Search Results for: auditory processing

Posted on by — 4 Comments

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

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

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

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

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

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

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

Now, let’s talk about why that is!

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 Kamhi discusses that some clinicians still possess an “outdated behavioral view of learning” in our field, which is not theoretically and clinically useful.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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

Helpful Social Media Resources:

SLPs for Evidence-Based Practice

Posted on by — 3 Comments

Enough with “grow out”, “grow in” and “it’s normal” or why a differential diagnosis is so important!

If someone asked me today how long I’ve been thinking about writing this post I wouldn’t hesitate and say… 3 years.  I know this because that’s when I encountered my very first case of “it’s normal”. I had been in private practice for several years, when I was contacted by parents who wanted me to evaluate their 4 year old son due to concerns over his language abilities.   When I first opened my office door to let them in I encountered a completely non-verbal child with significant behavioral deficits and limited communicative intent.

I have to confess, as I was conducting an extremely difficult assessment, I was very shocked by the fact that prior to seeing me, the child had not undergone any in-depth assessments with any related professionals despite presenting with pretty significant symptoms, which included: lack of meaningful interaction with toys,  stereotypical behaviors (e.g., rapid flicking of his fingers in front of his eyes for extended period of time, perseverative repetitions of unintelligible sounds out of context, etc), temper tantrums, as well as complete absence of words, phrases and sentences for his age. Very tactfully I broached the subject with the parents only to find out that the parents were concerned regarding their child’s development for quite a while, only to be told by over and over again by their pediatrician that “it’s normal”. I hastily bit back my reply, before I could rudely blurt out: “in which universe?”  Instead, I finished the assessment, wrote my 8 page report with extensive recommendations and referrals, and began treating the client. Luckily, since that time he had received numerous appropriate interventions from a variety of related professionals and made some nice gains. But to this day I wonder: Would his gains have been greater had his intervention was initiated at an earlier age (e.g., 2 instead of 4)?

Of course, this is by far one of the more extreme examples that I have seen during the course of my relatively short career (less than 10 years of practice) as a speech language pathologist.  But I have certainly seen others.

For example, a few years ago through my hospital based job I’ve treated a child with significant unilateral facial weakness, and a host of phonation, articulation, respiration, and resonance symptoms which included: difficulty managing oral secretions, weak voice, hypernasality, dysarthric vocal quality, and a few others. Again, the parent was told by the physician that the child’s facial asymmetry and symptomology was ‘not significant’’ despite the fact that in addition to the above signs, the child also presented with significantly delayed language development, cognitive limitations and severe behavioral manifestations.

Then of course there were a few stutterers with a host of social history red flags who stuttered for a few years well into early school age, each of whose parents were told by their child’s doctor that s/he will grow out of it.

I am not even counting dozens and dozens of phone calls from concerned parents of  language delayed toddlers and preschoolers whose pediatricians told them that they’ll “grow out of it” despite the fact that many of these children ended up receiving speech language services for language delays/disorders for several years afterwards.

I’ve also seen professionals without a specialization in International Adoption diagnosing recently adopted older post-institutionalized children with history of severe trauma, profound language delays, alcohol related deficits and symptoms of institutional autism as Pervasive Developmental Disorder (PDD).

But I don’t want you to think that I am singling out pediatricians in this post. The truth is that if we look closely we will find that this trend of overconfident recommendations is common to a vast majority of both medical and ancillary professionals (e.g., psychologists, occupational therapists, etc) with speech language pathologists not exempt from the above.

I’ve read a psychiatrist’s report, which diagnosed a child with Asperger’s based on a 15 minute conversation with the child, coupled with a brief physical examination (as documented in the child’s clinical record).  At my urging (based on the child’s adaptive behavior, linguistic profile and rather superior social pragmatic functioning) the parents sought a second opinion with another psychiatrist, which revealed that the child wasn’t even on the spectrum but had a anxiety disorder, some of which symptoms mimicked Asperger’s (e.g., perseveration on topics of interest).

I’ve read numerous neurological and neuropsychological reports which diagnosed children with ADD based on the symptoms of inattention and impulsivity in select settings (e.g., school only) without a differential diagnosis to rule out language deficits, auditory processing deficits, medical conditions, or acquired syndromes such as Fetal Alcohol Spectrum Disorders.

I’ve reviewed occupational therapy evaluations which reported on the language abilities of children vs. fine and gross motor function and sensory integration skills.

One parent even told me that when she asked a speech language therapist (who was treating her child for articulation difficulties) regarding her 10 year old son’s “ginormous” (parent’s words not mine) overbite she was told “he’ll grow into it”. I was told that the pediatric orthodontist did not appreciate that opinion and vigorously voiced his own as he was fitting the child for braces.

So when exactly did some of us decide that a differential diagnosis doesn’t matter? I’d be very curious to know what prompts professionals, who upon seeing some ‘garden variety’ symptoms, which could have a multitude of causes (e.g., inattention, echolalia, lack of speech, etc) decide that there could be only one definitive diagnosis or who merely shrug the displayed signs and accompanying parental concerns aside, expecting both to disappear on their own volition, given the passage of time.

Is it carelessness?

Is it overconfidence in own abilities?

Is it fear of losing face in front of the parent if you don’t have a ready answer?

Is it misguided belief that the child is displaying “textbook” behavior?

Is it “jadedness” or I’ve seen it all, so I know what it is, attitude?

I can venture hundreds more guesses, but it would be merely pointless speculation. Rather I prefer to focus on the intent of this post which is to outline why a differential diagnosis is so important!

1. Differential diagnosis saves lives!

Yes, I know I am only a speech pathologist and it’s true that I have yet to hear from anyone “I need a speech pathologist stat!” After all I don’t specialize in pediatric dysphagia and treat preemies in NICU.

But imagine the following scenario. A young preschool child shows up to your office with a hoarse vocal quality and a history of behavior tantrums. No problem you think, textbook vocal nodules, I got this, case closed! But what if the child was displaying additional symptoms such as stridor, coughing and difficulty breathing when sleeping? What if a few days after you’ve initiated voice therapy or told the parent that the child is too young for it, the child was rushed into the hospital because his airway was obstructed due to a laryngeal papilloma, which almost caused the child to asphyxiate. Still feel confident in your first diagnosis? Yet some speech language therapists routinely accept children into voice therapy without first referring them for an ENT consult that involves endoscopic imaging.  Some of you may scoff and tell me, common, when does thing ever happen? Wouldn’t a doctor have picked up on something like that well before a child seen an SLP? Guess what … not necessarily!

Although it may be hard to believe but an EI or school-based SLP may be the first diagnostic professional many children from at-risk backgrounds come in contact with. Obstacles to receiving appropriate early medical care and ancillary services like early intervention may include limited financial means, lack of education or information, and cultural and linguistic barriers.  Bilingual, multicultural, domestically adopted and foster care children from low-income households are particularly at risk since their deficits may not be detected until they begin receiving services in EI or preschool. After all, specialized medical care and related services must be sought out and paid for, which may be very hard to do for families from low SES households if they don’t have medical insurance or are having difficulty applying for Medicaid or state health insurance.

Similarly internationally adopted children are also at significant risk of despite the fact that most are adopted by middle class, financially solvent and highly educated parents. With this particular group the barriers to early identification are pre-adoption environmental risk factors (length of institutionalization and quality of medical care in that setting), combined with limited access to information (paucity of prenatal, medical and developmental history details in the adoption records).

2. Sometimes diagnosis DOES matter!  

I know, I know, a number of you will try to convince me that we need to treat the symptoms and NOT the label!  But humor me for a second! Let’s say you are a medical/ancillary professional (depending whom the child get’s to see first and for what reason) who gets to assess a new preschool patient/client, let’s call him Johnny.  So little 4 year old Johnny walk into your office with the following symptoms:

  • aggressive /inappropriate behaviors
  • odd fine and gross motor movements
  • clumsiness
  • blunted affect (facial expression)
  • inconsistent eye contact
  • speech/language deficits
  • picky eater with a history of stomach issues (e.g., nausea, vomiting, belly pain)

Everything you observe points to the diagnosis of Autism, after all you are the professional, and you’ve seen hundreds of such cases. It’s textbook, right? WRONG! I’ve just described to you some of the symptoms of Wilson’s disease.  It’s a genetic disorder in which large amounts of copper build up in the liver and brain. This disorder has degrees of severity ranging from mild/progressive to acute/severe.  It can cause brain and nervous system damage, hence the psychiatric and neuromuscular symptoms.  The bad news is that this condition can be fatal if misdiagnosed/undiagnosed! The good news is that it is also VERY treatable and can be easily managed with medication, dietary changes, and of course relevant therapies (e.g, PT, OT, ST, etc)!

3. Correct Diagnosis can lead to Appropriate Treatment!

So we all know that ADHD diagnosis is currently being doled out like candy to practically every child with the symptoms of Inattention, Hyperactivity and Impulsivity. But can you actually GUESS how many children are misdiagnosed with it?

Elder (2010), found that nearly 1 million children in US are potentially misdiagnosed with ADHD simply because they are the youngest and most immature in their kindergarten class. Here’s what he has to say on the subject: “A child’s birth date relative to the eligibility cutoff … strongly influences teachers’ assessments of whether the child exhibits ADHD symptoms but is only weakly associated with similarly measured parental assessments, suggesting that many diagnoses may be driven by teachers’ perceptions of poor behavior among the youngest children in a classroom. These perceptions have long-lasting consequences: the youngest children in fifth and eighth grades are nearly twice as likely as their older classmates to regularly use stimulants prescribed to treat ADHD.”  (Elder, 2010, 641)

Here are a few examples of ADHD misdiagnosis straight from my caseload.

Case A:  9 year old girl, Internationally Adopted at the age of 16 months diagnosed with ADHD based on the following symptoms:

  • Inattentive
  • Frequently misheard verbal messages
  • Difficulty following verbal directions
  • Very distractible
  • Blurted things out impulsively
  • Constantly forgot what had been told to her
  • Made careless mistakes on school/home work

Prior to medicating the child, the parents sought a language evaluation at the advice of a private social worker. My assessment revealed a language processing disorder and a recommendation for a comprehensive APD assessment with an audiologist. Comprehensive audiological assessment revealed the diagnosis of APD with recommendations for language intervention. After language therapy with a focus on improving the child’s auditory processing skills was initiated, her symptoms improved dramatically. The recommendations for medication were scrapped.

Case B: 12 year old boy attending outpatient school in a psychiatric hospital diagnosed with ADHD and medicated unsuccessfully for it for several years based on the following symptoms:

  • Severely Impulsive and Inattentive
  • Occasional tantrums, opposition and aggressive  behaviors
  • Difficulty with transitions
  • Odd Behaviors/Inappropriate Statements
  • Off-topic/Unrelated Comments
  • Topic Perseverations
  • Poor memory
  • Poor ability to follow directions

Detailed case history interview performed prior to initiation of a comprehensive language assessment revealed a history of Traumatic Brain Injury (TBI) at 18 months of age. Apparently the child was dropped on concrete floor head first by his biological father. However, no medical follow up took place at the time due to lack of household stability. The child was in and out of shelter with mother due to domestic abuse in the home perpetrated by biological father.

The child’s mother reported that he developed speech and language early without difficulties but experienced a significant skills regression around 1.5-2 years of age (hint, hint).  Comprehensive language assessment revealed numerous language difficulties, many of which were in the areas of memory, comprehension as well as social pragmatic language. Following the language assessment, relevant medical referrals at the age of 12 substantiated the diagnosis of TBI (better late than never). So no wonder the medication had no effect!

So what can parents do to ensure that their child is being diagnosed appropriately and receives the best possible services from various health professionals?

For starters, make sure to carefully describe all the symptoms that your child presents with (write them down to keep track of them if necessary). It is important to understand that many conditions are dynamic in nature and may change symptoms over time. For example, children with alcohol related disorders may display feeding deficits as infants, delayed developmental milestones as toddlers, good conversational abilities but poor social behavior and abstract thinking skills as school aged children and low academic achievement as adolescents.

Ensure that the professional spends adequate period of time with the child prior to generating a report or rendering a diagnosis.  We’ve all been in situations when reports/diagnoses were generated based on a 15 minute cursory visit, which did not involve any follow up testing or when the report was generated based on parental interview vs. actual face to face contact and interaction with the child.  THIS IS NOT HOW IT’S SUPPOSED TO WORK! THIS IS HOW MISDIAGNOSES HAPPEN!

Don’t be afraid to ask follow up questions or request rationale for the professionals’ decisions.  If you don’t understand something or are skeptical of the results, don’t be afraid to question the findings in a professional way.  If the information provided to you seems inadequate or poorly justified consider getting a second opinion with another professional.

Make sure that your child is being treated as a unique individual and not as a textbook subject.  Don’t you just hate it when you are trying to describe something to a professional and they look like they are listening but in reality they are not really ‘hearing’ you because they already “know what you have”.  Or they are looking at your child but they are not really seeing him/her, because he/she is just another ‘textbook case’ in a long cue of clients.  THIS IS NOT THE TREATMENT YOU ARE SUPPOSED TO GET FROM PROFESSIONALS! If this is how your child being treated then maybe it’s time to switch providers!

And another thing there are NO textbook clients! All clients are unique! I currently have about 10 post institutionalized Internationally Adopted children on my caseload with similar deficits but completely different symptom presentation, degrees of severely, as well as overall functioning. Even though some are around the same age, they are so dramatically different from one another that I need to use completely different approaches when I am planning their respective interventions.

Here’s how we as health professionals can better serve our clients/patients needs

It’s all in the details! Carefully collect the client’s background history without leaving anything out.  No piece of information is too small/inconsequential! You never know what might be relevant.

Get down to the nitty gritty by asking specific questions.  If you ask general questions you’ll get general responses.  For example, numerous health care professionals in various fields (doctors, psychiatrists, psychologists, SLPs, etc) routinely ask biological, adoptive and foster parents and adoptive caregivers whether substance abuse of drugs/alcohol took place before and during pregnancy (that they know of with respect to the latter two).   A number will respond that yes it took place during pregnancy but stopped as soon as the mother found out she was pregnant. Many professionals will leave it at that and move on to the next line of questioning. However, the follow up question to the above response should always be: “How many months along was the biological mother when she found out she was pregnant?” You’d be surprised at the responses you’ll get, which may significantly clarify the “mystery” of the child’s current symptomology.

Pretend that each new case is your very first case! Remember how you were fresh out of grad school/residency? How much enthusiasm, time, and effort you’ve put in leaving no stone unturned to diagnose your clients? That’s the passion and dedication the parents are looking for.

It’s always fun to play a detective! How cool was “House” when it first came out?  House and his team left no stone unturned in trying to correctly diagnose their patients. At times they even went to their houses or places of work in order to find any shred of information that would lead them on the right path. Admittedly you don’t have to go quite that far, but a consultation with a related professional might do the trick if a client is exhibiting certain symptoms outside your experience.

Turn your weakness into strength! No one likes to admit that they don’t have the answer. Many of us worry that our clients (those who work with adults) or their parents (those who work with children) may lose confidence in us and go elsewhere for services.  But everything depends on how you frame it! If you simply explain to the parent the rationale for the referral and why you want them to see another specialist prior to formulating the final diagnosis, they will only THANK YOU! It will show them that rather than making a casual decision, you want to make the best decision in their child’s case and they will only appreciate your candor as to them it shows your commitment to the care of their child.

It doesn’t matter how well educated and well trained many medical and related professionals are, the fact remains – no one knows everything! That is why each of us has our own unique scope of practice! That is why we should operate within our scope of practice and referral clients for additional assessments when needed.  Differential diagnosis should not be an exception; it should be a rule for any patient who does not show ‘unique’ symptoms indicative of very specific disorders/conditions! It should be performed with far greater frequency than it is done right now by medical and related health professionals!

After all: “When you have excluded all possibilities, then what remains -however improbable – must be the truth”. ~Sherlock Holmes

References:

  1. Elder, T (2010).  The Importance of Relative Standards in ADHD Diagnoses: Evidence Based on a Child’s Date of Birth, Journal of Health Economics, 29(5): 641-656.
  2. Zacharisen, M & Conley, S (2006) Recurrent Respiratory Papillomatosis in Children: Masquerader of Common Respiratory Diseases. Pediatrics 118 (5): 1925-1931.
  3. Gow P, Smallwood R, Angus P, Smith A, Wall A, Sewell R. (2000) Diagnosis of Wilson’s disease: an experience over three decades. GUT: International Journal of Gastroenterology and Hepatology, 46: 415–419.

Follow on Bloglovin

Posted on by — 17 Comments

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, HERE, or 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.

Related Posts:

Posted on by — 1 Comment

Tips Corner: Creating Opportunities for Spontaneous and Functional Communication

In today’s guest post,  Natalie Romanchukevich advises readers on how to create opportunities to expand children’s spontaneous communication skills.

Helping young children build speech- language skills is an exciting job that both caregivers and educators try to do every second of the day.  We spend so much time giving our children directions to follow, asking them a ton of questions, and modeling words and phrases to shape them into eloquent communicators.

What I find we do NOT do enough, sometimes, is hold back on our never ending “models” of what or how to say things, questions, and directions, instead of allowing our children initiate and engage with us.  Greenspan refers to these initiations as opening circles of communication (Weirder & Greenspan “Engaging Autism”, 2006).

Speech- language development can be thought of as having three interacting and equally important domains- Form ,Content, and Use (Lahey, 1988).

Form refers to the grammatical correctness of our words and sentences (eat vs. eat+ ing).

Content is what the we are essentially communicating- the meaning of our words and sentences.

Use (also known as pragmatics) refers to the function of our words or for what purpose we are using them.

The communicative functions that slowly emerge and characterize communication over the course of language acquisition in vary in typically developing young children.  Children communicate to greet others, comment on objects/actions, request desired objects, request assistance, protest, deny (a statement), ask questions, regulate others (e.g. “blow!”, “open!”), entertain, and narrate events.

In order for children to be able to express these functions, aside from the intent to communicate, there must also be opportunities to express ideas, wants, needs.  For example, why would Timmy request for an object (nonverbally or verbally) if the caregiver hands everything to the child at the slightest sign of a tantrum.  Why ask a “where?” question if every toy or beloved object is comfortably in sight?  Why ask for help if the caregiver readily assists the child with all activities.  The educators describe it as assuming the child’s needs.

Of course we do it out of love and care for the child, and, let’s be honest, sometimes, to save time.  However, it is important with both typical and delayed children to be mindful of what (form, content, use) we model, when (timing is crucial in teaching) we model it, how (facial expression, tone of voice, etc) we model it, and why (is it developmentally important to teach it now?) we model it at this very moment.

Just as it is important for kids to comprehend concepts, follow directions, and understand the different wh- questions, it is also paramount that your child is able to initiate communication.  After all, communication is the ability to express ideas, thoughts, and wants, not just understand those expressed by others.  Answering questions and following commands is not initiating.  Language that is elicited by us- is not spontaneous.

To use language spontaneously, effortlessly and creatively, children need opportunities to practice the skill, to experience taking the lead.  In order for our children to get there, we must first offer models of how to initiate communication and do so appropriately.  We can then create opportunities for the child to speak up.

The most basic strategies you can use to encourage spontaneous initiations (whether nonverbal or verbal) may seem seem initially as counterintuitive.  I mean what is the point to introducing attractive new toys or displaying a yummy snack and then putting it away? Yet it is exactly that action which may very much encourage your child to run after you with gestures or words.  Even then, you may still choose to play “dumb” and be “unsure” as to what it is your child wants.  Does s/he want that bag with new toy or snack “opened?” and “out?”

If the child is nonverbal, his use of gestures to regulate your actions to get the desired item out and open may be the child’s initial step toward sound imitation.  If you are working on getting the child to request help (not just objects), here is your opportunity to model “help” if the child can’t open the item independently.  On a side note, I often hear educators model “help me please!” when the child is clearly at a single word level.  This is not a developmental way of teaching.   Yes, it is nice to hear a full sentence but your child may not be ready for it.

While playing with your child and actively commenting on your joint play, you may find it productive to suddenly become quiet and cease all attempts to ask questions.   This often works beautifully in my therapy sessions; usually, after I have engaged the child into some sort of cooperative and enjoyable play! But it takes a conscious effort and self-control on the part of the adult, since we are so used to engaging in this adult- directed (telling the child what to do as opposed to letting him/her lead and you follow) approach to teaching.

However, once you are able to contain your speech and actions (I promise you it is possible), you may be surprised to hear some immediate or delayed imitations of words/ phrases as well as spontaneous meaningful language.  The language produced, to me, is an indication that the child wants more of the experience- more language enriched play.  Use this opportunity to expand on what s/he is already saying.

Here, timing is really important as you want to imitate back everything your child is doing.  This is another way to communicate with your child.  Build on your child’s language to further describe the objects or people in play without using long sentences.  So, allowing nothing to happen for a few minutes at a time may just be the push to help your child come out with some form of communication.

In addition, stopping a novel activity or toy exploration at the very height of your child’s excitement also works well with many children.  You don’t have to be  confrontational about it, “if you don’t imitate my word/ phrase I just won’t give it back to  you”.  make sure to create these “obstructions”, as Greenspan refers to them, in a friendly, playful and positive manner.  Obstructions or fabricated “problems” are also a big part of social-cognitive and constructivist theories of language learning.

The idea behind these “obstructions” is that the children are forced to problem solve and use resources (language being one of them!) so they can get what they want.  Allowing your child to problem solve is critical to overall cognitive development that affects and shapes speech and language. Presenting your child with developmentally appropriate activities that involve thinking and figuring out of how to get X is an invaluable strategy that I always use with all of my children.

In sum, stop access to items that are already loved, tape up containers, close boxes and jars with favorite snack and toys, give your child all but ONE important item that is needed to complete an activity (glue, scissors), give your child the “wrong” item, or offer the “wrong” solution to the problem.  All of these “problems” will push the kid to think and figure out what to do next.  This, in turn, facilitates spontaneous language use.

Letting go of control and just allowing for things to spill, break, or simply not follow the predictable comfortable routine, too, elicits a ton of speech- language and fun communication.  These are the most teachable moments as our children experience all the new words and concepts first hand.  Perhaps, this is why many children learn “dirty” or “wet” attributes before they learn their colors.  These concepts are more easily learned because they are experiential and bring about relevant words to describe these personally relevant and emotional experiences.  Cleaning up and taking turns arranging things back in place is super educational too as our children need to learn responsibility and helping others.

Moreover, exposing children to objects that are completely novel and foreign (but safe!) may help elicit an attempt to ask a question “what this?” because the child wants to know.  The motivation is there.  Now s/he needs language to get the answer from you.  Some children may use a word with a rising intonation, which too is a question form, just not grammatically mature one.  For example, “Hat?” is as much of a question as “Is that a hat?!”.  If all your child is capable of verbalizing is “wow”, then you can go ahead and model “what IS that?” question a few times.  Of course, you want to pair it up with an exaggerated expression of surprise and excitement in your voice.

To sum up, do not be afraid to experiment, get “messy”, stay silent, entice, intrigue and just wait for a few minutes to see what your child will do.  Yes, we want to teach our children to attend, sit down for a structured activity, and identify objects, shapes, colors, and actions; but these adult- directed activities do not allow for self- expression or spontaneous language use.  You also want to follow your child’s natural interests and inclinations as this is frequently a way into their world.  If you show interest in your friend’s ideas and you let him/her speak, will they not want to bond with you even more? Will they not want to communicate with you?

Creative and talented teachers are those who can use unconventional materials presented in unexpected ways while targeting all the skills that must be learned!  Learning to manipulate the environment to get the most out of your child’s skills can be difficult but indescribably rewarding.

References:

  1. Lahey, M. (1988). Language disorders and Language Development.
  2. Greenspan, S. & Weider, S. (2006). Engaging Autism: Using the Floortime approach to help children related, communicate, and think.
  3. Wetherby, A. & Prizant, B. (1990). Communication and Symbolic Behavior Scales. ChicagoIL: Applied Symblix. 

nrslp

Natalie Romanchukevich has a MS in Communication Sciences and Disorders from Long Island University (LIU) as well as Bilingual (Russian/English) Certification, which allows her to practice speech- language pathology in both Russian and English. Following graduation, Natalie has been working with both monolingual and bilingual 0- 5 population in New York City, and has been an active advocate for preschoolers with disabilities in her present setting.  Natalie’s clinical interests and experience have been focused on  early childhood speech- language delays and disorders including speech disorders (e.g., Articulation, Childhood Apraxia of Speech (CAS), Pervasive Developmental Disorders, Autistic Spectrum Disorders,  Auditory Processing Disorders, Specific Language Impairment (SLI), as well as Feeding Disorders. Presently she is working on developing her private practice in Brooklyn, NY.

Posted on by — 8 Comments

The Executive Functions Test-Elementary (EFT-E): What SLPs and Parents Need to Know

Image result for Executive Functions Test: ElementaryRecently 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

Posted on by — 10 Comments

Birthday Extravaganza Day Twenty Eight: Literacy Checklists for Grades K-3

Today I am bringing you yet another giveaway from the fabulous Maria Del Duca of Communication Station Blog entitled: “Literacy Checklists for K-3rd Grade“. She created a terrific set of checklists to address reading comprehension and written expression in children K-3rd grade because according to Maria: “dynamic assessment of functional skills, when done well, can at times yield more accurate and salient information than standardized tests.”

This 10 page packet uses observational as well as teacher and parent reported information to present a holistic view of a child’s literacy skills with a focus on the following areas: Continue reading Birthday Extravaganza Day Twenty Eight: Literacy Checklists for Grades K-3