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APD Update: New Developments on an Old Controversy

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

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

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

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

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Why Do I Have to Tell You What’s Wrong with My Child? Or On the Importance of Targeted Assessments

A few days ago I received a phone call from a parent who was seeking a language evaluation for her child. As it is my policy with all assessments, I asked her to fill out an intake and a checklist to identify her child’s specific areas of difficulty in order to compile a comprehensive and targeted testing battery.  Her response to me was: “I’ve never heard of this before? Why do I have to tell you what’s wrong with my child? Why can’t you figure it out?” Similarly, last week, another parent has questioned: “So you can’t do the assessment without this form?” Given the above questions, and especially because May is a Better Hearing and Speech Month #BHSM, during which it is important to raise awareness about communication disorders, I want to take this time to explain to parents why performing targeted speech language assessments is SO CRUCIAL.

To begin with it is very important to understand that speech and language can be analyzed in many different ways beyond looking at pronunciation, vocabulary or listening and speaking skills.

Targeted areas within the scope of practice of pediatric school based speech language pathologists include the assessment of:

  • SPEECH
    • The child may have difficulties with pronunciation of sounds in words, stutter, clutter, have a lisp or have difficulties in the areas of voice, prosody, or resonance. For the majority of  the above difficulties completely different tests and testing procedures may be needed in order to appropriately assess the child.
  • LANGUAGE
    • Receptive Language
      • Ability to follow directions, answer questions, recall sentences, understand verbal messages, as well as comprehend orally presented text
    • Memory and Attention 
      • Also see executive function skills
    • Expressive Language
      • Vocabulary knowledge and use, formulation of words and sentences as well as production of narratives or stories
    • Problem Solving
      • Verbal reasoning and critical thinking skills are very important for successful independent decision making as well as for interpretation of academically based texts and complete assignments
    • Pragmatic Language 
      • Successful use of language for a variety of communicative purposes
        • Initiate and maintain topics, maintain conversational exchanges, request help, etc
    • Social Emotional Competence
      • Effective interpersonal negotiation skills, compromise and negotiation abilities, as well as perspective taking are integral to academic and social success. These abilities are often compromised in children with language disorders and require a thorough assessment
    • Executive Functions (EFs) 
      • These are higher level cognitive processes involved in inhibition of thought, action and emotion, which are located in the prefrontal cortex of the frontal lobe of the brain.  
      • Major EF components include working memory, inhibitory control, planning, and set-shifting. EFs contribute to child’s ability to sustain attention, ignore distractions, and succeed in academic settings. 
  • READING DISABILITIES AND DYSLEXIA
    • Phonological Awareness
    • Reading Ability
    • Writing
    • Spelling 

One General Language Test Does Not Fit All! 

Children with speech and language disorders do not necessarily display weaknesses in all affected areas but may only display difficulties in selected few.

To illustrate, high functioning students on the autistic spectrum may have very strong academic skills related to comprehension and expression of language but may display significant social pragmatic language weaknesses, which will not be apparent on general language testing (e.g., administration of Clinical Evaluation of Language Fundamentals -5). Thus, the administration of a general language test will be contraindicated for these students as it will only show typical performance on these tests and will not qualify them for targeted language based services that they need.  However, by administering to them a testing battery composed of tests sensitive to social pragmatic language competence will highlight their areas of difficulty and result in a creation of a targeted intervention plan to improve their abilities in the affected areas. 

Similarly, children at risk for reading disabilities will not benefit from the administration of general language testing either, since their deficits may lie in the areas of sound discrimination, isolation, or blending as well as as impaired decoding ability.  So the administration of tests sensitive to phonological awareness and emergent reading ability would be much more relevant. 

This is exactly why taking an extra step and filling out a simple form will result in a much more targeted and beneficial speech language assessment for the child.  The goal of any competent professional assessment is to eliminate the administration of unnecessary and irrelevant tests and focus only on the administration of instruments directly targeting the areas of difficulty that the child presents with.  Given the fact that assessment of language covers so many broad areas, it makes perfect sense to ask parents to fill out relevant checklists/intakes as a routine part of a pre-assessment procedure.  Otherwise, even after observations in school setting, I would still just be blindly ‘fishing’ for deficits without really knowing whether I will  ‘accidentally stumble upon them’ using a general test at hand.

Of course, even checklists need to be targeted by age and areas of functioning. Here’s how I use mine. When performing comprehensive fist time assessments I ask the parent to fill out the comprehensive checklists based on the child’s age.    These are broken down as follows:

However, oftentimes when I perform reassessments or second opinion evaluations, I may ask the parent to fill out checklists pertaining to specific, known, areas of difficulty. These currently include:

After the parent fills the checklist out, the child’s areas of difficulty literally jump out from the pages. Now, all I need to do is to choose the appropriate testing instruments, which will BEST help me determine the exact nature and cause of the child’s deficits and I am all set. I administer the testing, interpret the results and write a comprehensive report detailing which therapy goals will be targeted. And this is why pre-assessment checklist administration is so important.

Helpful Resources: 

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Teaching “Insight” to students with language, social communication, and executive functions impairments

One common difficulty our “higher functioning” (refers to subjective notion of ‘perceived’ functioning in school setting only) language impaired students with social communication and executive function difficulties present with – is lack of insight into own strengths and weaknesses.

Yet insight is a very important skill, which most typically developing students exhibit without consciously thinking about it. Having insight allows students to review work for errors, compensate for any perceived weaknesses effectively, and succeed with efficient juggling of academic workload.

In contrast, lack of insight in students with language deficits further compounds their difficulties, as they lack realization into own weaknesses and as a result are unable to effectively compensate for them.

That is why I started to explicitly teach the students on my caseload in both psychiatric hospital and private practice the concept of insight.

Now some of you may have some legitimate concerns. You may ask: “How can one teach such an abstract concept to students who are already impaired in their comprehension of language?” The answer to that is – I teach this concept through a series of concrete steps as well as through the introduction of abstract definitions, simplified for the purpose of my sessions into concrete terms.

Furthermore, it is important to understand that the acquisition of “insight” cannot be accomplished in one or even several sessions. Rather after this concept is introduced and the related vocabulary has been ‘internalized’ by the student,  thematic therapy sessions can be used to continue the acquisition of “insight” for months and even years to come.

"The Beginning" Road Sign with dramatic blue sky and clouds.

How do we begin? 

When I first started teaching this concept I used to explain the terminology related to “insight” verbally to students. However, as my own ‘insight’ developed in response to the students’ performance, I created a product to assist them with the acquisition of insight (See HERE).

Intended Audiences:

  • Clients with Language Impairments
  • Clients with Social Pragmatic Language Difficulties
  • Clients with Executive Function Difficulties
  • Clients with Psychiatric Impairments
    • ODD, ADHD, MD, Anxiety, Depression, etc.
  • Clients with Autism Spectrum Disorders
  • Clients with Nonverbal Learning Disability
  • Clients with Fetal Alcohol Spectrum Disorders
  • Adult and pediatric post-Traumatic Brain Injury (TBI) clients
  • Clients with right-side CVA Damage

kid-lightbulb-shutterstock_166297358-300×198

This thematic 10 page packet targets the development of “insight” in students with average IQ, 8+ years of age, presenting with social pragmatic and executive function difficulties.

The packet contains 1 page text explaining the concept of insight to students.

It also contains 11 Tier II vocabulary words relevant to the discussion of insight and their simplified definitions. The words were selected based on course curriculum standards for several grade levels (fourth through seventh) due to their wide usage in a variety of subjects (social studies, science, math, etc.)

Language activities in this packet include:

  • Explaining definitions
  • Answering open-ended comprehension questions
  • Sentence construction activity
  • Crossword puzzle
  • Two morphological awareness activities
    • Define prefixes and suffixes
    • Change word meanings by adding prefixes and suffixes to words
  • Self-reflection page in written format contains questions for students to assist them with judging their own strengths and weaknesses related to academic performance

And now a few words regarding the lesson structure…

I introduce the concept of “insight” to clients by writing down the word and asking them to identify its parts: ‘in‘ and ‘sight‘. Depending on the student’s level of abilities I either get to the students to explain it to me or explain it myself that it is a compound word made up of two other words.

I then ask the students to interpret what the word could potentially mean. After I hear their responses I either confirm the correct one or end up explaining that this word refers to “looking into one’s brain” for answers related to how well someone understands information.

I have the students read the text located on the first page of my packet going over the concept of insight and some of its associated vocabulary words.  I ask the students to tell me the main idea of each paragraph as well as answer questions regarding supporting text details.

Once I am confident that the students have a fairly good grasp of the presented text I move on to the definitions page. There are actually two definition pages in the lesson: one at the beginning and one at the end of the packet. The first definitions page also contains word meaning and what parts of speech the definitions belong to.  The definition page at the end of the packet contains only the targeted words. It is now the students responsibility to write down the definition of all the vocabulary words and phrases in order for me to see how well they remember the meanings of pertinent words.

The packet also includes comprehension questions, a section on sentence construction several morphological awareness activities, a crossword puzzle and a self-reflection page.

The final activity in the packet requires the student to judge their own work performance during this activity.  I ask students questions such as:

  • How do you think you did on this task?
  • How do you know you did ________?
  • How can you prove to me you understood ________?

If a student responds “I know I did well because I understood everything”, I typically ask them to prove their comprehension to me, verbally. Here the goal is to have the student provide concrete verbal examples supporting their insight of their performance.

 This may include statements such as:

  • I know I did well because you said: “Nice Work!”
  • I know I did well because you didn’t correct me too much
  • I know I did well because you  kept smiling and showed me thumbs up as I was talking

As mentioned above this activity is only the beginning. After I ensure that the students have a decent grasp of this concept I continue working on it indirectly by having the students continuously judge their own performance on a variety of other therapy related activities and assignments.

You can find the complete packet on teaching “insight” in my online store (HERE).  Also, stay tuned for Part II of this series, which will describe how to continue solidifying the concept of “insight” in the context of therapy sessions for students with social pragmatic and executive function deficits.

Helpful Smart Speech Resources:

 

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On the Disadvantages of Parents Ceasing to Speak the Birth Language with Bilingual Language Impaired Children

ChildrenDespite significant advances in the fields of education and speech pathology, many harmful myths pertaining to multilingualism continue to persist. One particularly infuriating and patently incorrect recommendation to parents is the advice to stop speaking the birth language with their bilingual children with language disorders. Continue reading On the Disadvantages of Parents Ceasing to Speak the Birth Language with Bilingual Language Impaired Children

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Comprehensive Assessment of Adolescents with Suspected Language and Literacy Disorders

When many of us think of such labels as “language disorder” or “learning disability”, very infrequently do adolescents (students 13-18 years of age) come to mind. Even today, much of the research in the field of pediatric speech pathology involves preschool and school-aged children under 12 years of age.

The prevalence and incidence of language disorders in adolescents is very difficult to estimate due to which some authors even referred to them as a Neglected Group with Significant Problems having an “invisible disability“.

Far fewer speech language therapists work with middle-schoolers vs. preschoolers and elementary aged kids, while the numbers of SLPs working with high-school aged students is frequently in single digits in some districts while being completely absent in others. In fact, I am frequently told (and often see it firsthand) that some administrators try to cut costs by attempting to dictate a discontinuation of speech-language services on the grounds that adolescents “are far too old for services” or can “no longer benefit from services”.  

But of course the above is blatantly false. Undetected language deficits don’t resolve with age! They simply exacerbate and turn into learning disabilities. Similarly, lack of necessary and appropriate service provision to children with diagnosed language impairments  at the middle-school and high-school levels will strongly affect their academic functioning and hinder their future vocational outcomes.

A cursory look at the Speech Pathology Related  Facebook Groups as well as ASHA forums reveals numerous SLPs in a continual search for best methods of assessment and treatment of older students (~12-18 years of age).  

Consequently, today I wanted to dedicate this post to a review of standardized assessments options available for students 12-18 years of age with suspected language and literacy deficits.

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). Very few of them actually incorporate aspects of literacy into its subtests in a meaningful way.  Yet by the time students reach adolescence literacy begins to play an incredibly critical role not just in all the aspects of academics but also social communication.

So when it comes to comprehensive general language testing I highly recommended that SLPs select  standardized measures with a focus on not  language but also literacy.  Presently of all the comprehensive assessment tools   I highly prefer the Test of Integrated Language and Literacy (TILLS) for students up to 18 years of age, (see a comprehensive review HERE),  which covers such literacy areas as phonological awareness, reading fluency, reading comprehension, writing and spelling in addition to traditional language areas as as vocabulary awareness, following directions, story recall, etc. However,  while comprehensive tests have  numerous  uses,  their sole  administration will not constitute an adequate assessment.

So what areas should be assessed during language and literacy testing?  Below are  a few suggestions of standardized testing measures (and informal procedures) aimed at exploring the student abilities in particular areas pertaining to language and literacy.

TESTS OF LANGUAGE

TESTS OF LITERACYscreen-shot-2016-10-09-at-2-29-57-pm

It is understandable how given the sheer amount of assessment choices some clinicians may feel overwhelmed and be unsure regarding the starting point of an adolescent evaluation.   Consequently, the use the checklist prior to the initiation of assessment may be highly useful in order to identify potential language weaknesses/deficits the students might experience. It will also allow clinicians to prioritize the hierarchy of testing instruments to use during the assessment.  

While clinicians are encouraged to develop such checklists for their personal use,  those who lack time and opportunity can locate a number of already available checklists on the market. 

For example, the comprehensive 6-page Speech Language Assessment Checklist for Adolescents (below) can be given to caregivers, classroom teachers, and even older students in order to check off the most pressing difficulties the student is experiencing in an academic setting. 

It is important for several individuals to fill out this checklist to ensure consistency of deficits, prior to determining whether an assessment is warranted in the first place and if so, which assessment areas need to be targeted.

Checklist Categories:

  1. Receptive Languageadolescent checklist
  2. Memory, Attention and Cognition
  3. Expressive Language
  4. Vocabulary
  5. Discourse
  6. Speech
  7. Voice
  8. Prosody
  9. Resonance
  10. Reading
  11. Writing
  12. Problem Solving
  13. Pragmatic Language Skills
  14. Social Emotional Development
  15. Executive Functioning

alolescent pages sample

Based on the checklist administration SLPs can  reliably pinpoint the student’s areas of deficits without needless administration of unrelated/unnecessary testing instruments.  For example, if a student presents with deficits in the areas of problem solving and social pragmatic functioning the administration of a general language test such as the Clinical Evaluation of Language Fundamentals® – Fifth Edition (CELF-5) would NOT be functional (especially if the previous administration of educational testing did not reveal any red flags). In contrast, the administration of such tests as Test Of Problem Solving 2 Adolescent and Social Language Development Test Adolescent would be better reflective of the student’s deficits in the above areas. (Checklist HERE; checklist sample HERE). 

It is very important to understand that students presenting with language and literacy deficits will not outgrow these deficits on their own. While there may be “a time period when the students with early language disorders seem to catch up with their typically developing peers” (e.g., illusory recovery) by undergoing a “spurt” in language learning”(Sun & Wallach, 2014). These spurts are typically followed by a “post-spurt plateau”. This is because due to the ongoing challenges 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”(Sun & Wallach, 2014).  As such many adolescents “may not show academic or language-related learning difficulties until linguistic and cognitive demands of the task increase and exceed their limited abilities” (Sun & Wallach, 2014).  Consequently, 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 pre-literacy, literacy, and metalinguistic skills” (Sun & Wallach, 2014).

References:

  1. Hill, J. W., & Coufal, K. L. (2005). Emotional/behavioral disorders: A retrospective examination of social skills, linguistics, and student outcomes. Communication Disorders Quarterly, 27(1), 33–46.
  2. 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 

  1. Assessment of Adolescents with Language and Literacy Impairments in Speech Language Pathology 
  2. Assessment and Treatment Bundles 
  3. Social Communication Materials
  4. Multicultural Materials 

 

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Spotlight on Syndromes: An SLPs Perspective on Down Syndrome

Today’s guest post on genetic syndromes comes from Rachel Nortz, who is contributing a post on the Down Syndrome.

Down Syndrome is a genetic disorder that is characterized by all or part of a third copy of the 21st chromosome. There are three different forms of Down syndrome: trisomy 21, translocation, and mosaicism. Trisomy 21 is the most common form of Down syndrome. This occurs when the 21st chromosome pair does not split properly and the egg or sperm receives a double-dose of the extra chromosome. Translocation  (3-4% have this type) is the result of when the extra part of the 21st chromosome becomes attached (translocated) onto another chromosome.  Mosaicism is the result of an extra 21st chromosome in only some of the cells and this is the least common type of Down syndrome. Continue reading Spotlight on Syndromes: An SLPs Perspective on Down Syndrome

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Improving Executive Function Skills of Language Impaired Students with Hedbanz

Those of you who have previously read my blog know that I rarely use children’s games to address language goals.  However, over the summer I have been working on improving executive function abilities (EFs) of some of the language impaired students on my caseload. As such, I found select children’s games to be highly beneficial for improving language-based executive function abilities.

For those of you who are only vaguely familiar with this concept, executive functions are higher level cognitive processes involved in the inhibition of thought, action, and emotion, which located in the prefrontal cortex of the frontal lobe of the brain. The development of executive functions begins in early infancy; but it can be easily disrupted by a number of adverse environmental and organic experiences (e.g., psychosocial deprivation, trauma).  Furthermore, research in this area indicates that the children with language impairments present with executive function weaknesses which require remediation.

EF components include working memory, inhibitory control, planning, and set-shifting.

  • Working memory
    • Ability to store and manipulate information in mind over brief periods of time
  • Inhibitory control
    • Suppressing responses that are not relevant to the task
  • Set-shifting
    • Ability to shift behavior in response to changes in tasks or environment

Simply put, EFs contribute to the child’s ability to sustain attention, ignore distractions, and succeed in academic settings. By now some of you must be wondering: “So what does Hedbanz have to do with any of it?”

Well, Hedbanz is a quick-paced multiplayer  (2-6 people) game of “What Am I?” for children ages 7 and up.  Players get 3 chips and wear a “picture card” in their headband. They need to ask questions in rapid succession to figure out what they are. “Am I fruit?” “Am I a dessert?” “Am I sports equipment?” When they figure it out, they get rid of a chip. The first player to get rid of all three chips wins.

The game sounds deceptively simple. Yet if any SLPs or parents have ever played that game with their language impaired students/children as they would be quick to note how extraordinarily difficult it is for the children to figure out what their card is. Interestingly, in my clinical experience, I’ve noticed that it’s not just moderately language impaired children who present with difficulty playing this game. Even my bright, average intelligence teens, who have passed vocabulary and semantic flexibility testing (such as the WORD Test 2-Adolescent or the  Vocabulary Awareness subtest of the Test of Integrated Language and Literacy ) significantly struggle with their language organization when playing this game.

So what makes Hedbanz so challenging for language impaired students? Primarily, it’s the involvement and coordination of the multiple executive functions during the game. In order to play Hedbanz effectively and effortlessly, the following EF involvement is needed:

  • Task Initiation
    • Students with executive function impairments will often “freeze up” and as a result may have difficulty initiating the asking of questions in the game because many will not know what kind of questions to ask, even after extensive explanations and elaborations by the therapist.
  • Organization
    • Students with executive function impairments will present with difficulty organizing their questions by meaningful categories and as a result will frequently lose their track of thought in the game.
  • Working Memory
    • This executive function requires the student to keep key information in mind as well as keep track of whatever questions they have already asked.
  • Flexible Thinking
    • This executive function requires the student to consider a situation from multiple angles in order to figure out the quickest and most effective way of arriving at a solution. During the game, students may present with difficulty flexibly generating enough organizational categories in order to be effective participants.
  • Impulse Control
    • Many students with difficulties in this area may blurt out an inappropriate category or in an appropriate question without thinking it through first.
      • They may also present with difficulty set-shifting. To illustrate, one of my 13-year-old students with ASD, kept repeating the same question when it was his turn, despite the fact that he was informed by myself as well as other players of the answer previously.
  • Emotional Control
    • This executive function will help students with keeping their emotions in check when the game becomes too frustrating. Many students of difficulties in this area will begin reacting behaviorally when things don’t go their way and they are unable to figure out what their card is quickly enough. As a result, they may have difficulty mentally regrouping and reorganizing their questions when something goes wrong in the game.
  • Self-Monitoring
    • This executive function allows the students to figure out how well or how poorly they are doing in the game. Students with poor insight into own abilities may present with difficulty understanding that they are doing poorly and may require explicit instruction in order to change their question types.
  • Planning and Prioritizing
    • Students with poor abilities in this area will present with difficulty prioritizing their questions during the game.

Consequently, all of the above executive functions can be addressed via language-based goals.  However, before I cover that, I’d like to review some of my session procedures first.

Typically, long before game initiation, I use the cards from the game to prep the students by teaching them how to categorize and classify presented information so they effectively and efficiently play the game.

Rather than using the “tip cards”, I explain to the students how to categorize information effectively.

This, in turn, becomes a great opportunity for teaching students relevant vocabulary words, which can be extended far beyond playing the game.

I begin the session by explaining to the students that pretty much everything can be roughly divided into two categories animate (living) or inanimate (nonliving) things. I explain that humans, animals, as well as plants belong to the category of living things, while everything else belongs to the category of inanimate objects. I further divide the category of inanimate things into naturally existing and man-made items. I explain to the students that the naturally existing category includes bodies of water, landmarks, as well as things in space (moon, stars, sky, sun, etc.). In contrast, things constructed in factories or made by people would be example of man-made objects (e.g., building, aircraft, etc.)

When I’m confident that the students understand my general explanations, we move on to discuss further refinement of these broad categories. If a student determines that their card belongs to the category of living things, we discuss how from there the student can further determine whether they are an animal, a plant, or a human. If a student determined that their card belongs to the animal category, we discuss how we can narrow down the options of figuring out what animal is depicted on their card by asking questions regarding their habitat (“Am I a jungle animal?”), and classification (“Am I a reptile?”). From there, discussion of attributes prominently comes into play. We discuss shapes, sizes, colors, accessories, etc., until the student is able to confidently figure out which animal is depicted on their card.

In contrast, if the student’s card belongs to the inanimate category of man-made objects, we further subcategorize the information by the object’s location (“Am I found outside or inside?”; “Am I found in ___ room of the house?”, etc.), utility (“Can I be used for ___?”), as well as attributes (e.g., size, shape, color, etc.)

Thus, in addition to improving the students’ semantic flexibility skills (production of definitions, synonyms, attributes, etc.) the game teaches the students to organize and compartmentalize information in order to effectively and efficiently arrive at a conclusion in the most time expedient fashion.

Now, we are ready to discuss what type of EF language-based goals, SLPs can target by simply playing this game.

1. Initiation: Student will initiate questioning during an activity in __ number of instances per 30-minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

2. Planning: Given a specific routine, student will verbally state the order of steps needed to complete it with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

3. Working Memory: Student will repeat clinician provided verbal instructions pertaining to the presented activity, prior to its initiation, with 80% accuracy  given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

4. Flexible Thinking: Following a training by the clinician, student will generate at least __ questions needed for task completion (e.g., winning the game) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

5. Organization: Student will use predetermined written/visual cues during an activity to assist self with organization of information (e.g., questions to ask) with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

6. Impulse Control: During the presented activity the student will curb blurting out inappropriate responses (by silently counting to 3 prior to providing his response) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

7. Emotional Control: When upset, student will verbalize his/her frustration (vs. behavioral activing out) in __ number of instances per 30 minute session given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

8. Self-Monitoring:  Following the completion of an activity (e.g., game) student will provide insight into own strengths and weaknesses during the activity (recap) by verbally naming the instances in which s/he did well, and instances in which s/he struggled with __% accuracy given (maximal, moderate, minimal) type of  ___  (phonemic, semantic, etc.) prompts and __ (visual, gestural, tactile, etc.) cues by the clinician.

There you have it. This one simple game doesn’t just target a plethora of typical expressive language goals. It can effectively target and improve language-based executive function goals as well. Considering the fact that it sells for approximately $12 on Amazon.com, that’s a pretty useful therapy material to have in one’s clinical tool repertoire. For fancier versions, clinicians can use “Jeepers Peepers” photo card sets sold by Super Duper Inc. Strapped for cash, due to highly limited budget? You can find plenty of free materials online if you simply input “Hedbanz cards” in your search query on Google. So have a little fun in therapy, while your students learn something valuable in the process and play Hedbanz today!

Related Smart Speech Therapy Resources:

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Spotlight on Syndromes: An SLPs Perspective on Apert Syndrome

Today’s guest post on genetic syndromes comes from Rebecca Freeh Thornburg, who is contributing information on the Apert Syndrome. Rebecca is a repeated guest blog contributor. Her informative guest post on the CHARGE Syndrome can be found HERE.

Overview

Apert Syndrome is a genetic condition resulting from a mutation in gene FGRF2 – fibroblast growth factor receptor 2 – on chromosome 10. Incidence estimates vary from 1 in 65,000 to 1 in 120,000 births.  Most cases of Apert syndrome result from a new mutation, rather than being genetically inherited from a parent.  Children born with Apert Syndrome are affected by characteristic craniofacial differences caused by premature fusion of the bones of the skull, as well and limb anomalies, especially fusion of skin of the fingers and/or toes.  Multiple craniofacial and limb procedures, as well as other surgical interventions are often necessary to minimize the medical complications and cosmetic impact of the disorder. Continue reading Spotlight on Syndromes: An SLPs Perspective on Apert Syndrome

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Special Education Disputes and Comprehensive Language Testing: What Parents, Attorneys, and Advocates Need to Know

Image result for evaluationSeveral years after I started my private speech pathology practice, I began performing comprehensive independent speech and language evaluations (IEEs).

For those of you who may be hearing the term IEE for the first time, an Independent Educational Evaluation is “an evaluation conducted by a qualified examiner who is not employed by the public agency responsible for the education of the child in question.” 34 C.F.R. 300.503. IEE’s can evaluate a broad range of functioning outside of cognitive or academic performance and may include neurological, occupational, speech language, or any other type of evaluations  as long as they bear direct impact on the child’s educational performance.

Independent evaluations can be performed for a wide variety of reasons, including but not limited to:

  • To determine the student’s present level of functioning
  • To determine whether the student presents with hidden, previously undiscovered deficits (e.g., executive function, social communication, etc.)
  • To determine whether the student’s educational classification requires a change
  • To determine if the student requires additional, previously not provided, related services (e.g., language therapy, etc.) or an increase in related services
  • To determine whether a student might benefit from an application of a particular therapy technique or program (e.g, Orton-Gillingham)
  • To determine whether a student with a severe impairment (e.g., severe emotional and behavioral disturbances, genetic syndrome, significant intellectual disability, etc.) is a good candidate for an out of district specialized school

Why can’t similar assessments be performed in school settings?

There are several reasons for that.

Why are IEE’s Needed?

The answer to that is simple:  “To strengthen the role of parents in the educational decision-making process.” According to one Disability Rights site: “Many disagreements between parents and school staff concerning IEP services and placement involve, at some stage, the interpretation of evaluation findings and recommendations. When disagreements occur, the Independent Educational Evaluation (IEE) is one option lawmakers make available to parents, to help answer questions about appropriate special education services and placement“.

Indeed, many of the clients who retain my services also retain the services of educational advocates as well as special education lawyers.  Many of them work on determining appropriate level of services as well as an out of district placement for the children with a variety of special education needs. However, one interesting reoccurring phenomenon I’ve noted over the years is that only a small percentage of special education lawyers, educational advocates, and even parents believed that children with autism spectrum disorders, genetic syndromes, social pragmatic deficits, emotional disturbances, or reading disabilities required a comprehensive language evaluation/reevaluation prior to determining an appropriate out of district placement or an in-district change of service provision.

So today I would like to make a case, in favor of comprehensive independent language evaluations being a routine component of every special education dispute involving a child with impaired academic performance. I will do so through the illustration of past case scenarios that clearly show that comprehensive independent language evaluations do matter, even when it doesn’t look like they may be needed.

Case A: “He is just a weak student”.

Several years ago I was contacted by a parent of a 12 year old boy, who was concerned with his son’s continuously failing academic performance. The child had not qualified for an IEP but was receiving 504 plan in school setting and was reported to significantly struggle due to continuous increase of academic demands with each passing school year.  An in-district language evaluation had been preformed several years prior. It showed that the student’s general language abilities were in the low average range of functioning due to which he did not qualify for speech language services in school setting. However, based on the review of available records it very quickly became apparent that many of the academic areas in which the student struggled (e.g., reading comprehension, social pragmatic ability, critical thinking skills, etc)  were simply not assessed by the general language testing. I had suggested to the parent a comprehensive language evaluation and explained to him on what grounds I was recommending this course of action.  That comprehensive 4 hour assessment broken into several testing sessions revealed that the student presented with severe receptive, expressive, problem solving and social pragmatic language deficits, as well as moderate executive function deficits, which required therapeutic intervention.

Prior to that assessment the parent, reinforced by the feedback from his child’s educational staff believed his son to be an unmotivated student who failed to apply himself in school setting.  However, after the completion of that assessment, the parent clearly understood that it wasn’t his child’s lack of motivation which was impeding his academic performance but rather a true learning disability was making it very difficult for his son to learn without the necessary related services and support. Several months after the appropriate related services were made available to the child in school setting on the basis of the performed IEE, the parent reported significant progress in his child academic performance.

Case B: “She’s just not learning because of her behavior, so there’s nothing we can do”.  

This case involved a six year old girl who presented with a severe speech – language disorder and behavioral deficits in school setting secondary to an intellectual disability of an unspecified origin.

In contrast to Case A scenario, this child had received a variety of assessments and therapies since a very early age; however, her parents were becoming significantly concerned regarding her regression of academic functioning in school setting and felt that a more specialized out of district program with a focus on multiple disabilities would be better suitable to her needs. Unfortunately the school disagreed with them and believed that she could be successfully educated in an in-district setting (despite evidence to the contrary).  Interestingly, an in-depth comprehensive speech language assessment had never been performed on this child because her functioning was considered to be “too low” for such an assessment.

Comprehensive assessment of this little girl’s abilities revealed that via an application of a variety of behavioral management techniques (of non-ABA origin), and highly structured language input, she was indeed capable of significantly better performance then she had exhibited in school setting.  It stood to reason that if she were placed in a specialized school setting composed of educational professionals who were trained in dealing with her complex behavioral and communication needs, her performance would continue to steadily improve.  Indeed, six months following a transfer in schools her parents reported a “drastic” change pertaining to a significant reduction in challenging behavioral manifestations as well as significant increase in her linguistic output.

Case C: “Your child can only learn so much because of his genetic syndrome”.  

This case scenario does not technically involve just one child but rather three different male students between 9 and 11 years of age with several ‘common’ genetic syndromes: Down, Fragile X, and Klinefelter.  All three were different ages, came from completely different school districts, and were seen by me in different calendar years.

However, all three boys had one thing in common, because of their genetic syndromes, which were marked by varying degrees of intellectual disability as well as speech language weaknesses, their parents were collectively told that there could be very little done for them with regards to expanding their expressive language as well as literacy development.

Similarly to the above scenarios, none of the children had undergone comprehensive language testing to determine their strengths, weaknesses, and learning styles. Comprehensive assessment of each student revealed that each had the potential to improve their expressive abilities to speak in compound and complex sentences. Dynamic assessment of literacy also revealed that it was possible to teach each of them how to read.

Following the respective assessments, some of these students had became my private clients, while others’s parents have periodically written to me, detailing their children’s successes over the years.  Each parent had conveyed to me how “life-changing”a comprehensive IEE was to their child.

Case D: “Their behavior is just out of control”

The final case scenario I would like to discuss today involves several students with an educational classification of “Emotionally Disturbed” (pg 71).  Those of you who are familiar with my blog and my work know that my main area of specialty is working with school age students with psychiatric impairments and emotional behavioral disturbances.  There are a number of reasons why I work with this challenging pediatric population. One very important reason is that these students continue to be grossly underserved in school setting. Over the years I have written a variety of articles and blog posts citing a number of research studies, which found that a significant number of students with psychiatric impairments and emotional behavioral disturbances present with undiagnosed linguistic impairments (especially in the area of social communication), which adversely impact their school-based performance.

Here, we are not talking about two or three students rather we’re talking about the numbers in the double digits of students with psychiatric impairments and emotional disturbances, who did not receive appropriate therapies in their respective school settings.

The majority of these students were divided into two distinct categories. In the first category, students began to manifest moderate-to-severe speech language deficits from a very early age. They were classified in preschool and began receiving speech language therapy. However by early elementary age their general language abilities were found to be within the average range of functioning and their language therapies were discontinued.   Unfortunately since general language testing does not assess all categories of linguistic functioning such as critical thinking, executive functions, social communication etc., these students continued to present with hidden linguistic impairments, which continued to adversely impact their behavior.

Students in the second category also began displaying emotional and behavioral challenges from a very early age. However, in contrast to the students in the first category the initial language testing found their general language abilities to be within the average range of functioning. As a result these students never received any language-based therapies and similar to the students in the first category, their hidden linguistic impairments continued to adversely impact their behavior.

Students in both categories ended up following a very similar pattern of behavior. Their behavioral challenges in the school continued to escalate. These were followed by a series of suspensions, out of district placements, myriad of psychiatric and neuropsychological evaluations, until many were placed on home instruction. The one vital element missing from all of these students’ case records were comprehensive language evaluations with an emphasis on assessing their critical thinking, executive functions and social communication abilities. Their worsening patterns of functioning were viewed as “severe misbehaving” without anyone suspecting that their hidden language deficits were a huge contributing factor to their maladaptive behaviors in school setting.

Conclusion:

So there you have it!  As promised, I’ve used four vastly different scenarios that show you the importance of comprehensive language evaluations in situations where it was not so readily apparent that they were needed.  I hope that parents and professionals alike will find this post helpful in reconsidering the need for comprehensive independent evaluations for students presenting with impaired academic performance.

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A case for early speech-language assessments of adopted children in the child’s birth language.

A case for early speech-language assessments of adopted children in the child’s birth language.

Tatyana Elleseff MA CCC-SLP

As more and more research is being published on communication, linguistic abilities, as well as speech and language delay of adopted children, a debate has arisen with regard to the necessity of early assessment of speech and language abilities of newly adopted children. Many medical and related professionals have posed a relevant question: “What is the purpose of performing a speech-language evaluation immediately after arriving in the U.S.?” After all how can you perform an evaluation in English when the child has minimal knowledge of English at the time of arrival? And what about speech and language evaluation conducted in the birth language post arrival? Will it yield any definitive or predictive results given that within a relatively short period (2-6 months depending on which study you look at) the child would have lost the birth language and rapidly gained English? And honestly, can one really translate or adapt a test standardized on English speaking children to the child’s birth language (e.g., Russian) with any hope of reliable results?

The truth is that one definitive answer simply does not exist. It would be erroneous to state that ‘yes’ all newly adopted children need to be assessed within the first week of US arrival or “no” you can wait until the child has been in the country for several months before a reliable assessment can be performed. Here, I think that an individualized and educated approach is necessary in order to determine whether an early speech–language assessment may be appropriate for your newly adopted child.

In order to better explain my position on this issue, I must mention something of my own background and how it affects my approach to speech and language assessments. I am a bilingual, Russian-English, speaking speech language therapist, and I specialize in assessing children adopted from Eastern Europe (vs. South America or China, etc).

I am also in a rather unique position because all internationally adopted children that I’ve evaluated to date have traditionally been referred to me by a medical or a related professional (pediatrician or psychologist vs. a parent who’s contacted me without a specific referral) who felt that the child needed to be seen because of a specific speech or language deficit that was manifesting rather overtly (e.g., significant speech or language delay in birth language).

Since such referrals are frequently made within the child’s first 2 weeks of being in US (e.g., immediately following a visit to the pediatrician), I typically perform the initial speech and language assessment in Russian, using recently published Russian speech language pathology materials, which though are non-standardized (in Russia standardized speech and language protocols haven’t been developed yet) are still more reliable than the standardized tests translated from English. Here, my window of opportunity to assess the child in his/her native language is very narrow, as birth language attrition occurs very rapidly post adoption.

So what do these early speech and language assessments in the child’s birth language reveal to me?

Well, quite a lot actually!

Let’s start by age range:

First let’s talk about children ages 0-3.

Depending on a country, the youngest age children become available for adoption is 7-9 months and depending on length and complexity of the adoption process, may become legally adopted by 12 months of age or older. My first concern with this group (+/-1 – 3 years) is the child’s feeding and swallowing abilities. Difficulties may range from immature feeding skills (e.g., immature chewing abilities) to a more severe failure to thrive, to even structural or functional deviations of the swallow mechanism, which may require detailed imaging tests and subsequent dysphagia therapy. In some rare instances, more serious discoveries were made during those initial speech and language assessments such as presence of vocal webs and submucous clefts, conditions which actually required surgical intervention.

Another concern with this age range are the child’s speech and language abilities or I should say lack of thereof. In the case of younger children (15-18 months), the “red flag” is a complete absence of words, jargon, babbling or general lack of any sound production during both – their early development and the parent bonding pre-adoption period during which the parents intensively interact and communicate with the child. In older children (2.5-3 years of age) the “red flag” is the general absence of phrases and/or words in their birth language, which is a strong indication that assessment is merited.

Finally, with this age group, any form of abnormal social interaction should be thoroughly investigated. Many children who have resided in very deprived institutional environments may present with a pattern of autistic-type behaviors. In reaction to emotional trauma, loss of primary caregiver, isolation in hospital cribs, and lack of stimulation, some children may develop symptoms often found in autistic children and may exhibit limited communicative intent in the absence of speech (make limited gestures, vocalizations, eye contact, etc). As a result, an early speech and language assessment in conjunction with other testing (neurological, psychological, etc) may shed light on whether the child presents with a form of institutional autism or true autistic spectrum behavior.

Unfortunately, internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Knowing the above, oftentimes it is important to determine a degree of delay (severe vs. mild), and if it’s not that clear (especially if the child is under 3 years of age and the parents don’t speak the child’s birth language or are not familiar with typical developmental milestones) than a safer choice would be an initial speech and language assessment in the child’s birth language which can determine the type and degree of delay and make recommendations regarding the necessity of further services.

It is also important to highlight that a child’s mastery of the birth language is a good predictor of the rate of learning the new language. Many professionals make an error of assuming that internationally adopted infants and toddlers will not be affected by cross-linguistic interference because the children have just begun to learn the birth language at the time of adoption, before the attrition of birth language occurred. However, due to a complex constellation of factors, language delays in birth language transfer and become language delays in a new language. These delays will typically persist unless appropriate intervention is provided. For older children (3 years +), the delays will be very recognizable and will likely be part of the child’s adoption record but for younger children an early speech and language assessment may be the first step on the way to appropriate language remediation.

Now let’s talk about older children. In our second group, the age range at the time of adoption will range from 3-16 years (although it is important to note that most adopted older children will be in the range of 3-12 years, while adoption of children 12+ is somewhat less common).

Here, most speech and language delays will be more acutely pronounced and as a result far more recognizable. As mentioned above they will also probably be clearly documented in the child’s adoption records. With this age-range there are a number of concerns ranging from poor articulation to language delay to social pragmatic communication impairments.

So how do professionals and parents decide which child merits early assessment?
With regard to articulation, it’s important to keep in mind that if the child is limitedly intelligible in their birth language, they will continue making similar error patterns in English unless they receive appropriate intervention. So assessment is definitely merited.

Similarly, if at the time of adoption, a preschool or school age child presents with delayed language abilities in their birth tongue (e.g., inability to answer “wh” questions, speaking in phrases vs. sentences, etc) then no matter how quickly they will gain basic English proficiency, it is reasonable to expect that similar difficulty will be encountered in English with respect to academically based tasks. In other words they may gain basic skills fairly appropriately but then present with significant deficits acquiring higher level listening and speaking abilities required for long-term academic success.

Another reason why it’s important to assess a child in the birth language in the first few weeks post arrival has to do with their pragmatic language skills or the appropriate use of language. Pragmatic language ability is the ability to appropriately initiate conversations, maintain and terminate topics, appropriately narrate stories, understand jokes and sarcasm, interpret non-verbal body cues, all of which culminate into the child’s general ability to appropriately interact with others in a variety of social settings.

As mentioned above, many children who have resided in deprived institutional environments may present with a pattern of unusual social behaviors, be socially withdrawn, or present with poor ability to socialize with others. Thus, the longer is the period of time the child spends in the institutional environment the greater is the risk of social pragmatic deficits. Unfortunately, this important area of language often receives merely cursory attention.

To illustrate, in recent years I have assessed a number of adopted children, who were 5-7 years post adoption, and had never previously received any speech and language services. Once brought to US they quickly gained English language proficiency and did not seemingly present with any of the “red flags” described above.

The reason these children were referred for intervention so many years later was because “seemingly overnight” they developed numerous difficulties. Oh, they were still getting good grades and presented with adequate vocabulary skills. But both parents and educators were getting concerned that these children were acting very immature for their age, had problems socializing with other children, presented with difficulty understanding figurative language, could not understand non-verbal conversational and social cues, couldn’t coherently express their thoughts, and presented with significant difficulty understanding and retelling stories.

Interestingly, when questioned further, all interviewed parents revealed that the above difficulties had existed from the get-go albeit in a milder form in their child but in the presence of appropriate receptive and expressive skills these difficulties were not deemed worthy of assessment/ intervention. Had these children received early assessment when these problems were first noticed, the outcome (degree of impairment; duration of therapy) might have been entirely different.

Up until now we have discussed the ‘red flags’ which indicate the necessity for early speech and language assessment and intervention of adopted children in their birth language. However, once these children are in therapy, many parents would also like to know if there are any specific predictors for successful language remediation and decreased duration of services?

Unfortunately, it is impossible to answer this question definitively due to the variability of each child’s progress as well as the type and degree of their impairment. Having said that, from my personal clinical experience, what I have found is that if the child has good problem solving abilities (as per non-verbal IQ testing and certain language reasoning tasks) and grossly appropriate social pragmatic language skills, even if the child presents with a moderate-severe speech and language impairment, he/she will generally fare better in treatment with respect to duration of service as well as therapy gains, versus the less severely impaired peers with poorer problem solving and social pragmatic skills.

So, do all newly adopted children require early speech language assessments? Not, at all. However, understanding the “red flags” for each age group will be helpful for both parents and professionals when they make their decision to refer a newly adopted child for a an early speech-language assessment.

As always, if parents or related professionals would like to find more information on this topic, they should visit the ASHA website at www.asha.org and type in their query in the search window located in the upper right corner of the website.