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Is it Language Disorder or Learning Disability? A Tutorial for Parents and Professionals

Recently I read a terrific article written in 2014 by Sun and Wallach entitled: “Language Disorders Are Learning Disabilities: Challenges on the Divergent and Diverse Paths to Language Learning Disability“. I found it to be so valuable that I wanted to summarize some of its key points to my readers because it bears tremendous impact on our understanding of what happens to children with language disorders when they reach school years.

The authors begin the article by introducing a scenario familiar to numerous SLPs. A young child is diagnosed with receptive, expressive  and social pragmatic language deficits as a toddler (2.5 years of age) begins to receive speech language services, which continue through preschool and elementary school until 2nd grade. The child is receiving therapy under the diagnosis of specific language impairment (SLI), which is characterized by difficulties with acquiring language in the absence of any other known disorders. By 2nd grade the child has seemingly “caught up” in the areas of listening comprehension and complex sentence production but is now struggling academically in the areas of reading and writing. Now his teachers are concerned that he has a learning disability, and his bewildered parent asks “Is it true that my child now has another problem on top of his language problem?”

From that scenario the authors skillfully navigate the complex relationship between language disorders and school disability labels to explain that the child does NOT have a new disorder but rather continues to face new challenges presented by his old disorder due to which he is now struggling to meet the growing language demands of the academic curriculum.

Here’s the approximate hierarchy of language development in young children:

  • Exploration of the environment
  • Play
  • Receptive Language
    • Comprehension of  words, phrases, sentences, stories
  • Expressive Language
    • Speaking single words, phrases, sentences, engaging in conversations, producing stories
    • Reading
      • Words, sentences, short stories, chapter books, etc.
      • General topics
      • Domain specific topics (science, social studies, etc)
    • Spelling
    • Writing
      • Words, sentences, short stories, essays

The problem is that if the child experiences any deficits in the foundational language areas such as listening and speaking, he will most certainly experience difficulties in the more complex areas of language which is reading and writing.

The authors continue by explaining the complexity of various labels given to children with language and learning difficulties under the IDEA 2004, DSM-5, as well as “research literature and nonschool clinical settings”. They conclude that: “the use of different labels by different professionals in different contexts should not obscure the commonalities among children with language disorders, no matter what they are called”.

Then they go on to explain that longitudinal (over a period of time) research has revealed numerous difficulties experienced by children with “early language disorders” during school years and in adulthood “in all domains of academic achievement (spelling, reading comprehension, word identification, word attack, calculation)…”. They also point out that many of these children with language disorders were later classified with a learning disability because their “later learning difficulties [took on] the form of problems acquiring higher levels of spoken language comprehension and expression as well as reading and writing”.

The authors also explain the complex process of literacy acquisition as well as discuss the important concept of “illusory recovery“.  They note that there may be  “a time period when the students with early language disorders seem to catch up with their typically developing peers” by undergoing a “spurt” in language learning, which is followed by a “postspurt plateau” because due to their ongoing deficits and an increase in academic demands “many children with early language disorders fail to “outgrow” these difficulties or catch up with their typically developing peers”.

They pointed out that because many of these children “may not show academic or language-related learning difficulties until linguistic and cognitive demands of the task increase and exceed their limited abilities”, SLPs must consider the “underlying deficits that may be masked by early oral language development” and “evaluate a child’s language abilities in all modalities, including preliteracy, literacy, and metalinguistic skills”.

Finally, the authors reiterate that since language is embedded in all parts of the curriculum “intervention choices should be based on students’ ongoing language learning and literacy problems within curricular contexts, regardless of their diagnostic labels”. In other words, SLPs should actively use the students’ curriculum in the intervention process.

In their conclusion the authors summarize the key article points:

  • The diagnostic labels may change but the students linguistic needs stay the same. Thus clinicians need to a) “identify existing language/literacy needs that may have been unidentified previously” and b) provide “relevant and functional interventions that are curriculum-based and literacy-focused”
  • “Early language disorders are chronic and tend to follow children through time, manifesting themselves differently based upon an individual’s inherent abilities”. Thus SLPs need to be keenly aware regarding the nature and timing of “illusory recoveries” NOT to be fooled by them.
  • “Definitions of literacy have broadened” so “intervention goals and targeted language learning strategies should change accordingly to guide effective and relevant intervention“
  • “Majority of learning disabilities are language disorders that have changed over time”.

I hope that you’ve found this article helpful in furthering your understanding of these highly relevant yet often misunderstood labels and that this knowledge will assist you to make better decisions when serving the clients on your caseload.

 References:

Sun, L & Wallach G (2014) Language Disorders Are Learning Disabilities: Challenges on the Divergent and Diverse Paths to Language Learning Disability. Topics in Language Disorders, Vol. 34; (1), pp 25–38.

Helpful Smart Speech Therapy Resources:

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Why (C) APD Diagnosis is NOT Valid!

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

Here are just a few reasons why:

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

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

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

(C)APD symptomology:

A. Student presents with difficulty processing information efficiently

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

B. Student has difficulty maintaining attention on presented tasks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(From Kamhi, 2011, p. 268)

6. Are you sure it’s (C)APD?

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

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

7. (C)APD testing is NOT so PURE 

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

So what does the research show?

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

(From DeBonis, 2015 pgs. 126-127)

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

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

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

9. Looking for the “Right” Label 

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

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

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

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

10. Missing the Big Picture

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

Conclusion:

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

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

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

References:

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

I don’t about you but I am always looking for visually based social language materials for my clients. Luckily, even with a non-existent budget social skills materials are fairly easy to create. All you need is to locate a few relevant photos with faintly ambiguous scenarios and punctuate them by relevant to the scenarios questions.

Voilà! Your materials are ready for use.  It really is that easy. Want to take a look at a one such material in action?  Then check out the Multiple Interpretations Social Language Freebie I created specially for you. Click on the image below to get to my Facebook Page. There click on the Free Downloads Tab located on the top right corner and check it out for yourself.

 

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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

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For the Love of Speech Blog Hop: February Edition

Slide2Today I am very excited to participate along with 27 other talented SLPs in the For the Love of Speech  Blog Hop.  I love being an SLP, and to spread that love around  from February 1-4 I am giving away a Valentine’s Day Product: “The Origins of Valentine’s Day: At thematic language activity packet for middle and high school students” .  

This thematic packet was created to target listening and reading comprehension of middle and high school students diagnosed with language impairments and learning disabilities. The packet contains Response to Intervention (RTI) Tier 2 vocabulary words in story context. Expressive language activities for the packet include production of synonyms and antonyms, fill-in the blank, as well as sentence formulation using story vocabulary. Comprehension questions pertaining to story are provided in an open ended question format. It is great for teaching reading comprehension and sophisticated vocabulary in a thematic context related to familiar to the student events.

You can grab this product  for free for a limited time only in my online store (HERE) and then head on over to Teach Speech 365 to grab her freebie as well. Collect all freebies by the time the blog hop ends on  February 4th!

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For more useful FREE and PAID products check out my online store by clicking HERE or on the picture below SST Graphic

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Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

In the past several years, I wrote a series of posts on the topic of improving clinical practices in speech-language pathology.  Some of these posts were based on my clinical experience as backed by research,  while others summarized key point from articles written by prominent colleagues in our field such as Dr. Alan Kamhi,  Dr.  David DeBonnis,  Dr. Andrew Vermiglio, etc.

In the past, I have highlighted several articles from the 2014 LSHSS clinical forum entitled: Improving Clinical Practice. Today I would like to explicitly summarize another relevant article written by Dr. Wallach in 2014, entitled “Improving Clinical Practice: A School-Age and School-Based Perspective“, which discusses how to change the “persistence of traditional practices” in order to make our language interventions more functional and meaningful for students with language learning difficulties. Continue reading Do Our Therapy Goals Make Sense or How to Create Functional Language Intervention Targets

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Assessing Social Pragmatic Abilities in Children with Language Difficulties

You’ve received a referral to assess the language abilities of a school aged child with suspected language difficulties. The child has not been assessed before so you know you’ll need a comprehensive language test to look at the child’s ability to recall sentences, follow directions, name words, as well as perform a number of other tasks showcasing the child’s abilities in the areas of content and form (Bloom & Lahey, 1978).

But how about the area of language use? Will you be assessing the child’s pragmatic and social cognitive abilities as well during your language assessment? After all most comprehensive standardized assessments, “typically focus on semantics, syntax, morphology, and phonology, as these are the performance areas in which specific skill development can be most objectively measured” (Hill & Coufal, 2005, p 35). Continue reading Assessing Social Pragmatic Abilities in Children with Language Difficulties

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Comprehending Reading Comprehension

Image of three books open on a table with stacks of books in the background.How many parents and professionals have experienced the following scenario? The child in question is reading very fluently (Landi & Ryherd, 2017) but comprehending very little of what s/he is reading.  Attempts at remediation follow (oftentimes without the administration of a comprehensive assessment) with a focus on reading texts and answering text-related questions. However, much to everyone’s dismay the problem persists and worsens over time. The child’s mental health suffers as a result since numerous studies show that reading deficits including dyslexia are associated with depression, anxiety, attention, as well as behavioral problems (Arnold et al., 2005; Knivsberg & Andreassen, 2008; Huc-Chabrolle, et al, 2010; Kempe, Gustafson, & Samuelsson, 2011; Boyes, et al, 2016;   Livingston et al, 2018). Continue reading Comprehending Reading Comprehension

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#BHSM – School Based Innovation and RtI FREEBIE Blog Hop

Art by Margaret Warner mwa2808@gmail.com

To celebrate the 2015 ASHA Better Hearing and Speech Month in May, Speech Language Literacy Lab has organized an RtI Blog Hop. During the hop Smart Speech Therapy LLC along with 29 other professional bloggers from a variety of ancillary fields (e.g., OT, special education, etc.) will be sharing FREE materials and resources on the subject of School Based Innovation and RtI.

Each day, readers will have an access to a new blog post to have access to new freebies and resources. Our organizer Sl3l lab will also be linking these blog posts to their site daily.

Blog Posting Schedule:

5/1/2015 Kick Off to Better Hearing and Speech Month!

5/2/2015 RTI for the R sound! Badger State Speechy

5/3/2015 An effective RTI program Stephen Charlton Guest blogs on Speech Language Literacy Lab

5/4/2015 Technology and RTI  Building Successful Lives Speech & Language

5/5/2015 Starfish Therapies

5/6/2015 Orton Gillingham Approach & RTI  Orton Gillingham Online Academy

5/7/2015 Evidenced-based writing that works for RTI & SPED SQWrite

5/8/2015 RTI/MTSS/SBLT…OMG!  Let’s Talk! with Whitneyslp

5/9/2015 RtI, but why?  Attitudes are everything!  Crazy Speech World

5/10/2015      Consonantly Speaking

5/11/2015 Universal benchmarking for language to guide the RTI process in Pre-K and Kindergarten     Speech Language Literacy Lab

5/12/2015 Movement Breaks in the Classroom (Brain Breaks)   Your Therapy Source

5/13/2015 How to Write a Social Story   Blue Mango LLC

5/14/2015 Some Ideas on Objective Language Therapy    Language Fix

5/15/2015 Assistive Technology in the Classroom  OTMommy Needs Her Coffee

5/16/2015 Effective Tiered Early Literacy Instruction for Spanish-Speakers Bilingual Solutions Guest blog on Speech Language Literacy Lab

5/17/2015 Helping with Attention and Focus in the Classroom   The Pocket OT

5/18/2015 Tips on Effective Vocabulary Instruction  Smart Speech Therapy, LLC

5/19/2015 An SLP’s Role in RtI: My Story Communication Station: Speech Therapy, PLLC

5/20/2015 Incorporating Motor Skills into Literacy Centers   MissJaimeOT

5/21/2015 The QUAD Profile: A Language Checklist  The Speech Dudes

5/22/2015 Resources on Culturally Relevant Interventions  Tier 1 Educational Coaching and Consulting

5/23/2015 Language Goals Galore: Converting Real Pictures to Coloring Pages  Really Color guest blog on Speech Language Literacy Lab

5/24/2015 Lesson Pix: The Newest Must-Have Resource in your Tx Toolbox Speech Language Literacy Lab

5/25/2015 AAC & core vocabulary instruction Kidz Learn Language

5/26/2015 An RtI Alternative Old School Speech

5/27/2015 Intensive Service Delivery Model for Pre-Schoolers   Speech Sprouts

5/28/2015 RTI Success with Spanish-speakers     Speech is Beautiful

5/30/2015 The Importance of Social Language (pragmatic) Skills Linda Silver guest post on Speech Sprouts

5/31/2015 Sarah Warchol guest posts on Speech Language Literacy Lab

Hope to see you all hoping during #BHSM!

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My new article was published in January 2012 issue of Adoption Today Magazine

My article entitled: Speech Language Strategies for Multisensory Stimulation of Internationally Adopted Children has been published in the January 2012 Issue of Adoption Today Magazine

Summary:  The article introduces the concept of multisensory stimulation and explains its benefits for internationally adopted children of all ages.  It also provides suggestions for parents and professionals on how to implement multisensory strategies in a variety of educational activities in order to stimulate interest, increase task participation as well as facilitate concept retention.

References:

Doman, G & Wilkinson, R (1993) The effects of intense multi-sensory stimulation on coma arousal and recovery. Neuropsychological Rehabilitation. 3 (2): 203-212.

Johnson, D. E et al (1992) The health of children adopted from Romania. Journal of the American Medical Association. 268(24): 3446-3450

Ti, K, Shin YH, & White-Traut, RC (2003), Multisensory intervention improves physical growth and illness rates in Korean orphaned newborn infants. Research in Nursing Health.  26 (6): 424-33.

Milev et al (2008) Multisensory Stimulation for Elderly With Dementia: A 24-Week Single-Blind Randomized Controlled Pilot Study. American Journal of Alzheimer’s Disease and Other Dementias. 23 (4): 372-376.

Tarullo, A & Gunnar, M (2006). Child Maltreatment and Developing HPA Axis. Hormones and Behavior 50, 632-639.

White Traut (1999) Developmental Intervention for Preterm Infants Diagnosed with Periventricular Leukomalacia. Research in Nursing Health.  22: 131-143.

White Traut et al (2009) Salivary Cortisol and Behavioral State Responses of Healthy Newborn Infants to Tactile-Only and Multisensory Interventions. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 38(1): 22–34

 Resources: