Executive Function Impairments in At-Risk Pediatric Populations
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The Executive Functions Test-Elementary (EFT-E): What SLPs and Parents Need to Know
Recently I’ve purchased the Executive Functions Test-Elementary (EFT-E) by Linguisystems and used it with a few clients in my private practice and outpatient hospital-based school program. The EFT-E is a test of language skills that affect executive functions of working memory, problem solving, inferring, predicting outcomes, and shifting tasks. For those of you not familiar with executive functions (EFs), they are higher level cognitive processes involved in inhibition of thought, action and emotion, which are located in the prefrontal cortex of the frontal lobe of the brain. Continue reading The Executive Functions Test-Elementary (EFT-E): What SLPs and Parents Need to Know
Part IV: Components of Comprehensive Dyslexia Testing – Writing and Spelling
Recently I began writing a series of posts on the topic of comprehensive assessment of dyslexia.
In part I of my post (HERE), I discussed common dyslexia myths as well as general language testing as a starting point in the dyslexia testing battery.
In part II (HERE) I detailed the next two steps in dyslexia assessment: phonological awareness and word fluency testing.
In part III (HERE) I discussed reading fluency and reading comprehension testing.
Today I would like to discuss part IV of comprehensive dyslexia assessment, which involves spelling and writing testing.
Spelling errors can tell us a lot about the child’s difficulties, which is why they are an integral component of dyslexia assessment battery. There is a significant number of linguistic skills involved in spelling. Good spellers have well-developed abilities in the following areas (Apel 2006, Masterson 2014, Wasowicz, 2015):
- Phonological Awareness – segmenting, sequencing, identifying and discriminating sounds in words.
- Orthographic Knowledge – knowledge of alphabetic principle, sound-letter relationships; letter patterns and conventional spelling rules
- Vocabulary Knowledge -knowledge of word meanings and how they can affect spelling
- Morphological Knowledge- knowledge of “word parts”: suffixes, prefixes, base words, word roots, etc.; understanding the semantic relationships between base word and related words; knowing how to make appropriate modifications when adding prefixes and suffixes
- Mental Orthographic Images of Words- clear and complete mental representations of words or word parts
By administering and analyzing spelling test results or spelling samples and quizzes, we can determine where students’ deficits lie, and design appropriate interventions to improve knowledge and skills in the affected areas.
While there are a number of spelling assessments currently available on the market I personally prefer that the Test of Written Spelling – 5 (TWS-5) (Larsen, Hammill & Moats, 2013). The TWS-5 can be administered to students 6-18 years of age in about 20 minutes in either individual or group settings. It has two forms, each containing 50 spelling words drawn from eight basal spelling series and graded word lists. You can use the results in several ways: to identify students with significant spelling deficits or to determine progress in spelling as a result of RTI interventions.
Now, lets move on to assessments of writing. Here, we’re looking to assess a number of abilities, which include:
- Mechanics – is there appropriate use of punctuation, capitalization, abbreviations, etc.?
- Grammatical and syntactic complexity – are there word/sentence level errors/omissions? How is the student’s sentence structure?
- Semantic sophistication-use of appropriate vs. immature vocabulary
- Productivity – can the student generate enough paragraphs, sentences, etc. or?
- Cohesion and coherence- Is the writing sample organized? Does it flow smoothly? Does it make sense? Are the topic shifts marked by appropriate transitional words?
- Analysis – can the student edit and revise his writing appropriately?
Again it’s important to note that much like the assessments of reading comprehension there are no specific tests which can assess this area adequately and comprehensively. Here, a combination of standardized tests, informal assessment tasks as well as analysis of the students’ written classroom output is recommended.
For standardized assessment purposes clinicians can select Test of Early Written Language–Third Edition (TEWL–3) or Test of Written Language — Fourth Edition (TOWL-4).
The TEWL-3 for children 4-12 years of age, takes on average 40 minutes to administer (between 30-50 mins.) and examines the following skill areas:
Basic Writing. This subtest consists of 70 items ordered by difficulty, which are scored as 0, 1, or 2. It measures a child’s understanding of language including their metalinguistic knowledge, directionality, organizational structure, awareness of letter features, spelling, capitalization, punctuation, proofing, sentence combining, and logical sentences. It can be administered independently or in conjunction with the Contextual Writing subtest.
Contextual Writing. This subtest consists of 20 items that are scored 0 to 3. Two sets of pictures are provided, one for younger children (ages 5-0 through 6-11) and one for older children (ages 7-0 through 11-11). This subtest measures a child’s ability to construct a story given a picture prompt. It measures story format, cohesion, thematic maturity, ideation, and story structure. It can be administered independently or in conjunction with the Basic Writing subtest.
Overall Writing. This index combines the scores from the Basic Writing and Contextual Writing subtests. It is a measure of the child’s overall writing ability; students who score high on this quotient demonstrate strengths in composition, syntax, mechanics, fluency, cohesion, and the text structure of written language. This score can only be computed if the child completes both subtests and is at least 5 years of age.
The TOWL-4 for students 9-18 years of age, takes between 60-90 minutes to administer (often longer) and examines the following skill areas:
- Vocabulary – The student writes a sentence that incorporates a stimulus word. E.g.: For ran, a student writes, “I ran up the hill.”
- Spelling – The student writes sentences from dictation, making proper use of spelling rules.
- Punctuation – The student writes sentences from dictation, making proper use of punctuation and capitalization rules.
- Logical Sentences – The student edits an illogical sentence so that it makes better sense. E.g.: “John blinked his nose” is changed to “John blinked his eye.”
- Sentence Combining – The student integrates the meaning of several short sentences into one grammatically correct written sentence. E.g.: “John drives fast” is combined with “John has a red car,” making “John drives his red car fast.”
- Contextual Conventions – The student writes a story in response to a stimulus picture. Points are earned for satisfying specific arbitrary requirements relative to orthographic (E.g.: punctuation, spelling) and grammatic conventions (E.g.: sentence construction, noun-verb agreement).
- Story Composition – The student’s story is evaluated relative to the quality of its composition (E.g.: vocabulary, plot, prose, development of characters, and interest to the reader).
It has 3 composites:
- Overall Writing- results of all seven subtests
- Contrived Writing- results of 5 contrived subtests
- Spontaneous Writing-results of 2 spontaneous writing subtests
However, for the purposes of the comprehensive assessment only select portions of the above tests may need be administered since other overlapping areas (e.g., spelling, punctuation, etc.) may have already been assessed by other tests, a analyzed via the review of student’s written classroom assignments or were encompassed by educational testing.
SPELL-Links™ Wordtivities Word Lists Review and Giveaway
In 2020 I reviewed a product kit (instructional guide and cards) from SPELL-Links™ Learning By Design, Inc. entitled Wordtivities: Word Study Instruction for Spelling, Vocabulary, and Reading. Today, I am reviewing a companion to that product kit: SPELL-Links™ Wordtivities Word Lists. This 180-page guide contains sets of pattern-focused word lists for whole class, small group, and 1:1 word study instruction purposes. Each grade-level word list supports the simultaneous development of pattern-specific phonological (sound), orthographic (letter), and semantic morphological (meaning) skills. The aim of this guide is to systematically address spelling, reading, speaking, and listening all together by developing a neural network for literacy and language.
SPELL-Links™ Wordtivities Word Lists are useful for students 5+ years of age who have or are in the process of developing the following knowledge and skills:
- Letter-name knowledge
- Alphabetic letter writing ability
- Mastery of early phonological awareness (PA) skills by being able to segment words into syllables, understand and create rhyming words, and isolate sounds in words
- Basic concept knowledge of directionality (left/right; top/down)
The book is organized by patterns and grade levels (K-6 grade) and by the instructional focus. For each pattern, word lists are organized to support a specific instructional focus: phonological code, orthographic code, morphological code, storage and retrieval of orthographic representations, and writing application.
The Word Lists feature 128 patterns across grades K through 6. The number of patterns taught at each grade level ranges from 9 (K) to 25 (grades 4 and 5).
Here’s an example of a 4th-grade instructional overview:
Overview of Weekly Instruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Pattern: Prefixes pre- (before); mid- (middle); post- (after) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Pattern: Prefixes over- (above, more than); super- (superior, exceeding); under- (below, less than);
sub- (under, subordinate) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Pattern: ‘l, r’ Clusters ‘lb, ld, lf, lk, lm, lp, lt, lth, lve, lse’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Pattern: ‘l, r’ Clusters ‘rd, rf, rm, rn, rp, rt, rsh, rch, rth, rve, rge’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Pattern: ‘l, r’ Clusters ‘rse, rce’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Pattern: Homophones Set 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Pattern: Suffixes -ion, -ation, -ition (N) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Pattern: Suffix -ment (N) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Pattern: Suffix -en (V, ADJ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99
Pattern: ‘m, n, ng’ Clusters ‘nd, nt, mp, mph, nth, nch, ngth, nge’ . . . . . . . . . . . . . . . . . . . . . . . . . 100
Pattern: ‘m, n, ng’ Clusters ‘nk, nc’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Pattern: ‘m, n, ng’ clusters ‘nce, nse’ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Pattern: Homophones Set 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Pattern: Syllabic-r Vowel Sound as in bird, father . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
Pattern: Suffix -ward (ADJ, ADV) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Pattern: Unstressed Vowels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
Pattern: Syllabic-l Vowel Sound as in bottle, pencil . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Pattern: Suffix -al (ADJ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Pattern: Suffixes -able, ible (ADJ) …………………………………………….. 109
Pattern: Suffix -ous (ADJ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Pattern: Suffixes -ive, -ative, -itive (N, ADJ)………………………………………. 111
Pattern: Suffix -ure (N) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
Pattern: Contractions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Pattern: Prefix tele- (far); micro- (tiny) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Pattern: Prefixes mono-, uni-, bi-, tri-, quad-, oct- (number affixes) . . . . . . . . . . . . . . . . . . . . . . . . 115
Pattern Review
The weekly instruction will look as follows:
- Monday-Tuesday: Review of Phonological and Orthographic Codes (these word pattern lists are organized into 3 groups to support differentiated instruction)
- Wednesday–Thursday: Morphology
- Friday: Mental Orthographic Representations and Application to Sentence Writing
The book comes with access to digital Materials Library, which contains access to the following materials:
- List of pattern-loaded stories
- SPELL-Links™ Pattern Inventory & Analysis Tool (PIAT)
The appeal of the product for me is that it offers numerous group-based opportunities for the solidification of evidence-based instructional practices. The book comes with very detailed implementation instructions. A variety of daily activities allow students to further advance their abilities in the areas of prefixes and suffixes, numerous homophones and clusters, unstressed vowels and even contractions. The kit also offers several appendices that review the spelling rules for word roots prefixes and suffixes, as well as detailed recommendations for pattern-loaded reading materials. To me, the appeal of this curriculum is rather multifaceted. It continues to be very difficult to find an evidence-based group instruction curriculum, and Wordtivities Word Lists once again fit the bill for it. Because it focuses on skills integration of spelling, reading, speaking, and listening it allows the students to engage in contextually based opportunities to become better listeners, speakers, readers, spellers and writers.
You can find this kit for purchase on the SPELL-Links™ Learning By Design, Inc. Store HERE.
And now for the fun part. Want to win your own copy of SPELL-Links™ Wordtivities Word Lists? Enter to win here: I want to win SPELL-Links Wordtivities Word Lists! | Learning By Design They’ll send one lucky person a copy of SPELL-Links™ Wordtivities Word Lists. Entries are accepted until 3/1/24 at 5 pm CST. The winner will be notified by email.
Test Review: Test of Written Language-4 (TOWL-4)
Today due to popular demand I am reviewing The Test of Written Language-4 or TOWL-4. TOWL-4 assesses the basic writing readiness skills of students 9:00-17:11 years of age. The tests consist of two forms – A and B, (which contain different subtest content).
According to the manual, the entire test takes approximately 60-90 minutes to administer and examines 7 skill areas. Only the “Story Composition” subtest is officially timed (the student is given 15 minutes to write it and 5 minutes previous to that, to draft it). However, in my experience, each subtest administration, even with students presenting with mild-moderately impaired writing abilities, takes approximately 10 minutes to complete with average results (can you see where I am going with this yet?)
For detailed information regarding the TOWL-4 development and standardization, validity and reliability, please see HERE. However, please note that the psychometric properties of this test are weak.
Below are my impressions (to date) of using this assessment with students between 11-14 years of age with (known) mild-moderate writing impairments.
Subtests:
1. Vocabulary – The student is asked to write a sentence that incorporates a stimulus word. The student is not allowed to change the word in any way, such as write ‘running’ instead of run’. If this occurs, an automatic loss of points takes place. The ceiling is reached when the student makes 3 errors in a row. While some of the subtest vocabulary words are perfectly appropriate for younger children (~9), the majority are too simplistic to assess the written vocabulary of middle and high schoolers. These words may work well to test the knowledge of younger children but they do not take into the account the challenging academic standards set forth for older students. As a result, students 11+ years of age may pass this subtest with flying colors but still present with a fair amount of difficulty using sophisticated vocabulary words in written compositions.
2/3. Spelling and Punctuation (subtests 2 and 3). These two subtests are administered jointly but scored separately. Here, the student is asked to write sentences dictated by the examiner using appropriate rules for spelling and punctuation and capitalization. Ceiling for each subtest is reached separately. It occurs when the student makes 3 errors in a row in each of the subtests. In other words, if a student uses correct punctuation but incorrect spelling, his/her ceiling on the ‘Spelling’ subtest will be reached sooner then on the ‘Punctuation’ subtest and vise versa. Similar to the ‘Vocabulary‘ subtest I feel that the sentences the students are asked to write are far too simplistic to showcase their “true” grade level abilities.
The requirements of these subtests are also not too stringent. The spelling words are simple and the punctuation requirements are very basic: a question mark here, an exclamation mark there, with a few commas in between. But I was particularly disappointed with the ‘Spelling‘ subtest. Here’s why. I have a 6th-grade client on my caseload with significant well-documented spelling difficulties. When this subtest was administered to him he scored within the average range (Scaled Score of 8 and Percentile Rank of 25). However, an administration of Spelling Performance Evaluation for Language and Literacy – SPELL-2, yielded 3 assessment pages of spelling errors, as well as 7 pages of recommendations on how to remediate those errors. Had he received this assessment as part of an independent evaluation from a different examiner, nothing more would have been done regarding his spelling difficulties since the TOWL-4 revealed an average spelling performance due to its focus on overly simplistic vocabulary.
4. Logical Sentences – The student is asked to edit an illogical sentence so that it makes better sense. Ceiling is reached when the student makes 3 errors in a row. Again I’m not too thrilled with this subtest. Rather than truly attempting to ascertain the student’s grammatical and syntactic knowledge at sentence level a large portion of this subtest deals with easily recognizable semantic incongruities.
5. Sentence Combining – The student integrates the meaning of several short sentences into one grammatically correct written sentence. Ceiling is reached when the student makes 3 errors in a row. The first few items contain only two sentences which can be combined by adding the conjunction “and”. The remaining items are a bit more difficult due to the a. addition of more sentences and b. increase in the complexity of language needed to efficiently combine them. This is a nice subtest to administer to students who present with difficulty effectively and efficiently expressing their written thoughts on paper. It is particularly useful with students who write down a lot of extraneous information in their compositions/essays and frequently overuse run-on sentences.
6. Contextual Conventions – The student is asked to write a story in response to a stimulus picture. S/he earn points for satisfying specific requirements relative to combined orthographic (E.g.: punctuation, spelling) and grammatical conventions (E.g.: sentence construction, noun-verb agreement). The student’s written composition needs to contain more than 40 words in order for the effective analysis to take place.
The scoring criteria ranges from no credit or a score of 0 ( based on 3 or more mistakes), to partial credit, a score of 1 (based on 1-2 mistakes) to full a credit – a score of 3 (no mistakes). There are 21 scoring parameters which are highly useful for younger elementary-aged students who may exhibit significant difficulties in the domain of writing. However, older middle school and high-school aged students as well as elementary aged students with moderate writing difficulties may attain average scoring on this subtest but still present with significant difficulties in this area as compared to typically developing grade level peers. As a result, in addition to this assessment, it is recommended that a functional assessment of grade-level writing also be performed in order to accurately identify the student’s writing needs.
7. Story Composition – The student’s story is evaluated relative to the quality of its composition (E.g.: vocabulary, plot, development of characters, etc.). The examiner first provides the student with an example of a good story by reading one written by another student. Then, the examiner provides the student with an appropriate picture card and tell them that they need to take time to plan their story and make an outline on the (also provided) scratch paper. The student has 5 minutes to plan before writing the actual story. After the 5 minutes, elapses they 15 minutes to write the story. It is important to note that story composition is the very first subtest administered to the student. Once they complete it they are ready to move on to the Vocabulary subtest. There are 11 scoring parameters that are significantly more useful for me to use with younger students as well as significantly impaired students vs. older students or students with mild-moderate writing difficulties. Again if your aim is to get an accurate picture of the older students writing abilities I definitely recommend the usage of clinical writing assessment rubrics based on the student’s grade level in order to have an accurate picture of their abilities.
OVERALL IMPRESSIONS:
Strengths:
- A thorough assessment of basic writing areas for very severely impaired students with writing deficits
- Flexible subtest administration (can be done on multiple occasions with students who fatigue easily)
Limitations:
- Untimed testing administration (with the exception of story composition subtests) is NOT functional with students who present with significant processing difficulties. One 12-year-old student actually took ~40 minutes to complete each subtest.
- Primarily useful for students with severe deficits in the area of written expression
- Not appropriate for students with mild-moderate needs (requires suplementation)
- Lack of remediation suggestions based on subtest deficits
- Weak psychometric properties
Overall, TOWL-4 can be a useful testing measure for ruling out weaknesses in the student’s basic writing abilities, with respect to simple vocabulary, sentence construction, writing mechanics, punctuation, etc. If I identify previously unidentified gaps in basic writing skills I can then readily intervene, where needed, if needed. However, it is important to understand that the TOWL-4 is only a starting point for most of our students with complex literacy needs whose writing abilities are above severe level of functioning. Most students with mild-moderate writing difficulties will pass this test with flying colors but still present with significant writing needs. As a result I highly recommend a functional grade-level writing assessment as a supplement to the above-standardized testing.
References:
Hammill, D. D., & Larson, S. C. (2009). Test of Written Language—Fourth Edition. (TOWL-4). Austin, TX: PRO-ED.
Disclaimer: The views expressed in this post are the personal impressions of the author. This author is not affiliated with PRO-ED in any way and was NOT provided by them with any complimentary products or compensation for the review of this product.
What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?
I frequently see a variation of the following question on a variety of speech language forums: “My student scored within the average range on all the tested subtests with the exception of working memory and sentence recall. What other testing do you recommend to determine whether these difficulties are impacting their academics?”
First, lets provide a definition of working memory (WM). WM is the memory used for temporarily storing and manipulating information so we can perform a particular task. It’s one of the executive functions (EFs) and contains two important subcomponents: a phonological loop that stores verbal information and a visuo-spatial ‘sketchpad’ which stores visual and spatial information (Baddeley & Hitch, 2007). Together they are responsible for acquisition of sound-letter correspondence, phonemic awareness and ultimately reading comprehension since WM influences the duration the information stays in memory as well as its eventual transfer (or lack of thereof) to long-term memory.
In other words, students with adequate working memory will have enough capacity to appropriately decode, fluently read and adequately comprehend text while students with poor working memory will expend all their capacity on basic tasks such as decoding, which leaves them with very little capacity to devote to comprehension of read material.
Outside of testing, WM deficits typically become glaringly apparent as students move up grade levels and are given challenging subject-specific abstract texts, requiring in-depth analysis. This is when parents and professionals start to see that in addition to experiencing difficulty comprehending the read texts, students with poor WM also tire easily when presented with lengthy texts, and tend to evidence increased frustration and decreased self-efficacy during reading tasks.
Now let’s get back to our original question: “What other testing do you recommend to determine whether these [memory] difficulties are impacting their academics?”
Typically when asked that question I always tend to recommend that a trained SLP performs a series of tests aimed to determine whether the student presents with reading and writing deficits.
In my clinical experience (which is of course substantiated by research) in 99% of cases, reading disabilities are the hidden culprit behind seemingly average oral language skills and working memory deficits. For more information on what testing is recommended to tease out the presence of reading disorders, see my series posts on Comprehensive Dyslexia Testing (HERE) as well as on the validity of (C)APD diagnosis (HERE).
So the next time you encounter this perplexing pattern of strengths and weaknesses don’t just ignore it as inconsequential and not recommend or dismiss the student from language services. Delve into it further! You will often find that it is representative of reading difficulties, the cumulative impact of which may significantly affect the student’s academic performance and ultimately school outcomes, unless appropriate therapeutic interventions are provided.
References:
- Baddeley, A. D., & Hitch, G. J. (2007). Working memory: Past, present…and future? In N.Osaka, R. Logie & M. D’Esposito (Eds), Working Memory – Behavioural & Neural Correlates. Oxford University Press.
Useful Resources:
Articulation Assessment ToolKt
In February 2013 I did a review of the Sunny Articulation Test by Smarty Apps. At that time I really liked the test but felt that a few enhancements could really make it standout from other available articulation tests and test apps on the market. Recently, the developer, Barbara Fernandes, contacted me again and asked me to take a second look at the new and improved Sunny Articulation and Phonology Kit (SAPT-K), which is what I am doing today. Continue reading Articulation Assessment ToolKt
Dear Pediatrician: Please Don’t Say That!
Recently, a new client came in for therapy. He was a little over three years of age with limited verbal abilities, and a number of stereotypical behaviors consistent with autism spectrum disorder. During the course of parental interview, the child’s mother mentioned that he had previously briefly received early intervention services but aged out from the early intervention system after only a few months. As we continued to discuss the case, his mother revealed that she had significant concerns regarding her son’s language abilities and behavior from a very early age because it significantly differed from his older sister’s developmental trajectory. However, every time she brought it up to her pediatrician she invariably received the following answers: “Don’t compare him to his sister, they are different children” and “Don’t worry, he will catch up”, which resulted in the child being referred for early intervention services when he was almost 3 years of age, and unable to receive consistent speech therapy services prior to aging out of the program all together.
This is not the first time I heard such a story, and I’m sure it won’t be the last time as well. Sadly, myself and other speech language therapists are very familiar with such cases and that is such a shame. It is a shame, because a parent was absolutely correct in trusting her instincts but was not validated by a medical professional she trusted the most, her child’s pediatrician. Please don’t get me wrong, I am not playing the blame game or trying to denigrate members of another profession. My aim today is rather different and that is along with my colleagues to continue increasing awareness among all health professionals regarding the early identification of communication disorders in children in order for them to receive effective early intervention services to improve their long-term outcomes.
Whenever one “Googles” the term “Language Milestones In Children” or “When do children begin to talk?” Numerous links pop-up, describing developmental milestones in children. Most of them contain fairly typical information such as: first word emerge at approximately 12 months of age, 2 word combinations emerge when the child has a lexicon of approximately 50 words or more, which corresponds to a period between 18 months to 2 years of age, and sentences emerge when a child is approximately 3 years of age. While most of this information is hopefully common knowledge for many healthcare professionals working with children including pediatricians, is also important to understand that when the child comes in for a checkup one should not look at these abilities in isolation but rather look at the child holistically. That means asking the parents the right questions to compare the child’s cognitive, adaptive, social emotional, as well as communicative functioning to that of typically developing peers or siblings in order to determine whether anything is amiss. Thus, rather than to discourage the parent from comparing their child to typically developing children his age, the parents should actually be routinely asked the variation of the following question: “How do your child’s abilities and functioning compare to other typically developing children your child age?”
Whenever I ask this question during the process of evaluation or initiation of therapy services, 90% of the time I receive highly detailed and intuitive responses from well-informed parents. They immediately begin describing in significant detail the difference in functioning between their own delayed child and his/her siblings/peers. That is why in the majority of cases I find the background information provided by the parent to be almost as valuable as the evaluation itself. For example, I recently assessed a 3-5 year-old child due to communication concerns. The pediatrician was very reluctant to refer to the child for services due to the fact that the child was adequately verbal. However, the child’s parents were insistent, a script for services was written, and the child was brought to me for an evaluation. Parents reported that while their child was very verbal and outgoing, most of the time they had significant difficulty understanding what she was trying to tell them due to poor grammar as well as nonsensical content of her messages. They also reported that the child had a brother , who was older than her last several years. However, they stated that they had never experienced similar difficulties with the child’s brother when he was her age, which is why they became so concerned with each passing day regarding the child’s language abilities.
Indeed, almost as soon as the evaluation began, it became apparent that while the child’s verbal output was adequate, the semantic content of those messages as well as the pragmatic use in conversational exchanges was significantly impaired. In other words, the child may have been adequately verbose but the coherence of her discourse left a lot to be desired. This child was the perfect candidate for therapy but had parents not insisted, the extent of her expressive language difficulties may have been overlooked until she was old enough to go to kindergarten. By then many valuable intervention hours would have been lost and the extent of the child deficits have been far greater.
So dear pediatrician, the next time a concerned parent utters the words: “I think something is wrong…” or “His language is nothing like his brother’s/sister’s when s/he was that age” don’t be so hasty in dismissing their concerns. Listen to them, understand that while you are the expert in childhood health and diseases, they are the expert in their own child, and are highly attuned to their child’s functioning and overall abilities. Encourage them to disclose their worries by asking follow-up questions and validating their concerns.
There are significant benefits to receiving early targeted care beyond the improvement in language abilities. These include but are not limited to: reduced chances of behavioral deficits or mental illness, reduced chances of reading, writing and learning difficulties when older, reduced chances of impaired socialization abilities and self-esteem, all of which can affect children with language deficits when appropriate services are delayed or never provided. So please, err on the side of caution and refer the children with suspected deficits to speech language pathologists. Please give us an opportunity to thoroughly assess these children in order to find out whether there truly is speech/language disorder/delay. Because by doing this you truly will be serving the interests of your clients.
Helpful Smart Speech Therapy Resources:
- Pediatric Background History Questionnaire
- The Checklists Bundle
- Introduction to Prevalent Disorders Bundle
- Language Difference vs. Language Disorder: Assessment & Intervention Strategies for SLPs Working with Bilingual Children
- Recognizing the Warning Signs of Social Emotional Difficulties in Language Impaired Toddlers and Preschoolers
- Genetics in Speech Language Pathology
- Differential Diagnosis of ADHD in Speech Language Pathology
- Recognizing Speech-Language Delay in School-Age Children
Phonological Awareness Screening App Review: ProPA
Summer is in full swing and for many SLPs that means a welcome break from work. However, for me, it’s business as usual, since my program is year around, and we have just started our extended school year program.
Of course, even my program is a bit light on activities during the summer. There are lots of field trips, creative and imaginative play, as well as less focus on academics as compared to during the school year. However, I’m also highly cognizant of summer learning loss, which is the phenomena characterized by the loss of academic skills and knowledge over the course of summer holidays.
According to Cooper et al, 1996, while generally, typical students lose about one month of learning, there is actually a significant degree of variability of loss based on SES. According to Cooper’s study, low-income students lose approximately two months of achievement. Furthermore, ethnic minorities, twice-exceptional students (2xE), as well as students with language disorders tend to be disproportionately affected (Graham et al, 2011; Kim & Guryan, 2010; Kim, 2004). Finally, it is important to note that according to research, summer loss is particularly prominent in the area of literacy (Graham et al, 2011).
So this summer I have been busy screening the phonological awareness abilities (PA) of an influx of new students (our program enrolls quite a few students during the ESY), as well as rescreening PA abilities of students already on my caseload, who have been receiving services in this area for the past few months.
Why do I intensively focus on phonological awareness (PA)? Because PA is a precursor to emergent reading. It helps children to manipulate sounds in words (see Age of Aquisition of PA Skills). Children need to attain PA mastery (along with a host of a few literacy-related skills) in order to become good readers.
When children exhibit poor PA skills for their age it is a red flag for reading disabilities. Thus it is very important to assess the child’s PA abilities in order to determine their proficiency in this area.
While there are a number of comprehensive tests available in this area, for the purposes of my screening I prefer to use the ProPA app by Smarty Ears.
The Profile of Phonological Awareness (Pro-PA) is an informal phonological awareness screening. According to the developers on average it takes approximately 10 to 20 minutes to administer based on the child’s age and skill levels. In my particular setting (outpatient school based in a psychiatric hospital) it takes approximately 30 minutes to administer to students on the individual basis. It is by no means a comprehensive tool such as the CTOPP-2 or the PAT-2, as there are not enough trials, complexity or PA categories to qualify for a full-blown informal assessment. However, it is a highly useful measure for a quick determination of the students’ strengths and weaknesses with respect to their phonological awareness abilities. Given its current retail price of $29.99 on iTunes, it is a relatively affordable phonological awareness screening option, as the app allows its users to store data, and generates a two-page report at the completion of the screening.
The Pro-PA assesses six different skill areas:
- Rhyming
- Identification
- Production
- Blending
- Syllables
- Sounds
- Sound Isolation
- Initial
- Final
- Medial
- Segmentation
- Words in sentences
- Syllables in words
- Sounds in words
- Words with consonant clusters
- Deletion
- Syllables
- Sounds
- Words with consonant clusters
- Substitution
- Sounds in initial position of words
- Sounds in final position of words
After the completion of the screening, the app generates a two-page report which describes the students’ abilities as:
- Achieved (80%+ accuracy)
- Not achieved (0-50% accuracy)
- Emerging (~50-79% accuracy)
The above is perfect for quickly tracking progress or for generating phonological awareness goals to target the students’ phonological awareness weaknesses. While the report can certainly be provided as an attachment to parents and teachers, I usually tend to summarize its findings in my own reports for the purpose of brevity. Below is one example of what that looks like:
The Profile of Phonological Awareness (Pro-PA), an informal phonological awareness screening was administered to “Justine” in May 2017 to further determine the extent of her phonological awareness strengths and weaknesses.
On the Pro-PA, “Justine” evidenced strengths (80-100% accuracy) in the areas of rhyme identification, initial and final sound isolation in words, syllable segmentation, as well as substitution of sounds in initial position in words.
She also evidenced emerging abilities (~60-66% accuracy) in the areas of syllable and sound blending in words, as well as sound segmentation in CVC words,
However, Pro-PA assessment also revealed weaknesses (inability to perform) in the areas of: rhyme production, isolation of medial sounds in words, segmentation of words, segmentation of sounds in words with consonant blends,deletion of first sounds, consonant clusters, as well as substitution of sounds in final position in words. Continuation of therapeutic intervention is recommended in order to improve “Justine’s” abilities in these phonological awareness areas.
Now you know how I quickly screen and rescreen my students’ phonological awareness abilities, I’d love to hear from you! What screening instruments are you using (free or paid) to assess your students’ phonological awareness abilities? Do you feel that they are more or less comprehensive/convenient than ProPA?
References:
- Cooper, H., Nye, B., Charlton, K., Lindsay, J., & Greathouse, S. (1996). “The effects of summer vacation on achievement test scores: A narrative and meta analytic review.” Review of Educational Research, 66, 227–268.
- Graham, A., McNamara, J. K., & Van Lankveld, J. (2011). Closing the summer learning gap for vulnerable learners: An exploratory study of a summer literacy programme for kindergarten children at-risk for reading difficulties. Early Child Development and Care, 181, 575–585.
- Kim, J. S. (2004). Summer reading and the ethnic achievement gap. Journal of Education for Students Placed
at Risk, 9, 169–188. - Kim, J.,S. & Guryan, J. (2010). The efficacy of a voluntary summer book reading intervention for low-income Latino children from language minority families. Journal of
Educational Psychology, 102(1), 20-31
Comprehensive Assessment of Monolingual and Bilingual Children with Down Syndrome
Assessing speech-language abilities of children with genetic disorders and developmental disabilities is no easy feat. Although developmental and genetic disorders affecting cognition, communication and functioning are increasingly widespread, speech-language assessment procedures for select populations (e.g., Down Syndrome) remain poorly understood by many speech-language professionals, resulting in ineffective or inappropriate service provision. Continue reading Comprehensive Assessment of Monolingual and Bilingual Children with Down Syndrome