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A case for early speech-language assessments of adopted children in the child’s birth language.

A case for early speech-language assessments of adopted children in the child’s birth language.

Tatyana Elleseff MA CCC-SLP

As more and more research is being published on communication, linguistic abilities, as well as speech and language delay of adopted children, a debate has arisen with regard to the necessity of early assessment of speech and language abilities of newly adopted children. Many medical and related professionals have posed a relevant question: “What is the purpose of performing a speech-language evaluation immediately after arriving in the U.S.?” After all how can you perform an evaluation in English when the child has minimal knowledge of English at the time of arrival? And what about speech and language evaluation conducted in the birth language post arrival? Will it yield any definitive or predictive results given that within a relatively short period (2-6 months depending on which study you look at) the child would have lost the birth language and rapidly gained English? And honestly, can one really translate or adapt a test standardized on English speaking children to the child’s birth language (e.g., Russian) with any hope of reliable results?

The truth is that one definitive answer simply does not exist. It would be erroneous to state that ‘yes’ all newly adopted children need to be assessed within the first week of US arrival or “no” you can wait until the child has been in the country for several months before a reliable assessment can be performed. Here, I think that an individualized and educated approach is necessary in order to determine whether an early speech–language assessment may be appropriate for your newly adopted child.

In order to better explain my position on this issue, I must mention something of my own background and how it affects my approach to speech and language assessments. I am a bilingual, Russian-English, speaking speech language therapist, and I specialize in assessing children adopted from Eastern Europe (vs. South America or China, etc).

I am also in a rather unique position because all internationally adopted children that I’ve evaluated to date have traditionally been referred to me by a medical or a related professional (pediatrician or psychologist vs. a parent who’s contacted me without a specific referral) who felt that the child needed to be seen because of a specific speech or language deficit that was manifesting rather overtly (e.g., significant speech or language delay in birth language).

Since such referrals are frequently made within the child’s first 2 weeks of being in US (e.g., immediately following a visit to the pediatrician), I typically perform the initial speech and language assessment in Russian, using recently published Russian speech language pathology materials, which though are non-standardized (in Russia standardized speech and language protocols haven’t been developed yet) are still more reliable than the standardized tests translated from English. Here, my window of opportunity to assess the child in his/her native language is very narrow, as birth language attrition occurs very rapidly post adoption.

So what do these early speech and language assessments in the child’s birth language reveal to me?

Well, quite a lot actually!

Let’s start by age range:

First let’s talk about children ages 0-3.

Depending on a country, the youngest age children become available for adoption is 7-9 months and depending on length and complexity of the adoption process, may become legally adopted by 12 months of age or older. My first concern with this group (+/-1 – 3 years) is the child’s feeding and swallowing abilities. Difficulties may range from immature feeding skills (e.g., immature chewing abilities) to a more severe failure to thrive, to even structural or functional deviations of the swallow mechanism, which may require detailed imaging tests and subsequent dysphagia therapy. In some rare instances, more serious discoveries were made during those initial speech and language assessments such as presence of vocal webs and submucous clefts, conditions which actually required surgical intervention.

Another concern with this age range are the child’s speech and language abilities or I should say lack of thereof. In the case of younger children (15-18 months), the “red flag” is a complete absence of words, jargon, babbling or general lack of any sound production during both – their early development and the parent bonding pre-adoption period during which the parents intensively interact and communicate with the child. In older children (2.5-3 years of age) the “red flag” is the general absence of phrases and/or words in their birth language, which is a strong indication that assessment is merited.

Finally, with this age group, any form of abnormal social interaction should be thoroughly investigated. Many children who have resided in very deprived institutional environments may present with a pattern of autistic-type behaviors. In reaction to emotional trauma, loss of primary caregiver, isolation in hospital cribs, and lack of stimulation, some children may develop symptoms often found in autistic children and may exhibit limited communicative intent in the absence of speech (make limited gestures, vocalizations, eye contact, etc). As a result, an early speech and language assessment in conjunction with other testing (neurological, psychological, etc) may shed light on whether the child presents with a form of institutional autism or true autistic spectrum behavior.

Unfortunately, internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Knowing the above, oftentimes it is important to determine a degree of delay (severe vs. mild), and if it’s not that clear (especially if the child is under 3 years of age and the parents don’t speak the child’s birth language or are not familiar with typical developmental milestones) than a safer choice would be an initial speech and language assessment in the child’s birth language which can determine the type and degree of delay and make recommendations regarding the necessity of further services.

It is also important to highlight that a child’s mastery of the birth language is a good predictor of the rate of learning the new language. Many professionals make an error of assuming that internationally adopted infants and toddlers will not be affected by cross-linguistic interference because the children have just begun to learn the birth language at the time of adoption, before the attrition of birth language occurred. However, due to a complex constellation of factors, language delays in birth language transfer and become language delays in a new language. These delays will typically persist unless appropriate intervention is provided. For older children (3 years +), the delays will be very recognizable and will likely be part of the child’s adoption record but for younger children an early speech and language assessment may be the first step on the way to appropriate language remediation.

Now let’s talk about older children. In our second group, the age range at the time of adoption will range from 3-16 years (although it is important to note that most adopted older children will be in the range of 3-12 years, while adoption of children 12+ is somewhat less common).

Here, most speech and language delays will be more acutely pronounced and as a result far more recognizable. As mentioned above they will also probably be clearly documented in the child’s adoption records. With this age-range there are a number of concerns ranging from poor articulation to language delay to social pragmatic communication impairments.

So how do professionals and parents decide which child merits early assessment?
With regard to articulation, it’s important to keep in mind that if the child is limitedly intelligible in their birth language, they will continue making similar error patterns in English unless they receive appropriate intervention. So assessment is definitely merited.

Similarly, if at the time of adoption, a preschool or school age child presents with delayed language abilities in their birth tongue (e.g., inability to answer “wh” questions, speaking in phrases vs. sentences, etc) then no matter how quickly they will gain basic English proficiency, it is reasonable to expect that similar difficulty will be encountered in English with respect to academically based tasks. In other words they may gain basic skills fairly appropriately but then present with significant deficits acquiring higher level listening and speaking abilities required for long-term academic success.

Another reason why it’s important to assess a child in the birth language in the first few weeks post arrival has to do with their pragmatic language skills or the appropriate use of language. Pragmatic language ability is the ability to appropriately initiate conversations, maintain and terminate topics, appropriately narrate stories, understand jokes and sarcasm, interpret non-verbal body cues, all of which culminate into the child’s general ability to appropriately interact with others in a variety of social settings.

As mentioned above, many children who have resided in deprived institutional environments may present with a pattern of unusual social behaviors, be socially withdrawn, or present with poor ability to socialize with others. Thus, the longer is the period of time the child spends in the institutional environment the greater is the risk of social pragmatic deficits. Unfortunately, this important area of language often receives merely cursory attention.

To illustrate, in recent years I have assessed a number of adopted children, who were 5-7 years post adoption, and had never previously received any speech and language services. Once brought to US they quickly gained English language proficiency and did not seemingly present with any of the “red flags” described above.

The reason these children were referred for intervention so many years later was because “seemingly overnight” they developed numerous difficulties. Oh, they were still getting good grades and presented with adequate vocabulary skills. But both parents and educators were getting concerned that these children were acting very immature for their age, had problems socializing with other children, presented with difficulty understanding figurative language, could not understand non-verbal conversational and social cues, couldn’t coherently express their thoughts, and presented with significant difficulty understanding and retelling stories.

Interestingly, when questioned further, all interviewed parents revealed that the above difficulties had existed from the get-go albeit in a milder form in their child but in the presence of appropriate receptive and expressive skills these difficulties were not deemed worthy of assessment/ intervention. Had these children received early assessment when these problems were first noticed, the outcome (degree of impairment; duration of therapy) might have been entirely different.

Up until now we have discussed the ‘red flags’ which indicate the necessity for early speech and language assessment and intervention of adopted children in their birth language. However, once these children are in therapy, many parents would also like to know if there are any specific predictors for successful language remediation and decreased duration of services?

Unfortunately, it is impossible to answer this question definitively due to the variability of each child’s progress as well as the type and degree of their impairment. Having said that, from my personal clinical experience, what I have found is that if the child has good problem solving abilities (as per non-verbal IQ testing and certain language reasoning tasks) and grossly appropriate social pragmatic language skills, even if the child presents with a moderate-severe speech and language impairment, he/she will generally fare better in treatment with respect to duration of service as well as therapy gains, versus the less severely impaired peers with poorer problem solving and social pragmatic skills.

So, do all newly adopted children require early speech language assessments? Not, at all. However, understanding the “red flags” for each age group will be helpful for both parents and professionals when they make their decision to refer a newly adopted child for a an early speech-language assessment.

As always, if parents or related professionals would like to find more information on this topic, they should visit the ASHA website at www.asha.org and type in their query in the search window located in the upper right corner of the website.

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How to select the right speech language pathologist for your adopted child?


How to select the right speech language pathologist for your adopted child?

You have decided to consult a private speech language pathologist because of concerns over your adopted child’s developing speech and language. But how do you choose the right one? There are many speech therapists out there and not all of them are alike in experience and skills. On top of it all, you are also looking for a bilingual therapist, one who is not only proficient in your child’s native language but is also knowledgeable regarding the speech and language issues of international adoptees. That is not an easy decision to make, especially for many parents who until now have not had any direct contact with a speech language pathologist.
Not to worry, below is a list of simple guidelines designed to assist you in the right therapist selection.

Let’s begin with something basic: educational and professional credentials. A speech language pathologist must possess a Master’s Degree (or its equivalent) from a reputable academic institution of higher learning. They must also have a Certificate of Clinical Competence from the American Speech Language Hearing Association as well as an appropriate licensure from the state in which they maintain their practice. Additionally, it is highly recommended that they have Bilingual Certification as it indicates that they have completed the necessary academic coursework and are proficient in the issues surrounding normal and disordered speech-language acquisition of bilingual children in dual languages.

Now we are ready to proceed to experience. Here its gets a little tricky. The traditional approach: “I want the therapist with a gazillion years of experience” is just not going to be all that useful. It can’t be just any experience; it has to be the right experience! After all do you really want a therapist with 30 years of experience in exclusively treating articulation deficits when your child needs help with feeding and swallowing or with developing augmentative/alternative communication?

It is important to choose a therapist who has a rich and varied experience from multiple settings, total years of experience may not be as important as the qualitative value of that experience. A good therapist has probably spent a considerable portion of his/her time in a variety of settings from schools and early intervention agencies to hospitals and rehabilitation clinics. As the result of working in these diverse environments that therapist is much more likely to come up with innovative ideas and solutions to your child’s problems as opposed to just using the same old remediation strategies that they have learned way back then. It is also a good idea to inquire regarding the areas of specialization of the therapist in order to find out whether he/she has successfully treated children with similar problems to your child’s.

Typically, private speech language pathologists who maintain some type of pediatric hospital affiliation (e.g. per diem or part-time employees) are up to date regarding the current methodologies, which they apply to practice on daily basis. The reasons for that are twofold:

Speech departments in hospitals deal with diverse caseloads, with patients ranging in ages, diagnoses (some of which can be quite unusual), and levels of severity. In an average inpatient department staff SLP’s are expected to carry caseloads of 12-16 patients per day.
In order to keep up with the caseload diversity and with the latest treatment trends, hospitals require these SLP’s to actively take professional development courses in order to provide their patients with the best quality of care.
This brings us to another important consideration: professional development. To maintain their state licensure and national certification all therapists are required to take professional education courses in order to stay up to date with all the relevant research and new treatments developed in our field. The minimum requirement is to accumulate 30 professional education hours every 3 years whether by attending courses in person, taking them online through qualified providers, or by conducting workshops and presenting at conferences. Professional development provides the speech therapists with an opportunity to use evidence based techniques supported and tested by research to treat a variety of communication disorders. Consequently, when selecting your therapist it is important to find out just how up to date are they on the current treatment methods and methodologies pertaining to your child speech and language deficits. You can always find out this information by politely questioning the therapist regarding their background and “resume highlights.”

It is also important to find out whether you understand and agree with the therapist’s methods and approaches. For example, if your child is a toddler, it probably does not make sense for him/her to spend most sessions doing worksheets and drills when he/she needs to be engaged in play based, child centered therapy. Don’t be intimidated by the therapist’s credentials and your lack of knowledge, if something they said doesn’t make sense, ask follow up questions and/or look up pertinent information online. While you should not use the internet to diagnose your child’s problems, it can be used as a valuable learning tool to look up information and to share ideas with other parents who experience similar difficulties.

Now that we have specified general selection criteria, let’s talk about how to initiate your search for the right SLP. The best way is again to go online. Start your search by going to the ASHA website and clicking on the ‘Find Professional Button’ located in the top of the page and then follow the instructions on the screen. Fill out your search criteria carefully but don’t be too specific. For example, don’t look for a Russian speaking SLP in Blue Creek, California as you will probably not find one. Instead try typing in the first 3 digits of your zipcode or your state of residence (if it’s small enough) and don’t forget to specify the language of the practitioner. That will get you the optimum results.

Once you have located several candidates, you can narrow down the search by trying to learn something about them online. Google the clinician’s name (or the name of their practice) to see whether they have their own website, have written any articles or have been profiled by any organizations. To make sure that your practitioner’s licensure is up to date, visit your state’s speech language accreditation website and type in the last name of the professional. Typically, a window will pop up listing the therapists’ names alphabetically, find the one you are looking for and check if their license is active. Finally, armed with your research, create a list of questions that you might have for the practitioners and start making phone calls. Find out all the pertinent information and don’t forget to ask about rates which may differ depending on what services the practitioner is providing.

Please note that many private practitioners refuse to deal with insurance companies directly due to the hassle of multiclient billing as well as extended wait for reimbursement. They will instead provide you with a letter for your insurance company, containing the necessary diagnosis and treatment codes, incurred fees as well as a brief description of services provided, and will expect you to apply for reimbursement on your own.

Now that we have gone over the selection process in some detail, please keep in mind that you can always learn more information on this and any other speech pathology related topic by visiting the ASHA website and clicking on the ‘Public’ tab located at the top of the screen.

Best of luck in your search and happy hunting!

Useful websites:
Find a Professional SLP on the ASHA website: http://www.asha.org/proserv/
State Contacts & Licensure Requirements: http://www.asha.org/about/legislation-advocacy/state/

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Functional Strategies for Improving the Language Abilities of Your Adopted School-Age Child

Functional Strategies for Improving the Language Abilities of Your Adopted School-Age Child.

While most internationally adopted children catch up to their peers in language development somewhat quickly, not all internationally adopted children demonstrate equal progress by the time they reach school age. Below are some suggestions on how parents can facilitate their school age child’s language skills and improve their language abilities via fun interactive games that the whole family can enjoy and benefit from.

There are several language functions important for academic success. Typically this hierarchy develops from the most basic to the most complex, with the earliest stages beginning long before the child reaches school age. These functions include the ability to: seek information, inform, compare, order, classify, analyze, infer, justify/persuade, solve problems, synthesize, and evaluate. For some children those abilities come naturally while for others – a creative push in the right direction might just do the trick. Luckily, there are plenty of children’s games on the market that address the above skills in a fun and functional way, oftentimes without the child even realizing that they are doing work.

One of the earliest and important areas of language development is vocabulary knowledge. Good vocabulary skills are essential for communication of thoughts and ideas, interaction with peers, as well as meeting the demands of the classroom. As academic demands increase the importance of good vocabulary comes prominently into play. Vocabulary hierarchy ranges from a simple ability of labeling (providing a name for people, actions and objects) to the advanced descriptions (using attributes, functions, and learned concepts to depict an object/item in a cohesive manner). As children’s vocabulary increases from basic labeling to using sophisticated descriptions it goes through several other important stages outlined below:

• Concept Knowledge – the ability to comprehend and identify qualitative (e.g., same–different, big– little, hot-cold), quantitative (e.g., few-many, more-less), temporal (e.g., before-after, next, first, last), or spatial (e.g., in-on, under-over) concepts
• Associations – knowledge of how words are semantically related/linked (e.g., knowing why a spoon and a knife go together)
• Categorization/Classification – the ability to identify items within a category (divergent naming) and provide labels for groups/classes of objects (convergent naming)

The following are just a few selected examples of available games (a more complete list will be provided at the end of this article) that should help facilitate the development of vocabulary language skills:
A to Z Jr- a game of early categorizations is recommended for players 5 – 10 years of age, but can be used with older children depending on their knowledge base. The object of the game is to cover all letters on your letter board by calling out words in specific categories before the timer runs out. This game can be used to increase word finding abilities in children with weak language skills as the categories range from simple (e.g., colors) to more complicated (e.,. animals with stripes). This game is great for several players of different age groups (e.g., older siblings), since children with weaker knowledge and language skills can answer simpler questions and learn the answers to the harder questions as other players get their turn.

Tribond Jr – is another great game which purpose is to determine how 3 seemingly random items are related to one another. Good for older children 7-12 years of age it’s also great for problem solving and reasoning as some of the answers are not so straight forward (e.g., what do the clock, orange and circle have in common? Psst…they are all round)

Password Jr-is a great game to develop the skills of description. In the game you guess passwords based on the one word clues. This game is designed to play with children ages 7 years and older as long as the parents help the non readers with the cards. It’s great for encouraging children to become both better at describing and at listening. Parents are encouraged to allow their kids to select the word they want to describe in order to boost their confidence in own abilities. Parents are also encouraged to provide visual cheat sheets (listing ways we can describe something such as: what does it do, where does it go, how can we use it etc) to the child as they will be much more likely to provide more complete descriptions of the target words given visual cues.

Blurt – a game for children 10 and up is a game that works on a simple premise. Blurt out as many answers as you can in order to guess what the word is. Blurt provides ready-made definitions that you read off to players so they could start guessing what the word is. Players and teams use squares on the board strategically to advance by competing in various definition challenges that increase language opportunities.

However, vocabulary knowledge alone does not determine academic success. There are other equally valuable language skills which are important as well. One of them is asking and answering questions. Being able to ask and answer questions is an integral part of academic success.

Asking questions is one of the main ways that children obtain knowledge about the world beyond their immediate experience. Children who are unable to ask questions are at a disadvantage when it comes to following directions or understanding difficult concepts since they are unable to request repetition and clarification from speakers. Moreover, the inability to answer questions effectively is an indication that the child will not be understood well by others. Being able to answer concrete and abstract questions is another necessary requirement for success in school. Games such as Guess Who (age 6+), Guess Where (age 6+), and Mystery Garden (age 4+) are great for encouraging students to ask relevant questions in order to be the first to win the game. They are also terrific for encouraging reasoning skills. Questions have to be thought through carefully in order to be the first one to win the game.

Another important ability in the language learning hierarchy is story telling. Being able to tell good stories is a difficult task for many children, even those without language impairment. Consequently, one way of learning to become a good story teller is through the usage of visual cues such as picture cards, or games. When children are very young speech therapists often work on improving their story telling abilities using props such as a variety of toys or puppets. As they get older they transition to picture cards or wordless story books with the final step being spontaneously produced stories with no visual support. One of such games is Fib or Not (ages 10+). The game encourages the players to fool other players by either telling an outlandish true story or a truly believable made up story. For the players who are listening to the story, the objective is to correctly guess if the story teller is fibbing or being truthful. Players advance by fooling the other players or by guessing correctly.

As children grow older, they are required to do more and more tasks that focus on their verbal reasoning and problem solving abilities. If your child’s problem solving skills are on the weaker side consider using events from storybooks that illustrate problems. Talk aloud about the problem and offer a list of choices if your child is having difficulties figuring out the answers. Have your child talk through the process of how they arrived to their conclusions and offer suggestions and guidance along the way. The two popular games that work on improving verbal reasoning and problem solving abilities are: 30 Second Mysteries (ages 8-12) and 20 Questions for Kids (ages 7+).

In 30 Second Mysteries kids need to use critical thinking and deductive reasoning in order to solve mysteriously sounding cases of everyday events. Each clue read aloud reveals more about the mystery and the trick is to solve it given the fewest number of clues in order to gain the most points. In 20 Questions for Kids, a classic guessing game of people, places, and things, children need to generate original questions in order to obtain information. Here again, each clue read aloud reveals more about the secret identity and the trick is to solve it given the fewest number of clues.

A good way of implementing the above games in action is during family fun night. Select a game that focuses on one or more elements that you feel your child needs to work on and then involve your entire family in a game playing activity so the child does not feel that they are being isolated for “work”. For children who are younger or with weaker vocabularies, modify the rules to help to simplify the demands of the game, or play in a team so that the child doesn’t feel overwhelmed. Feel free to provide your own cues and prompts in order to achieve maximum success with all gaming activities.

Now that we have gone over the game description and selection process in some detail, please keep in mind that you can always learn more about children’s games by simply going to a popular internet websites such as Amazon and reading product descriptions in order to figure out whether specific game is right fit for your child.

As always, parents are advised to consult with related professionals (speech and language therapists, psychologists, etc) if they have any serious concerns regarding their child’s communication skills. Early detection and treatment are critical to the process of successful speech and language development not just in early childhood but also during school age, adolescence, and even early adulthood.

Best of luck and have fun playing!

List of Selected Games:
• 20 Questions for Kids
• 30 Second Mysteries
• A to Z Jr.
• Blurt
• Fib or Not
• Guess Where?
• Guess Who?
• Last Word
• Loaded Questions
• Mystery Garden
• Outburst
• Password Junior
• Tribond Junior