI SLP evaluations, namely, assessments of toddlers with suspected motor speech disorders.

Firstly, it is important to note that CAS is disturbingly overdiagnosed. A cursory review of both parent and professional social media forums quickly reveals that this diagnosis is doled out like candy by both SLPs and medical professionals alike, often without much training and knowledge regarding the disorder in question. The child is under 3, has a limited verbal output coupled with a number of phonological processes, and the next thing you know, s/he is labeled as having Childhood Apraxia of Speech (CAS). But is this diagnosis truly that straightforward?

Let us begin with the fact that all reputable organizations involved in the dissemination of information on the topic of CAS (e.g., ASHA, CASANA, etc.), strongly discourage the diagnosis of CAS in children under three years of age with limited verbal output, and limited time spent in EBP therapy specifically targeting the remediation of motor speech disorders.

Assessment of motor speech disorders in young children requires solid knowledge and expertise. That is because CAS has a number of overlapping symptoms with other speech sound disorders (e.g., severe phonological disorder, dysarthria, etc). Furthermore, symptoms which may initially appear as CAS may change during the course of intervention by the time the child is older (e.g., 3 years of age) which is why diagnosing toddlers under 3 years of age is very problematic and the use of “suspected” or “working” diagnosis is recommended (Davis & Velleman, 2000) in order to avoid misdiagnosis. Finally, the diagnosis of CAS is also problematic due to the fact that there are still to this day no valid or reliable standardized assessments sensitive to CAS detection (McCauley & Strand, 2008).

In March 2017, Dr. Edythe Strand wrote an excellent article for the ASHA Leader entitled: “Appraising Apraxia“, in which she used a case study of a 3-year-old boy to describe how a differential diagnosis for CAS can be performed. She reviewed CAS characteristics, informal assessment protocols, aspects of diagnosis and treatment, and even included ‘Examples of Diagnostic Statements for CAS’ (which illustrate how clinicians can formulate their impressions regarding the child’s strengths and needs without explicitly labeling the child’s diagnosis as CAS).

Today, I’d like to share what information I tend to include in speech-language reports geared towards the assessing motor speech disorders in children under 3 years of age. I have a specific former client in mind for whom a differential diagnosis was particularly needed. Here’s why.

This particular 30-month client, TQ, (I did mention that I get quite a few clients for assessment around that age), was brought in due to parental concerns over her significantly reduced speech and expressive language abilities characterized by unintelligible “babbling-like” utterances and lack of expressive language. All of TQ’s developmental milestones with the exception of speech and language had been achieved grossly at age expectancy. She began limitedly producing word approximations at ~16 months of age but at 30 months of age, her verbal output was still very restricted. She mainly communicated via gestures, pointing, word approximations, and a handful of signs.

Interestingly, as an infant, she had a restricted lingual frenulum. However, since it did not affect her ability to feed, no surgical intervention was needed. Indeed, TQ presented with an adequate lingual movement for both feeding and speech sound production, so her ankyloglossia (or anterior tongue tie) was definitely not the culprit which caused her to have limited speech production.

Prior to being reevaluated by me, TQ underwent an early intervention assessment at ~26 months of age. She was diagnosed with CAS by an evaluating SLP and was found to be eligible for speech-language services, which she began receiving shortly thereafter. However, Mrs. Q noted that TQ was making very few gains in therapy and her treating SLP was uncertain regarding why her progress in therapy was so limited. Mrs. Q was also rather uncertain that TQ’s diagnosis of CAS was indeed a correct one, which was another reason why she sought a second opinion.

Assessment of TQ’s social-emotional functioning, play skills, and receptive language (via a combination of Revised Westby Play Scale (Westby, 2000), REEL-3, & PLS-5) quickly revealed that she was a very bright little girl who was developing on target in all of the tested areas. Assessment of TQ’s expressive language (via REEL-3, PLS-5 & LUI*), revealed profoundly impaired, expressive language abilities. But due to which cause?

Despite lacking verbal speech, TQ’s communicative frequency (how often she attempted to spontaneously and appropriately initiate interactions with others), as well as her communicative intent (e.g., gaining attention, making requests, indicating protests, etc), were judged to be appropriate for her age. She was highly receptive to language stimulation given tangible reinforcements and as the assessment progressed she was observed to significantly increase the number and variety of vocalizations and word approximations including delayed imitation of words and sounds containing bilabial and alveolar nasal phonemes.

For the purpose of TQ’s speech assessment, I was interested in gaining knowledge regarding the following:

Automatic vs. volitional control
Simple vs. complex speech production
Consistency of productions on repetitions of the same words/word approximations
Vowel Productions
Imitation abilities
Prosody
Phonetic inventory
Phonotactic Constraints
Stimulability

TQ’s oral peripheral examination yielded no difficulties with oral movements during non-speaking as well as speaking tasks. She was able to blow bubbles, stick out tongue, smile, etc as well as spontaneously vocalize without any difficulties. Her voice quality, pitch, loudness, and resonance during vocalizations and approximated utterances were judged to be appropriate for age and gender. Her prosody and fluency could not be determined due to lack of spontaneously produced continuous verbal output.

Phonetic inventory of all the sounds TQ produced during the assessment is as follows:
- Consonants: plosive nasals (/m/) and alveolars (/t/, /d/, n), as well as a glide (/w/)
- Vowels: (/a/, /e/, /i/, /o/)
TQ’s phonotactic repertoire was primarily comprised of word approximations restricted to specific sounds and consisted of CV (e.g., ne), VCV (e.g., ada), CVC (e.g., nyam), CVCV (e.g., nada), VCVC (e.g., adat), CVCVCV (nadadi), VCVCV(e.g., adada) syllable shapes
TQ’s speech intelligibility in known and unknown contexts was profoundly reduced to unfamiliar listeners. However, her word approximations were consistent across all productions.
Due to the above I could not perform an in-depth phonological processes analysis

However, by this time I had already formulated a working hypothesis regarding TQ’s speech production difficulties. Based on her speech sound assessment TQ presented with severe phonological disorder characterized by restricted sound inventory, simplification of sound sequences, as well as patterns of sound use errors (e.g., predominance of alveolar /d/ and nasal /n/ sounds when attempting to produce most word approximations) in speech (Stoel-Gammon, 1987).

TQ’s difficulties were not consistent with the diagnosis Childhood Apraxia of Speech (CAS) at that time due to the following:

Adequate and varied production of vowels
Lack of restricted use of syllables during verbalizations (TQ was observed to make verbalizations up to 3 syllables in length)
Lack of disruptions in rate, rhythm, and stress of speech
Frequent and spontaneous use of consistently produced verbalizations
Lack of verbal groping behaviors when producing word-approximations
Good control of pitch, loudness and vocal quality during vocalizations

I felt that the diagnosis of CAS was not applicable because TQ lacked a verbal lexicon and no specific phonological intervention techniques had been trialed with her during the course of her brief therapy (~4 months) to elicit word productions (Davis & Velleman, 2000; Strand, 2003). While her EI speech therapist documented that therapy has primarily focused on ‘oral motor activities to increase TQ’s awareness of her articulators and to increase imitation of oral motor movements’, I knew that until a variety of phonological/motor-speech specific interventions had been trialed over a period of time (at least ~6 months as per Davis & Velleman, 2000) the diagnosis of CAS could not be reliably made.

I still, however, wanted to be cautious as there were a few red flags I had noted which may have potentially indicative of a non-CAS motor speech involvement, due to which I wanted to include some recommendations pertaining to motor speech remediation.

Now it is possible that after 6 months of intensive application of EBP phonological and motor speech approaches TQ would have turned 3 and still presented with highly restricted speech sound inventory and profoundly impaired speech production, making her eligible for the diagnosis of CAS in earnest. However, at the time of my assessment, making such diagnosis in view of all the available evidence would have been both clinically inappropriate and unethical.

So what were my recommendations you may ask? Well, I provisionally diagnosed TQ with a severe phonological disorder and recommended that among a variety of phonologically-based approaches to trial, an EBP approach to the treatment of motor speech disorders be also used with her for a period of 6 months to determine if it would expedite speech gains.

*For those of you who are interested in the latest EBP treatment for motor speech disorders, current evidence supports the use of the Rapid Syllable Transition Treatment (ReST). ReST is a free EBP treatment developed by the SLPs at the University of Sydney, which uses nonsense words, designed to help children coordinate movements across syllables in long words and phrases as well as helps them learn new speech movements. It is, however, important to note for young children with highly restricted sound inventories, characterized by a lack of syllable production, ReST will not be applicable. For them, the Integral Stimulation/Dynamic Temporal and Tactile Cueing (DTTC) approaches do have some limited empirical support.

I also made sure to make a note in my report regarding the inappropriate use of non-speech oral motor exercises (NSOMEs) in therapy, indicating that there is NO research to support the use of NSOMEs to stimulate speech production (Lof, 2010).

In addition to the trialing of phonological and motor based approaches I also emphasized the need to establish consistent lexicon via development of functional words needed in daily communication and listed a number of examples across several categories. I made recommendations regarding select approaches and treatment techniques to trial in therapy, as well as suggestions for expansion of sounds and structures. Finally, I made suggestions for long and short term therapy goals for a period of 6 months to trial with TQ in therapy and provided relevant references to support the claims I’ve made in my report.

You may be interested in knowing that nowadays TQ is doing quite well, and at this juncture, she is still, ineligible for the diagnosis CAS (although she needs careful ongoing monitoring with respect to the development of reading difficulties when she is older).

Now I know that some clinicians will be quick to ask me: “What’s the harm in overdiagnosing CAS if the child’s speech production will still be treated via the application of motor speech production principles?” Well, aside from the fact that it’s obviously unethical and can result in terrifying the parents into obtaining all sorts of questionable and even downright harmful bunk treatments for their children, the treatment may only be limitedly appropriate, and may not result in the best possible outcomes for a particular child. To illustrate, TQ never presented with CAS and as such, while she may have initially limitedly benefited from the application of motor speech principles to address her speech production, shortly thereafter, the application of the principles of the dynamic systems theory is what brought about significant changes in her phonological repertoire.

That is why the correct diagnosis is so important for young children under 3 years of age. But before it can be made, extensive (reputable and evidence supported) training and education are needed by evaluating SLPs on the assessment and treatment of motor speech disorders in young children.

References:

Davis, B & Velleman, S (2000). Differential diagnosis and treatment of developmental apraxia of speech in infants and toddlers”. The Transdisciplinary Journal. 10 (3): 177 – 192.
Lof, G., & Watson, M. (2010). Five reasons why nonspeech oral-motor exercises do not work. Perspectives on School-Based Issues, 11.109-117.
McCauley RJ, Strand EA. (2008). A Review of Standardized Tests of Nonverbal Oral and Speech Motor Performance in Children. American Journal of Speech-Language Pathology, 17,81-91.
McCauley R.J., Strand E., Lof, G.L., Schooling T. & Frymark, T. (2009). Evidence-Based Systematic Review: Effects of Nonspeech Oral Motor Exercises on Speech, American Journal of Speech-Language Pathology, 18, 343-360.
Murray, E., McCabe, P. & Ballard, K.J. (2015). A Randomized Control Trial of Treatments for Childhood Apraxia of Speech. Journal of Speech, Language and Hearing Research 58 (3) 669-686.
Stoel-Gammon, C. (1987). Phonological skills of 2-year-olds. Language, Speech, and Hearing Services in Schools, 18, 323-329.
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