As SLPs we routinely administer a variety of testing batteries in order to assess our students’ speech-language abilities. Grammar, syntax, vocabulary, and sentence formulation get frequent and thorough attention. But how about narrative production? Does it get its fair share of attention when the clinicians are looking to determine the extent of the child’s language deficits? I was so curious about what the clinicians across the country were doing that in 2013, I created a survey and posted a link to it in several SLP-related FB groups. I wanted to find out how many SLPs were performing narrative assessments, in which settings, and with which populations. From those who were performing these assessments, I wanted to know what type of assessments were they using and how they were recording and documenting their findings. Since the purpose of this survey was non-research based (I wasn’t planning on submitting a research manuscript with my findings), I only analyzed the first 100 responses (the rest were very similar in nature) which came my way, in order to get the general flavor of current trends among clinicians, when it came to narrative assessments. Here’s a brief overview of my [limited] findings. Continue reading The Importance of Narrative Assessments in Speech Language Pathology (Revised)
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What do Auditory Memory Deficits Indicate in the Presence of Average General Language Scores?
I frequently see a variation of the following question on a variety of speech language forums: “My student scored within the average range on all the tested subtests with the exception of working memory and sentence recall. What other testing do you recommend to determine whether these difficulties are impacting their academics?”
First, lets provide a definition of working memory (WM). WM is the memory used for temporarily storing and manipulating information so we can perform a particular task. It’s one of the executive functions (EFs) and contains two important subcomponents: a phonological loop that stores verbal information and a visuo-spatial ‘sketchpad’ which stores visual and spatial information (Baddeley & Hitch, 2007). Together they are responsible for acquisition of sound-letter correspondence, phonemic awareness and ultimately reading comprehension since WM influences the duration the information stays in memory as well as its eventual transfer (or lack of thereof) to long-term memory.
In other words, students with adequate working memory will have enough capacity to appropriately decode, fluently read and adequately comprehend text while students with poor working memory will expend all their capacity on basic tasks such as decoding, which leaves them with very little capacity to devote to comprehension of read material.
Outside of testing, WM deficits typically become glaringly apparent as students move up grade levels and are given challenging subject-specific abstract texts, requiring in-depth analysis. This is when parents and professionals start to see that in addition to experiencing difficulty comprehending the read texts, students with poor WM also tire easily when presented with lengthy texts, and tend to evidence increased frustration and decreased self-efficacy during reading tasks.
Now let’s get back to our original question: “What other testing do you recommend to determine whether these [memory] difficulties are impacting their academics?”
Typically when asked that question I always tend to recommend that a trained SLP performs a series of tests aimed to determine whether the student presents with reading and writing deficits.
In my clinical experience (which is of course substantiated by research) in 99% of cases, reading disabilities are the hidden culprit behind seemingly average oral language skills and working memory deficits. For more information on what testing is recommended to tease out the presence of reading disorders, see my series posts on Comprehensive Dyslexia Testing (HERE) as well as on the validity of (C)APD diagnosis (HERE).
So the next time you encounter this perplexing pattern of strengths and weaknesses don’t just ignore it as inconsequential and not recommend or dismiss the student from language services. Delve into it further! You will often find that it is representative of reading difficulties, the cumulative impact of which may significantly affect the student’s academic performance and ultimately school outcomes, unless appropriate therapeutic interventions are provided.
References:
- Baddeley, A. D., & Hitch, G. J. (2007). Working memory: Past, present…and future? In N.Osaka, R. Logie & M. D’Esposito (Eds), Working Memory – Behavioural & Neural Correlates. Oxford University Press.
Useful Resources:
Dear School Professionals Please Be Aware of This
I frequently get emails, phone calls, and questions from parents and professionals regarding academic functioning of internationally adopted post institutionalized children. Unfortunately despite the fact that there is a fairly large body of research on this topic there still continue to be numerous misconceptions regarding how these children’s needs should be addressed in academic settings.
Perhaps one of the most serious and damaging misconceptions is that internationally adopted children are bilingual/multicultural children with Limited English Proficiency who need to be treated as ESL speakers. This erroneous belief often leads to denial or mismanagement of appropriate level of services for these children not only with respect to their language processing and verbal expression but also their social pragmatic language abilities.
Even after researchers published a number of articles on this topic, many psychologists, teachers and speech language pathologists still don’t know that internationally adopted children rapidly lose their little birth language literally months post their adoption by English-speaking parents/families. Gindis (2005) found that children adopted between 4-7 years of age lose expressive birth language abilities within 2-3 months and receptive abilities within 3-6 months post- adoption. This process is further expedited in children under 4, whose language is delayed or impaired at the time of adoption (Gindis, 2008). Even school-aged children of 10-12 years of age who were able to read and write in their birth language, rapidly lose their comprehension and expression of birth language within their first year post adoption, if adopted by English-speaking parents who are unable to support their birth language.
So how does this translate into appropriate provision of speech language services you may ask? To begin with, I often see posts on the ASHA forums or in Facebook speech pathology and special education groups seeking assistance with finding interpreters fluent in various exotic languages. However, unless the child is “fresh off the boat” (several months post arrival to US) schools shouldn’t be feverishly trying to locate interpreters to assist with testing in the child’s birth language. They will not be able to obtain any viable results especially if the child had been residing in the United States for several years.
So if the post-institutionalized, internationally adopted child is still struggling with academics several years post adoption, one should not immediately jump to the conclusion that this is an “ESL” issue, but get relevant professionals (e.g., speech pathologists, psychologists) to perform thorough testing in order to determine whether it’s the lack of foundational abilities due to institutionalization which is adversely impacting the child’s academic abilities.
Furthermore, ESL itself is often not applicable as an educational method to internationally adopted children. Here’s why:
Let’s literally take the first definition of ESL which pops-up on Google when you put in a query: “What is ESL?” “English as a Second Language (ESL) is an instructional program for students whose dominant language is not English. The purpose of the program is to increase the English language proficiency of eligible students so they can attain academic standards and achieve success in the classroom.”
Here is our first problem. These students don’t have a dominant language. They are typically adopted by parents who do not speak their birth language and that are unable to support them in their birth language. So upon arrival to US, IA children will typically acquire English via the subtractive model of language acquisition (birth language is replaced and eliminated by English), which is a direct contrast to bilingual children, many of whom learn via the additive model (adding English to the birth language (Gindis, 2005). As a result, of subtractive language acquisition IA children experience very rapid birth language attrition (loss) post-adoption (Gindis, 2003; Glennen, 2009). Thus they will literally undergo what some researchers have called: “second-first language acquisition” (Scott et al., 2011) and their first language will “become completely obsolete as English is learned” (Nelson, 2012, p. 2).
This brings us to our second problem: the question of “eligibility”. Historically, ESL programs have been designed to assist children of immigrant families acquire academic readiness skills. This methodology is based on the fact that skills from first language was ultimately transfer to the second language. However, since post-institutionalized children don’t technically have a “first language” and their home language is English, how could they technically be eligible for ESL services? Furthermore, because of frequent lack of basic foundational skills in the birth language internationally adopted post-institutionalized children will not benefit the same way from ESL instruction the same way bilingual children of immigrant families do. So instead of focusing on these children’s questionable eligibility for ESL services it is important to perform detailed review of their pre-adoption records in order to determine birth language deficits and consider eligibility for speech language services with the emphasis on improving these children’s foundational skills.
Now that we have discussed the issue of ESL services, lets touch upon social pragmatic language abilities of internationally adopted children. Here’s how erroneous beliefs can contribute to mismanagement of appropriate services in this area.
Different cultures have different pragmatic conventions, therefore we are taught to be very careful when labeling certain behaviors of children from other cultures as atypical, just because they are not consistent with the conventions and behaviors of children from the mainstream culture. Here’s a recent example. A mainstream American parent consulted an SLP regarding the inappropriate social pragmatic skills of her teenaged daughter adopted almost a decade ago from Southeast Asia. The SLP was under the impression that some of the child’s deficits were due to multicultural differences and had to do with the customs and traditions of the child’s country of origin. She was considering advising the parent regarding requesting an evaluation by a SLP who spoke the child’s birth language.
Here are two problems with the above scenario. Firstly, any internationally adopted post-institutionalized child who was adopted by American parents who were not part of the culture from which the child was adopted, the child will quickly become acculturated and immersed in the American culture. These children “need functional English for survival”, and thus have a powerful incentive to acquire English (Gindis, 2005; p. 299). consequently, any unusual or atypical behaviors they exhibit in social interactions and in academic setting with other individuals cannot be attributed to customs and traditions of another culture.
Secondly, It is very important to understand that institutionalization and orphanage care have been closely linked to increase in mental health disorders and psychiatric impairments. As a result, internationally adopted children have a high incidence of social pragmatic deficits as compared to non-adopted peers as well as post-institutionalized children adopted at younger ages, (under 3). Given this, if parents present with concerns regarding their internationally adopted post-institutionalized children’s social pragmatic and behavioral functioning it is very important not to jump to erroneous conclusion pertaining to these children’s birth countries but rather preform comprehensive evaluations in order to determine whether these children can be assisted further in the realm of social pragmatic functioning in a variety of settings.
In order to develop a clear picture regarding appropriate service delivery for IA children, school based professionals need to educate themselves regarding the fundamental differences between development and learning trajectories of internationally adopted children and multicultural/bilingual children. Children, who struggle academically, after years of adequate schooling exposure, do not deserve a “wait and see” approach. They should start receiving appropriate intervention as soon as possible (Hough & Kaczmarek, 2011; Scott & Roberts, 2007).
Dinner with Friends or the Value of Interdisciplinary Collaboration and Follow Up
Several months ago I had dinner with two of my colleagues, a pediatrician and a clinical social worker, to iron out the details of our upcoming conference presentation. As time went by we managed to discuss every topic under the sun, yet still the subject of our presentation was sadly not on the agenda. Exhausted from working at the hospital a full day and seeing private clients afterwards, I was getting distinctly antsy as the hand clock kept climbing closer to midnight.
The conversation began to feel more productive when we started to touch base on our mutual clients. Mostly they wanted to hear from me, since they both share an office suite and I was the only one located off-site. So, even though we all individually frequently conferred via phone regarding clients, that was the first time all three of us got together in the same room to discuss them. Quickly, I rattled off each of my clients’ progress in therapy, until I got to D, and paused. Oh, don’t get me wrong I am very proud of my work with D, whom I’ve been working with for several years, and who went from being limitedly verbal, severely echolalic, and “autistic like” at the age of 4-5 to fluent complex sentence speaker, fledgling problem solver, and a little charmer by the age of 6-5. Yet something was still bothering me regarding D’s performance that I couldn’t put my finger on. Despite the absence of a particular diagnosis (e.g., ASD) and significant gains, his issues with attention and cognition persisted, and his progress was still halting and inconsistent, even with rigorous language therapy and supplementary academic instruction at home 4 times a week.
In my desperation I have already considered and mentally rejected a number of referrals (“No it doesn’t seem to be a psychiatric issue”, “Yes he can benefit from a neurological but should I refer him to a psychological assessment first, could it be an IQ issue?” I pondered out loud as I shared my concerns with my colleagues. Both of them haven’t seen him for about 6 months so the clinical social worker immediately whipped out his chart busily looking for appropriate information, while the pediatrician started to frown, searching her memory for an “appropriate entry.” “Wait a second”, she said, “when I last saw him, during his physical exam I saw brown café au lait spots on his skin that I didn’t like at all, so I referred mom to get some blood work done but I haven’t heard from her since that time. Since you see her every week, can you please ask her to call me ASAP so I could remind her to do the blood test, as the information you are telling me makes it even more imperative that she follow up with the lab work.”
Right away, I became alert. Though the pediatrician was not stating her suspicious explicitly, through years of working with medical professionals I was familiar with the implications of what café au lait spots can potentially represent and that is neurofibromatosis. It is a neurocutaneous syndrome that leads to benign tumor growths in various parts of the body and can affect the brain, spinal cord, nerves, skin, and other body systems. In additional to all the medical implications of this syndrome (e.g., tumors becoming cancerous), it can also cause cognitive deficits and subsequent learning disabilities that affect appropriate knowledge acquisition and retention.
To me the situation was clear, no matter what the outcome, as the only team professional in contact with the parent at the time, it was my job to counsel the parent that she get in touch with the pediatrician so she can successfully pursue the recommended course of action. It may not have been the position I wanted to be in but unfortunately I knew that if this matter was left unpursued, I was left with a whole host of unanswered questions regarding further treatment options for this child.
I use the above example to emphasize the value and importance of working as part of a team to treat the “whole” child. Therapists specializing in working with children on the spectrum are most familiar with being part of a team, since they are just one of many professionals such as behaviorists, OT’s, psychologists or neurologists who are working with a child. Being part of a team is also a much more acceptable practice when a child is treated in a hospital or a rehab setting and presents with a complex disorder (e.g., is medically fragile, has a genetic syndrome, etc).
However, in our field, even outside of specialty settings (hospital/rehab) we are frequently confronted with speech or language disordered clients who stump our thinking processes, and who require the team approach (including the involvement of specialized medical professionals). Yet oftentimes that creates a significant challenge for many clinicians who are working contractually (through an agency) in school settings or in private practice. Being part of a team when one is contractor or a sole practitioner in a private practice is a much more difficult feat, especially when the clinicians are just striking out on their own for the first time.
Both interdisciplinary and multidisciplinary teamwork is oftentimes so crucial in our field. Working as part of a team allows us to collectively pursue common goals, combine our selective expertise, initiate a discussion to solve difficult problems, as well as to have professional lifelines when working on difficult cases. Different providers (neurologist, SLP, OT) see different symptoms as well as different aspects of the patient’s disorder. Consequently, different providers bring different perspectives to the table, which ultimately positively contributes to the treatment of the whole child.
Interestingly, many private speech language practitioners have wide referral networks (e.g., pediatricians, OT’s, PT’s and others who refer clients to them) yet when asked regarding frequency of contact with respect to conferences/discussions about the progress of specific clients, many clinicians draw a blank.
So how can we develop productive professional relationships with other service providers which go beyond the initial referral? I’ll be the first one to admit that it is not an easy accomplishment especially which it comes to physicians such as psychiatrists, neurologists, geneticists, or developmental pediatricians. I can tell you that while some of my professional relationships came easy, others took years to attain and refine.
In my hospital setting I work as part of a team. However, when I first started out in private practice, in a fairly short period of time I ended up having a number of clients with complex diagnoses and no one to refer them to. What complicated matters further that in contrast to them being referred to me by a pediatrician, these clients came to me first, since their most “visible issues” at the time were speech language deficits. I had to be the one to initiate the referral process to suggest to their parents relevant medical professionals, which needed to be visited in order to figure out why their children were having such complex language difficulties (among other symptoms) in the first place.
So here are a few suggestions on how to initiate and maintain professional relationships with medical service providers.
Start with doing a little research. You have worked hard to build your practice and your clients deserve the best, so locate the best medical service providers in your area. In the past I’ve had some excellent recommendations from locally based colleagues who were active on the ASHA discussion forums, other client’s parents who already did the necessary legwork, or hospital based colleagues who recommended peers in private practice. Several times I actually liked the initial medical reports I’ve received on a client so much – that I’ve referred other clients to the same doctor.
When word of mouth fails to do the trick, I turn to “Google” to provide me with desired results. Surprisingly, simply typing in “best _______in _____(name of state)” frequently does the trick and allows me to locate relevant professionals, after browsing through the multitude of web reviews.
Of course depending on the length of client treatment, you will have different relationships with different medical providers. I have collaborated for years with some (e.g., pediatrician, psychiatrist), and only infrequently spoken with others (geneticist, otolaryngologist, pediatric ophthalmologist).
Typically, when I refer a client for additional testing or consultation, in my referral letter to the physician, I request to receive the results in writing, asking the physician to also include relevant recommendations (if needed). Oftentimes, I also try to set some time to discuss the findings in a phone call in case I have any additional questions or concerns. Of course, I also send the physician (and other providers working with the child) the information from my end (progress reports, evaluations) so all of us can have a more comprehensive profile of the client’s disorder/deficit.
After all, ST’s, OT’s and PT’s are not the only ones who are dependent on information from doctors in order to do our work better. There are times when physicians need information from us in order to move further in treatment such as order specific tests. For example, just recently a pediatrician used my therapy progress report in conjunction with another provider’s, to order an MRI on our mutual client. The pediatrician had significant concerns over client’s development and presenting symptomatology, and needed to gather additional reports supporting her cause for concern in order to justify her course of action (ordering an MRI) to the HMO.
As mentioned previously there are numerous benefits to teamwork including the fact that it allows for appreciation of other disciplines, creation of functional goals for the child, integration of interventions as well as “brings together diverse knowledge and skills and can result in quicker decision making” (Catlett & Halper, 1992).
Given the above, it is important that speech language pathologists help to coordinate care and maintain relationships with other medical and related professionals who are treating the child. This will improve decision making, allow the professionals to address the child’s deficits in a holistic manner, an even potentially expedite the child’s length of stay in therapy.
References:
Catlett, C & Halper, A (1992) Team Approaches: Working Together to Improve Quality. ASHA: Quality Improvement Digest. http://www.asha.org/uploadedFiles/aud/TeamApproaches.pdf
National Institute of Neurological Disorders and Stroke (NINDS) Neurofibromatosis Information Page http://www.ninds.nih.gov/disorders/neurofibromatosis/neurofibromatosis.htm
Spotlight on Syndromes: An SLPs Perspective on Spinal Muscle Atrophy
The following is an informational post on the disease SMA (spinal muscle atrophy) by Rose Ann Kesting M.A. CCC-SLP. After reading, please visit her blog post “My Wednesday Morning Wake Up Call,” for a personal account of her experience with a very special boy with Type 1 SMA and his amazingly dedicated family. Continue reading Spotlight on Syndromes: An SLPs Perspective on Spinal Muscle Atrophy