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Why “good grades” do not automatically rule out “adverse educational impact”

Image result for good grades?As a speech-language pathologist (SLP) working with school-age children, I frequently assess students whose language and literacy abilities adversely impact their academic functioning.   For the parents of school-aged children with suspected language and literacy deficits as well as for the SLPs tasked with screening and evaluating them, the concept of ‘academic impact’ comes up on daily basis. In fact, not a day goes by when I do not see a variation of the following question: “Is there evidence of academic impact?”, being discussed in a variety of Facebook groups dedicated to speech pathology issues. Continue reading Why “good grades” do not automatically rule out “adverse educational impact”

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APD Update: New Developments on an Old Controversy

In the past two years, I wrote a series of research-based posts (HERE and HERE) regarding the validity of (Central) Auditory Processing Disorder (C/APD) as a standalone diagnosis as well as questioned the utility of it for classification purposes in the school setting.

Once again I want to reiterate that I was in no way disputing the legitimate symptoms (e.g., difficulty processing language, difficulty organizing narratives, difficulty decoding text, etc.), which the students diagnosed with “CAPD” were presenting with.

Rather, I was citing research to indicate that these symptoms were indicative of broader linguistic-based deficits, which required targeted linguistic/literacy-based interventions rather than recommendations for specific prescriptive programs (e.g., CAPDOTS, Fast ForWord, etc.),  or mere accommodations.

I was also significantly concerned that overfocus on the diagnosis of (C)APD tended to obscure REAL, language-based deficits in children and forced SLPs to address erroneous therapeutic targets based on AuD recommendations or restricted them to a receipt of mere accommodations rather than rightful therapeutic remediation. Continue reading APD Update: New Developments on an Old Controversy

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FREE Resources for Working with Russian Speaking Clients: Part III Introduction to “Dyslexia”

Image result for дислексияGiven the rising interest in recent years in the role of SLPs in the treatment of reading disorders, today I wanted to share with parents and professionals several reputable  FREE resources on the subject of “dyslexia” in Russian-speaking children.

Now if you already knew that there was a dearth of resources on the topic of treating Russian speaking children with language disorders then it will not come as a complete shock to you that very few legitimate sources exist on this subject.

Related imageFirst up is the Report on the Russian Language for the World Dyslexia Forum 2010 by Dr. Grigorenko, the coauthor of the Dyslexia Debate. This 25-page report contains important information including Reading/Writing Acquisition of Russian in the Context of Typical and Atypical Development as well as on the state of Individuals with Dyslexia in Russia.

Related imageNext up is this delightful presentation entitled: “If John were Ivan: Would he fail in reading? Dyslexia & dysgraphia in Russian“. It is a veritable treasure trove of useful information on the topics of:

  • The Russian language
  • Literacy in Russia (Russian Federation)
  • Dyslexia in Russia
    • Definition
    • Identification
    • Policy
  • Examples of good practice
    • Teaching reading/language arts
      • In regular schools
      • In specialized settings
    • Encouraging children to learn

Image result for orthographyNow let us move on to the “The Role of Phonology, Morphology, and Orthography in English and Russian Spelling” which discusses that “phonology and morphology contribute more for spelling of English words while orthography and morphology contribute more to the spelling of Russian words“. It also provides clinicians with access to the stimuli from the orthographic awareness and spelling tests in both English and Russian, listed in its appendices.

Finally, for parents and Russian speaking professionals, there’s an excellent article entitled, “Дислексия” in which Dr. Grigorenko comprehensively discusses the state of the field in Russian including information on its causes, rehabilitation, etc.

Related Helpful Resources:

  1. Анализ Нарративов У Детей С Недоразвитием Речи (Narrative Discourse Analysis in Children With Speech Underdevelopment)
  2. Narrative production weakness in Russian dyslexics: Linguistic or procedural limitations?

 

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

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

               

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

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

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

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

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

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

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

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

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

TIILLS-subtest-2-phonemic-awareness

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

TILLS-subtest-3-story-retelling

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

TILLS-subtest-4-nonword-repetition

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

TILLS-subtest-5-nonword-spelling

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

TILLS-subtest-6-listening-comprehension

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

TILLS-subtest-7-reading-comprehension

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

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

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

TILLS-subtest-8-following-directions

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

TILLS-subtest-9-delayed-story-retelling

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

TILLS-subtest-10-nonword-reading

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

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

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

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

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

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

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

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

TILLS-subtest-12-written-expression

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

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

tills

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

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

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

TILLS-subtest-13-social-communication

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

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

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

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

TILLS-subtest-14-digit-span-forward

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

TILLS-subtest-15-digit-span-backward

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

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

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

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

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

tills quadrant model

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

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

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

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

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

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

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

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

To access TILLS fully-editable template, click HERE

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

References: 

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

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Quality Assessments for Students with Suspected/Confirmed “APD”

Recently I wrote a blog post offering a free handout for parents and professionals entitled, “Deconstructing Auditory Processing Disorder (APD) for Parents and Professionals: Informational Handout“. While it was incredibly well-received, it resulted in numerous professionals asking the same questions:

  1. How do we help students with “APD?
  2. What constitutes a good quality assessment for a student with “APD”?

Today I would like to answer the above questions by providing further helpful information and links for parents and professionals seeking evidence-based assistance for students with suspected/confirmed “APD”.

Continue reading Quality Assessments for Students with Suspected/Confirmed “APD”
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Helpful Smart Speech Therapy Site Searching Tips

Related imageOver the years this blog has amassed many posts on a variety of topics pertaining to the assessment and treatment in speech-language pathology. With over 300 posts and over 130 search categories it’s no wonder that some of you have reached out to ask about effective ways of finding relevant information quickly. As such, in addition to the existing categories pertaining to specific topics (e.g., writing, social communication, etc.) I have created two specific categories which were asked about by numerous blog subscribers in recent emails. Continue reading Helpful Smart Speech Therapy Site Searching Tips

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Why (C) APD Diagnosis is NOT Valid!

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

Here are just a few reasons why:

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

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

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

(C)APD symptomology:

A. Student presents with difficulty processing information efficiently

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

B. Student has difficulty maintaining attention on presented tasks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(From Kamhi, 2011, p. 268)

6. Are you sure it’s (C)APD?

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

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

7. (C)APD testing is NOT so PURE 

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

So what does the research show?

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

(From DeBonis, 2015 pgs. 126-127)

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

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

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

9. Looking for the “Right” Label 

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

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

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

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

10. Missing the Big Picture

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

Conclusion:

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

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

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

References:

  • Burkard, R. (2009). Foreword. In A. Cacace & D. McFarland (Eds.), Controversies in central auditory processing disorder (pp. vii-viii). San Diego, CA: Plural.
  • Cowan, J., Rosen, S., & Moore, D. (2009). Putting the auditory back into auditory processing disorder in children. In Cacace, A., & McFarland, D. (Eds.),Controversies in central auditory processing disorder(pp. 187–197). San Diego, CA: Plural Publishing.
  • Dawes, P., & Bishop, D. (2009). Auditiory processing disorder in relation to developmental disorders of language, communication and attention: A review and critique. International Journal of Language and Communication Disorders, 44, 440–465.
  • DeBonis, D. A. (2015) It Is Time to Rethink Central Auditory Processing Disorder Protocols for School-Aged Children. American Journal of Audiology. v. 24, 124-136.
  • Ferguson, M. A., Hall, R. L., Moore, D. R., & Riley, A. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54, 211–227.
  • Fey, M. E., Richard, G. J., Geffner, D., Kamhi, A. G., Medwetsky, L., Paul, D., Schooling, T. (2011). Auditory processing disorder and auditory/language interventions: An evidence-based systematic review. Language, Speech and Hearing Services in Schools, 42, 246–264.
  • Hazan, V., Messaoud-Galusi, S., Rosen, S., Nouwens, S., Shakespeare, B. (2009). Speech perception abilities of adults with dyslexia: Is there any evidence for a true deficit?. Journal of Speech, Language, and Hearing Research. 52 1510–1529
  • Kamhi, A. G. (2011). What speech-language pathologists need to know about auditory processing disorder. Language, Speech, and Hearing Services in Schools, 42, 265–272.
  • Kamhi, A & Wallach, G (2012) What Speech-Language Pathologists Need to Know about Auditory Processing Disorders. ASHA Convention Presentation. Atlanta, GA.
  • Kelly, A. S., Purdy, S. C., & Sharma, M. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research, 53, 706–722.
  • Lemos IC, Jacob RT, Gejao MG, et al. (2009) Frequency modulation (FM) system in auditory processing disorder: An evidence-based practice? Pró-Fono Produtos Especializados para Fonoaudiologia Ltda. 21(3):243-248.
  • Melby-Lervåg, M., & Hulme, C. (2013). Is working memory training effective? A meta-analytic review. Developmental Psychology, 49, 270–291.
  • Ramus, F., White, S., Frith, U. (2006). Weighing the evidence between competing theories of dyslexia.Developmental Science. 9 265–269
  • Sharma, M., Purdy, S. C., Kelly, A. S. (2009). Comorbidity of auditory processing, language, and reading disorders. Journal of Speech, Language, and Hearing Research. 52 706–722
  • Wallach, G. P. (2011). Peeling the onion of auditory processing disorder: A language/curricular-based perspective. Language, Speech, and Hearing Services in Schools, 42, 273–285.
  • Watson, C., Kidd, G. (2009). Associations between auditory abilities, reading, and other language skills in children and adults. Cacace, A., McFarland, D.Controversies in central auditory processing disorder.  218–242 San Diego, CA Plural.
  • Wilson, W. J., & Arnott, W. (2013). Using different criteria to diagnose (central) auditory processing disorder: How big a difference does it make? Journal of Speech, Language, and Hearing Research, 56, 63–70.