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Assessing and Treating Bilinguals Who Stutter: Facts for Bilingual and Monolingual SLPs

Introduction: When it comes to bilingual children who stutter there is still considerable amount of misinformation regarding the best recommendations on assessment and treatment. The aim of this article is to review best practices in assessment and treatment of bilingual children who stutter, to shed some light on this important yet highly misunderstood area in speech-language pathology.

Types of Bilingualism: Young bilingual children can be broadly divided into two categories: those who are learning several languages simultaneously from birth (simultaneous bilingual), and those who begin to learn a second language after two years of age (sequential bilingual) (De Houwer, 2009b). The language milestones for simultaneous bilinguals may be somewhat uneven but they are not that much different from those of monolingual children (De Houwer, 2009a). Namely, first words emerge between 8 and 15 months and early phrase production occurs around +/-20 months of age, with sentence production following thereafter (De Houwer, 2009b). In contrast, sequential bilinguals undergo a number of stages during which they acquire abilities in the second language, which include preproduction, early production, as well as intermediate and advanced proficiency in the second language.

Stuttering and Monolingual Children: With respect to stuttering in the monolingual children we know that there are certain risk factors associated with stuttering. These include family history (family members who stutter), age of onset (children who begin stuttering before the age of three have a greater likelihood of outgrowing stuttering), time since onset (depending on how long the child have been stuttering certain children may outgrow it), gender (research has shown that girls are more likely to outgrow stuttering than boys), presence of other speech/language factors (poor speech intelligibility, advance language skills etc.) (Stuttering Foundation: Risk Factors).  We also know that the symptoms of stuttering manifest via sound, syllable and word repetitions, sound prolongations as well as sound and word blocks. In addition to overt stuttering characteristics there could also be secondary characteristics including gaze avoidance, word substitutions, anxiety about speaking, muscle tension in the face, jaw and neck, as well as fist clenching, just to name a few.

Stuttering and Bilingual Children: So what do we currently know regarding the manifestations of stuttering in bilingual children?  Here is some information based on existing research. While some researchers believe that stuttering is more common in bilingual versus monolingual individuals, currently there is no data which supports such a hypothesis.  The distribution and severity of stuttering tend to differ from language to language and one language is typically affected more than the other (Van Borsel, Maes & Foulon, 2001). Lim and colleagues (2008) found that language dominance influences the severity but not the types of stuttering behaviors.  They also found that bilingual stutterers exhibit different stuttering characteristics in both languages such as displaying stuttering on content words in L1 and function words in L2 (less-developed language system). According to Watson & Kayser (1994) key features of ‘true’ stuttering include the presence of stuttering in both languages with accompanying self-awareness as well as secondary behaviors.   This is important to understand giving the fact that bilingual children in the process of learning another language may present with pseudo-stuttering characteristics related to word retrieval rather than true stuttering.

Assessment of Bilingual Stutterers: Now let’s talk about aspects of the assessment. Typically assessment should begin with the taking of detailed background history regarding stuttering risk factors, the extent of the child’s exposure and proficiency in each language, age of stuttering onset, the extent of stuttering in each language, as well as presence of any other concomitant concerns regarding the child’s speech and language (e.g., suspicion of language/articulation deficits etc.)  Shenker (2013) also recommends the parental use of perceptual rating scales to assess child’s proficiency in each language.

Assessment procedures, especially those for newly referred children (vs. children whose speech and language abilities were previously assessed), should include comprehensive assessments of speech and language in addition to assessment of stuttering in order to rule out any hidden concomitant deficits.  It is also important to obtain conversational and narrative samples in each language as well as reading samples when applicable.   When analyzing the samples it is very important to understand and make allowance for typical disfluencies (especially when it comes to preschool children) as well as understand the difference between true stuttering and word retrieval deficits (which pertain to linguistic difficulties), which can manifest as fillers, word phrase repetitions, as well as conversational pauses (German, 2005).

When analyzing the child’s conversational speech for dysfluencies it may be helpful to gradually increase linguistic complexity in order to determine at which level (e.g., word, phrase, etc.) dysfluencies take place (Schenker, 2013). To calculate frequency and duration of disfluencies, word-based (vs. syllable-based) counts of stuttering frequency will be more accurate across languages (Bernstein Ratner, 2004).

Finally during the assessment it is also very important to determine the family’s cultural beliefs toward stuttering since stuttering perceptions vary greatly amongst different cultures (Tellis & Tellis, 2003) and may not always be positive. For example, Waheed-Kahn (1998) found that Middle Eastern parents attempted to deal with their children’s stuttering in the following ways: prayed for change, asked them to “speak properly”, completed their sentences, changed their setting by sending them to live with a relative as well as asked them not to talk in public.  Gauging familial beliefs toward stuttering will allow clinicians to: understand parental involvement and acceptance of therapy services, select best treatment models for particular clients as well as gain knowledge of how cultural attitudes may impact treatment outcomes (Schenker, 2013).

 Image courtesy of mnsu.edu 

Treatment of Bilingual Stutterers: With respect to stuttering treatment delivery for bilingual children, research has found that treatment in one language results in spontaneous improvement in fluency in the untreated language (Rousseau, Packman, & Onslow, 2005). This is helpful for monolingual SLPs who often do not have the option of treating clients in their birth language.

For young preschool children both direct and indirect therapy approaches may be utilized.

For example, the Palin (PCI) approach for children 2-7 years of age uses play-based sessions, video feedback, and facilitated discussions to help parents support and increase their child’s fluency. Its primary focus is to modify parent–child interactions via a facilitative rather than an instructive approach by developing and reinforcing parents’ expertise via use of video feedback to set own targets and reinforce progress. In contrast, the Lidcombe Program for children 2-7 years of age is a behavioral treatment with a focus on stuttering elimination.  It is administered by the parents under the supervision of an SLP, who teaches the parents how to control the child’s stuttering with verbal response contingent stimulation (Onslow & Millard, 2012).   While the Palin PCI approach still requires further research to determine its use with bilingual children, the Lidcombe Program has been trialed in a number of studies with bilingual children and was found to be effective in both languages (Schenker, 2013).

For bilingual school-age children with persistent stuttering, it is important to focus on stuttering management vs. stuttering elimination (Reardon-Reeves & Yaruss, 2013).  Here we are looking to reduce frequency and severity of disfluencies, teach the children to successfully manage stuttering moments, as well as work on the student’s emotional attitude toward stuttering. Use of support groups for children who stutter (e.g., “FRIENDS”: http://www.friendswhostutter.org/), may also be recommended.

Depending on the student’s preferences, desires, and needs, the approaches may involve a combination of fluency shaping and stuttering modification techniques.  Fluency shaping intervention focuses on increasing fluent speech through teaching methods that reduce speaking rate such as easy onsets, loose contacts, changing breathing, prolonging sounds or words, pausing, etc. The goal of fluency shaping is to “encourage spontaneous fluency where possible and controlled fluency when it is not” (Ramig & Dodge, 2004). In contrast stuttering modification therapy focuses on modifying the severity of stuttering moments as well as on reduction of fear, anxiety and avoidance behaviors associated with stuttering. Stuttering modification techniques are aimed at assisting the client “to confront the stuttering moment through implementation of pre-block, in-block, and/or post-block corrections, as well as through a change in how they perceive the stuttering experience” (Ramig & Dodge, 2004). While studies on these treatment methods are still very limited it is important to note that each technique as well as a combination of both techniques have been trialed and found successful with bilingual and even trilingual speakers (Conture & Curlee, 2007; Howell & Van Borsel, 2011).

Finally, it is very important for clinicians to account for cultural differences during treatment. This can be accomplished by carefully selecting culturally appropriate stimuli, preparing instructions which account for the parents’ language and culture, attempting to provide audio/video examples in the child’s birth language, as well as finding/creating opportunities for practicing fluency in culturally-relevant contexts and activities (Schenker, 2013).

Conclusion:  Presently, no evidence has been found that bilingualism causes stuttering. Furthermore, treatment outcomes for bilingual children appear to be comparable to those of monolingual children. Bilingual SLPs encountering bilingual children who stutter are encouraged to provide stuttering treatment in the language the child is most proficient in. Monolingual SLPs encountering bilingual children are encouraged to provide stuttering treatment in English with the expectation that the treatment will carry over into the child’s birth language. All clinicians are encouraged to involve the children’s families in the stuttering treatment as well as utilize methods and interventions that are in agreement with the family’s cultural beliefs and values, in order to create optimum treatment outcomes for bilingual children who stutter.

References:

  1. Bernstein Ratner, N. (2004). Fluency and stuttering in bilingual children. In B. Goldstein (ed.). Language Development: a focus on the Spanish-English speaker. Baltimore, MD: Brookes. (287-310).
  2. Conture, E. G., & Curlee, R. F. (2007). Stuttering and related disorders of fl uency. New York, NY: Thieme Medical Publishers.
  3. De Houwer, A. (2009a). Bilingual first language acquisition. Bristol: Multilingual Matters.
  4. De Houwer, A. (2009b). Assessing lexical development in bilingual first language acquisition: What can we learn from monolingual norms? In M. Cruz-Ferreira (Ed.), Multilingual norms (pp. 279-322). Frankfurt: Peter Lang.
  5. German, D.J. (2005) Word-Finding Intervention Program, Second Edition (WFIP-2)Austin Texas: Pro.Ed
  6. Howell, P & Van Borsel, , (2011). Multicultural Aspects of Fluency Disorders, Multilingual Matters, Bristol, UK.
  7. Lim, V. P. C., Rickard Liow, S. J., Lincoln, M., Chan, Y. H., & Onslow, M. (2008). Determining language dominance in English–Mandarin bilinguals: Development of a selfreport classification tool for clinical use. Applied Psycholinguistics, 29, 389–412.
  8. Onslow M, Millard S. (2012). Palin Parent Child Interaction and the Lidcombe Program: Clarifying some issues. Journal of Fluency Disorders37(1 ):1-8.
  9. Tellis, G. & Tellis, C. (2003). Multicultural issues in school settings. Seminars in Speech and Language, 24, 21-26.
  10. Ramig, P. R., & Dodge, D. (2004, September 08). Fluency shaping intervention: Helpful, but why it is important to know more. Retrieved from http://www.mnsu.edu/comdis/isad7/papers/ramig7.html
  11. Reardon-Reeves, N., & Yaruss, J.S. (2013). School-age Stuttering Therapy: A Practical Guide. McKinney, TX: Stuttering Therapy Resources, Inc.
  12. Rousseau, I., Packman, A., & Onslow, M. (2005, June). A trial of the Lidcombe Program with school age stuttering children. Paper presented at the Speech Pathology National Conference, Canberra, Australia.
  13. Shenker, R. C. (2013). Bilingual myth-busters series. When young children who stutter are also bilingual: Some thoughts about assessment and treatment. Perspectives on Communication Disorders and Sciences in Culturally and Linguistically Diverse (CLD) Populations, 20(1), 15-23.
  14. Stuttering Foundation website: Stuttering Risk Factors http://www.stutteringhelp.org/risk-factors
  15. Van Borsel, J. Maes, E., & Foulon, S. (2001). Stuttering and bilingualism: A review. Journal of Fluency Disorders, 26, 179-205.
  16. Waheed-Kahn, N. (1998). Fluency therapy with multilingual clients. In Healey, E. C. & Peters, H. F. M. (Eds.),Proceedings of the Second World Congress on Fluency Disorders, San Francisco, August 18. 22(pp. 195–199). Nijmegen, The Netherlands: Nijmegen University Press.
  17. Watson, J., & Kayser, H. (1994). Assessment of bilingual/bicultural adults who stutter. Seminars in Speech and Language, 15, 149-163.

 

 

 

 

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Bilingual Therapy Resources Linky Party!

bilingual therapy resources link upThe Dabbling Speechie is having a bilingual therapy resources Linky Party so I decided to join in and write a few posts on what I am using and referencing when it comes to assessment and treatment of bilingual and multicultural children.

First up I’d like to tell you a little bit about the post I wrote and materials I created for this purpose.

A few months ago I did a post on Integrating aspects of multiculturalism into group language therapy sessions where I offered some suggestions on how to integrate multiculturalism into your group therapy sessions, which included books, activities and websites.

Below are a few products I’ve created for bilingual/multicultural assessment and treatment purposes:

I also created specific products relevant to comprehensive data collection and narrative assessment of multicultural children

  • General Assessment and Treatment Start-Up Bundle
    • This product bundle contains 5 downloads for general speech language assessment and treatment planning and includes:
      1. Speech Language Assessment Checklist for a Preschool Child
      2. Speech Language Assessment Checklist for a School-Aged Child
      3. Creating a Functional Therapy Plan: Therapy Goals & SOAP Note Documentation
      4. Selecting Clinical Materials for Pediatric Therapy
      5. Recognizing Speech-Language delay in school age-children: a tutorial for teachers
  • The Checklists Bundle
    • This product contains 4 checklists relevant to screening and assessment in speech language pathology
      1. Speech Language Assessment Checklist for a Preschool Child
      2. Speech Language Assessment Checklist for a School-Aged Child
      3. Auditory Processing Deficits (APD) Checklist for School Aged Children
      4. Social Pragmatic Deficits Checklist for School Aged Children
  • Narrative Assessment Bundle
    • This product contains ontains 3 downloads relevant to narrative assessment
      1. Narrative Assessments of Preschool and School Aged Children
      2. Understanding Complex Sentences
      3. Vocabulary Development: Working with Disadvantaged Populations

What materials are you using to assess your bilingual/multicultural students?

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What Research Shows About the Functional Relevance of Standardized Language Tests

Image result for standardized language testsAs an SLP who routinely conducts speech and language assessments in several settings (e.g., school and private practice), I understand the utility of and the need for standardized speech, language, and literacy tests.  However, as an SLP who works with children with dramatically varying degree of cognition, abilities, and skill-sets, I also highly value supplementing these standardized tests with functional and dynamic assessments, interactions, and observations.

Since a significant value is placed on standardized testing by both schools and insurance companies for the purposes of service provision and reimbursement, I wanted to summarize in today’s post the findings of recent articles on this topic.  Since my primary interest lies in assessing and treating school-age children, for the purposes of today’s post all of the reviewed articles came directly from the Language Speech and Hearing Services in Schools  (LSHSS) journal.

We’ve all been there. We’ve all had situations in which students scored on the low end of normal, or had a few subtest scores in the below average range, which equaled  an average total score.  We’ve all poured over eligibility requirements trying to figure out whether the student should receive therapy services given the stringent standardized testing criteria in some states/districts.

Of course, as it turns out, the answer is never simple.  In 2006, Spaulding, Plante & Farinella set out to examine the assumption: “that children with language impairment will receive low scores on standardized tests, and therefore [those] low scores will accurately identify these children” (61).   So they analyzed the data from 43 commercially available child language tests to identify whether evidence exists to support their use in identifying language impairment in children.

Turns out it did not!  Turns out due to the variation in psychometric properties of various tests (see article for specific details), many children with language impairment are overlooked by standardized tests by receiving scores within the average range or not receiving low enough scores to qualify for services. Thus, “the clinical consequence is that a child who truly has a language impairment has a roughly equal chance of being correctly or incorrectly identified, depending on the test that he or she is given.” Furthermore, “even if a child is diagnosed accurately as language impaired at one point in time, future diagnoses may lead to the false perception that the child has recovered, depending on the test(s) that he or she has been given (69).”

Consequently, they created a decision tree (see below) with recommendations for clinicians using standardized testing. They recommend using alternate sources of data (sensitivity and specificity rates) to support accurate identification (available for a small subset of select tests).

The idea behind it is: “if sensitivity and specificity data are strong, and these data were derived from subjects who are comparable to the child tested, then the clinician can be relatively confident in relying on the test score data to aid his or her diagnostic decision. However, if the data are weak, then more caution is warranted and other sources of information on the child’s status might have primacy in making a diagnosis (70).”

Fast forward 6 years, and a number of newly revised tests later,  in 2012, Spaulding and colleagues set out to “identify various U.S. state education departments’ criteria for determining the severity of language impairment in children, with particular focus on the use of norm-referenced tests” as well as to “determine if norm-referenced tests of child language were developed for the purpose of identifying the severity of children’s language impairment”  (176).

They obtained published procedures for severity determinations from available U.S. state education departments, which specified the use of norm-referenced tests, and reviewed the manuals for 45 norm-referenced tests of child language to determine if each test was designed to identify the degree of a child’s language impairment.

What they found out was “the degree of use and cutoff-point criteria for severity determination varied across states. No cutoff-point criteria aligned with the severity cutoff points described within the test manuals. Furthermore, tests that included severity information lacked empirical data on how the severity categories were derived (176).”

Thus they urged SLPs to exercise caution in determining the severity of children’s language impairment via norm-referenced test performance “given the inconsistency in guidelines and lack of empirical data within test manuals to support this use (176)”.

Following the publication of this article, Ireland, Hall-Mills & Millikin issued a response to the  Spaulding and colleagues article. They pointed out that the “severity of language impairment is only one piece of information considered by a team for the determination of eligibility for special education and related services”.  They noted that  they left out a host of federal and state guideline requirements and “did not provide an analysis of the regulations governing special education evaluation and criteria for determining eligibility (320).” They pointed out that “IDEA prohibits the use of ‘any single measure or assessment as the sole criterion’ for determination of disability  and requires that IEP teams ‘draw upon information from a variety of sources.”

They listed a variety of examples from several different state departments of education (FL, NC, VA, etc.), which mandate the use of functional assessments, dynamic assessments criterion-referenced assessments, etc. for their determination of language therapy eligibility.

But are the SLPs from across the country appropriately using the federal and state guidelines in order to determine eligibility? While one should certainly hope so, it does not always seem to be the case.  To illustrate, in 2012, Betz & colleagues asked 364 SLPs to complete a survey “regarding how frequently they used specific standardized tests when diagnosing suspected specific language impairment (SLI) (133).”

Their purpose was to determine “whether the quality of standardized tests, as measured by the test’s psychometric properties, is related to how frequently the tests are used in clinical practice” (133).

What they found out was that the most frequently used tests were the comprehensive assessments including the Clinical Evaluation of Language Fundamentals and the Preschool Language Scale as well as one word vocabulary tests such as the Peabody Picture Vocabulary Test. Furthermore, the date of publication seemed to be the only factor which affected the frequency of test selection.

They also found out that frequently SLPs did not follow up the comprehensive standardized testing with domain specific assessments (critical thinking, social communication, etc.) but instead used the vocabulary testing as a second measure.  They were understandably puzzled by that finding. “The emphasis placed on vocabulary measures is intriguing because although vocabulary is often a weakness in children with SLI (e.g., Stothard et al., 1998), the research to date does not show vocabulary to be more impaired than other language domains in children with SLI (140).“

According to the authors, “perhaps the most discouraging finding of this study was the lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores (141).”

If since the time (2012) SLPs have not significantly change their practices, the above is certainly disheartening, as it implies that rather than being true diagnosticians, SLPs are using whatever is at hand that has been purchased by their department to indiscriminately assess students with suspected speech language disorders. If that is truly the case, it certainly places into question the Ireland, Hall-Mills & Millikin’s response to Spaulding and colleagues.  In other words, though SLPs are aware that they need to comply with state and federal regulations when it comes to unbiased and targeted assessments of children with suspected language disorders, they may not actually be using appropriate standardized testing much less supplementary informal assessments (e.g., dynamic, narrative, language sampling) in order to administer well-rounded assessments.  

So where do we go from here? Well, it’s quite simple really!   We already know what the problem is. Based on the above articles we know that:

  1. Standardized tests possess significant limitations
  2. They are not used with optimal effectiveness by many SLPs
  3.  They may not be frequently supplemented by relevant and targeted informal assessment measures in order to improve the accuracy of disorder determination and subsequent therapy eligibility

Now that we have identified a problem, we need to develop and consistently implement effective practices to ameliorate it.  These include researching psychometric properties of tests to review sample size, sensitivity and specificity, etc, use domain specific assessments to supplement administration of comprehensive testing, as well as supplement standardized testing with a plethora of functional assessments.

SLPs can review testing manuals and consult with colleagues when they feel that the standardized testing is underidentifying students with language impairments (e.g., HERE and HERE).  They can utilize referral checklists (e.g., HERE) in order to pinpoint the students’ most significant difficulties. Finally, they can develop and consistently implement informal assessment practices (e.g., HERE and HERE) during testing in order to gain a better grasp on their students’ TRUE linguistic functioning.

Stay tuned for the second portion of this post entitled: “What Research Shows About the Functional Relevance of Standardized Speech Tests?” to find out the best practices in the assessment of speech sound disorders in children.

References:

  1. Spaulding, Plante & Farinella (2006) Eligibility Criteria for Language Impairment: Is the Low End of Normal Always Appropriate?
  2. Spaulding, Szulga, & Figueria (2012) Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers
  3. Ireland, Hall-Mills & Millikin (2012) Appropriate Implementation of Severity Ratings, Regulations, and State Guidance: A Response to “Using Norm-Referenced Tests to Determine Severity of Language Impairment in Children: Disconnect Between U.S. Policy Makers and Test Developers” by Spaulding, Szulga, & Figueria (2012)
  4. Betz et al. (2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment

 

Links

Organizations:

ASHA
The American Speech-Language-Hearing Association (ASHA) is the professional, scientific, and credentialing association for 145,000 members and affiliates who are audiologists, speech-language pathologists and speech, language, and hearing scientists.

The Childhood Apraxia of Speech Association of North America (CASANA) The mission: To strengthen the support systems in the lives of children with apraxia, so that each child has their best opportunity to develop speech

Selective Mutism nation’s premier resource for SM information, providing a network of families and treating professionals across the world who uniquely understand the struggles of SM

The Stuttering Foundation The Stuttering Foundation provides free online resources, services and support to those who stutter and their families, as well as support for research into the causes of stuttering

The Cleft Palate Foundation The mission of CPF is to enhance the quality of life for individuals affected by cleft lip and palate and other craniofacial birth defects.

Down Syndrome Education Online Comprehensive information about Down syndrome, including articles, books and scientific papers (Speech and Language Issues)

 The Autism Society The Autism Society, the nation s leading grassroots autism organization, exists to improve the lives of all affected by autism.

The International Dyslexia Foundation
The International Dyslexia Association (IDA) is an international organization that concerns itself with the complex issues of dyslexia.

Websites: 

Social Thinking  

Sensory Processing  

Genetics in the Practice of Speech Language Pathology 

Professionals: 

Speech Language Pathologists:

Nicole Kollenda MS CCC-SLP (offices on the Upper East Side and Mineola) 

Psychotherapists: 

Lydia Shifrin, Bilingual School Psychologist & Licensed Social Worker 
Psychotherapist since 1971, first in the former Soviet Union, and than for over twenty years in the US, as a bilingual/bicultural professional.

Psychologists: 

The Center for Cognitive-Developmental Assessment and Remediation (BGCenter) 
under the leadership of eminent psychologist, Dr. Boris Gindis, the center is composed of independent professionals, specializing with services to the internationally adopted children, who work at the center as well as offsite.

 

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Dear School Professionals Please Be Aware of This

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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.

If the child’s pre-adoption records specifically state that s/he has birth language delay then it should be taken seriously (Gindis, 1999) since language delays in the birth language transfer and affect the new language (McLaughlin, Gesi, & Osani, 1995). These delays will not “go away” without appropriate interventions.  “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)

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).

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Dear SLPs, Try Asking This Instead

Image result for functionalI frequently see numerous posts on Facebook that ask group members, “What are your activities/goals for a particular age group (e.g., preschool, middle school, high school, etc.) or a particular disorder (e.g., Down Syndrome)? After seeing these posts appear over and over again in a variety of groups, I decided to write my own post on this topic, explaining why asking such broad questions will not result in optimal therapeutic interventions for the clients in question. Continue reading Dear SLPs, Try Asking This Instead

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Spotlight on Syndromes: An SLPs Perspective on Hurler Syndrome

Today’s guest post on genetic syndromes comes from Kelly Hungaski, who is contributing an informative piece on the Hurler Syndrome.

Hurler Syndrome is a rare, inherited metabolic disease in which a person can’t break down lengthy chains of sugar molecules called glycosaminoglycans. Hurler syndrome belongs to a group of diseases called mucopolysaccharidoses, or MPS. Continue reading Spotlight on Syndromes: An SLPs Perspective on Hurler Syndrome

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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.

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Pediatric Background History Questionnaire Giveaway

peds questionnaireToday I am very excited to introduce my new product “Pediatric Background History Questionnaire”. I’ve been blogging quite a bit lately on the topic of obtaining a thorough developmental client history in order to make an appropriate and accurate diagnosis of the child’s difficulties for relevant classroom placement, appropriate accommodations and modifications as well as targeted and relevant therapeutic services.  
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