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It’s All Due to …Language: How Subtle Symptoms Can Cause Serious Academic Deficits

Scenario: Len is a 7-2-year-old, 2nd-grade student who struggles with reading and writing in the classroom. He is very bright and has a high average IQ, yet when he is speaking he frequently can’t get his point across to others due to excessive linguistic reformulations and word-finding difficulties. The problem is that Len passed all the typical educational and language testing with flying colors, receiving average scores across the board on various tests including the Woodcock-Johnson Fourth Edition (WJ-IV) and the Clinical Evaluation of Language Fundamentals-5 (CELF-5). Stranger still is the fact that he aced Comprehensive Test of Phonological Processing, Second Edition (CTOPP-2), with flying colors, so he is not even eligible for a “dyslexia” diagnosis. Len is clearly struggling in the classroom with coherently expressing self, telling stories, understanding what he is reading, as well as putting his thoughts on paper. His parents have compiled impressively huge folders containing examples of his struggles. Yet because of his performance on the basic standardized assessment batteries, Len does not qualify for any functional assistance in the school setting, despite being virtually functionally illiterate in second grade.

The truth is that Len is quite a familiar figure to many SLPs, who at one time or another have encountered such a student and asked for guidance regarding the appropriate accommodations and services for him on various SLP-geared social media forums. But what makes Len such an enigma, one may inquire? Surely if the child had tangible deficits, wouldn’t standardized testing at least partially reveal them?

Well, it all depends really, on what type of testing was administered to Len in the first place. A few years ago I wrote a post entitled: “What Research Shows About the Functional Relevance of Standardized Language Tests“.  What researchers found is that there is a “lack of a correlation between frequency of test use and test accuracy, measured both in terms of sensitivity/specificity and mean difference scores” (Betz et al, 2012, 141). Furthermore, they also found 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”. Most damaging finding was the fact 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”.(Betz et al, 2012, 140)

In other words, many SLPs only use the tests at hand rather than the RIGHT tests aimed at identifying the student’s specific deficits. But the problem doesn’t actually stop there. Due to the variation in psychometric properties of various tests, 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 (Spaulding, Plante & Farinella, 2006, 69).”

There’s of course yet another factor affecting our hypothetical client and that is his relatively young age. This is especially evident with many educational and language testing for children in the 5-7 age group. Because the bar is set so low, concept-wise for these age-groups, many children with moderate language and literacy deficits can pass these tests with flying colors, only to be flagged by them literally two years later and be identified with deficits, far too late in the game.  Coupled with the fact that many SLPs do not utilize non-standardized measures to supplement their assessments, Len is in a pretty serious predicament.

But what if there was a do-over? What could we do differently for Len to rectify this situation? For starters, we need to pay careful attention to his deficits profile in order to choose appropriate tests to evaluate his areas of needs. The above can be accomplished via a number of ways. The SLP can interview Len’s teacher and his caregiver/s in order to obtain a summary of his pressing deficits. Depending on the extent of the reported deficits the SLP can also provide them with a referral checklist to mark off the most significant areas of need.

In Len’s case, we already have a pretty good idea regarding what’s going on. We know that he passed basic language and educational testing, so in the words of Dr. Geraldine Wallach, we need to keep “peeling the onion” via the administration of more sensitive tests to tap into Len’s reported areas of deficits which include: word-retrieval, narrative production, as well as reading and writing.

For that purpose, Len is a good candidate for the administration of the Test of Integrated Language and Literacy (TILLS), which was developed to identify language and literacy disorders, has good psychometric properties, and contains subtests for assessment of relevant skills such as reading fluency, reading comprehension, phonological awareness,  spelling, as well as writing  in school-age children.

Given Len’s reported history of narrative production deficits, Len is also a good candidate for the administration of the Social Language Development Test Elementary (SLDTE). Here’s why. Research indicates that narrative weaknesses significantly correlate with social communication deficits (Norbury, Gemmell & Paul, 2014). As such, it’s not just children with Autism Spectrum Disorders who present with impaired narrative abilities. Many children with developmental language impairment (DLD) (#devlangdis) can present with significant narrative deficits affecting their social and academic functioning, which means that their social communication abilities need to be tested to confirm/rule out presence of these difficulties.

However, standardized tests are not enough, since even the best-standardized tests have significant limitations. As such, several non-standardized assessments in the areas of narrative production, reading, and writing, may be recommended for Len to meaningfully supplement his testing.

Let’s begin with an informal narrative assessment which provides detailed information regarding microstructural and macrostructural aspects of storytelling as well as child’s thought processes and socio-emotional functioning. My nonstandardized narrative assessments are based on the book elicitation recommendations from the SALT website. For 2nd graders, I use the book by Helen Lester entitled Pookins Gets Her Way. I first read the story to the child, then cover up the words and ask the child to retell the story based on pictures. I read the story first because: “the model narrative presents the events, plot structure, and words that the narrator is to retell, which allows more reliable scoring than a generated story that can go in many directions” (Allen et al, 2012, p. 207).

As the child is retelling his story I digitally record him using the Voice Memos application on my iPhone, for a later transcription and thorough analysis.  During storytelling, I only use the prompts: ‘What else can you tell me?’ and ‘Can you tell me more?’ to elicit additional information. I try not to prompt the child excessively since I am interested in cataloging all of his narrative-based deficits. After I transcribe the sample, I analyze it and make sure that I include the transcription and a detailed write-up in the body of my report, so parents and professionals can see and understand the nature of the child’s errors/weaknesses.

Now we are ready to move on to a brief nonstandardized reading assessment. For this purpose, I often use the books from the Continental Press series entitled: Reading for Comprehension, which contains books for grades 1-8.  After I confirm with either the parent or the child’s teacher that the selected passage is reflective of the complexity of work presented in the classroom for his grade level, I ask the child to read the text.  As the child is reading, I calculate the correct number of words he reads per minute as well as what type of errors the child is exhibiting during reading.  Then I ask the child to state the main idea of the text, summarize its key points as well as define select text embedded vocabulary words and answer a few, verbally presented reading comprehension questions. After that, I provide the child with accompanying 5 multiple choice question worksheet and ask the child to complete it. I analyze my results in order to determine whether I have accurately captured the child’s reading profile.

Finally, if any additional information is needed, I administer a nonstandardized writing assessment, which I base on the Common Core State Standards for 2nd grade. For this task, I provide a student with a writing prompt common for second grade and give him a period of 15-20 minutes to generate a writing sample. I then analyze the writing sample with respect to contextual conventions (punctuation, capitalization, grammar, and syntax) as well as story composition (overall coherence and cohesion of the written sample).

The above relatively short assessment battery (2 standardized tests and 3 informal assessment tasks) which takes approximately 2-2.5 hours to administer, allows me to create a comprehensive profile of the child’s language and literacy strengths and needs. It also allows me to generate targeted goals in order to begin effective and meaningful remediation of the child’s deficits.

Children like Len will, unfortunately, remain unidentified unless they are administered more sensitive tasks to better understand their subtle pattern of deficits. Consequently, to ensure that they do not fall through the cracks of our educational system due to misguided overreliance on a limited number of standardized assessments, it is very important that professionals select the right assessments, rather than the assessments at hand, in order to accurately determine the child’s areas of needs.

References:

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Dear SLPs, Don’t Base Your Language Intervention on Subtests Results

Tip: Click on the bolded words to read more.

For years, I have been seeing a variation of the following questions from SLPs on social media on a weekly if not daily basis:

  • “My student has slow processing/working memory and did poorly on the (insert standardized test here), what goals should I target?”
  • “Do you have sample language/literacy goals for students who have the following subtest scores on the (insert standardized test here)?”
  • “What goals should I create for my student who has the following subtest scores on the (insert standardized test here)?”

Let me be frank, these questions show a fundamental lack of understanding regarding the purpose of standardized tests, the knowledge of developmental norms for students of various ages, as well as how to effectively tailor and prioritize language intervention to the students’ needs.

So today, I wanted to address this subject from an evidence-based lens in order to assist SLPs with effective intervention planning with the consideration of testing results but not actually based on subtest results. So what do I mean by this seemingly confusing statement? Before I begin let us briefly discuss several highly common standardized assessment subtests:

Continue reading Dear SLPs, Don’t Base Your Language Intervention on Subtests Results
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Alternative Therapies, Herbs, Pills, and Snake Oils or “What’s the Harm in That?”

I’ve been meaning to write this post for some time and have finally decided to do it now due to an increased prevalence of “non-traditional” treatment options available to parents of language impaired children.

More and more unscrupulous or misguided individuals are offering fantastical cures to children diagnosed with the wide variety of disorders including but not limited to: Autism (ASD), Childhood Apraxia of Speech (CAS), language disorders, “Auditory Processing Deficits (APD)“, Dyslexia, and much much more.

What are some examples of controversial products and therapies you may ask?

Below I cite several links (which are in no way exhaustive) for your convenience.

Controversial Autism Treatments: 

In 2013, Dr. Emily Willingham, guest writer for Forbes magazine wrote a post on the topic of “The 5 Scariest Autism ‘Treatments.  In it she described some pretty horrifying methods (e.g., chelation, chemical castration, hyperbaric oxygen therapy) which purportedly promised to “cure” autism. For more information on other controversial treatments in autism click to read this keynote address entitled Evidence-Based Practices for Children with Autism Spectrum Disorders by Dr. Tristram Smith for The Society for Clinical Child and Adolescent Psychology (SCCAP).

Controversial Speech Sound Disorder Treatments 

Dr. Caroline Bowen respected Speech Language Researcher from Australia has a delightfully edifying page on her website (http://speech-language-therapy.com/) entitled: “Controversial Practices in Children’s Speech Sound Disorders – Oral Motor Exercises, Dietary Supplements, Auditory Integration Training”.  On it she thoroughly reviews non-research supported practices to improve children’s sound production including the use of oral motor/mouth exercises, dietary supplements (Apraxia Diet, Nourish Life Speak, Nutri Veda, etc.), as well as Auditory Integration Training (AIT).

Parent‐Friendly Information about Nonspeech Oral Motor Exercises (HERE)

Controversial Treatments for Children with Developmental and Learning Disabilities 

Macquarie University Special Education Centre in Sydney Australia has even developed concise one-page briefings of a vast number of controversial treatments for children with developmental and learning disabilities (selected briefing links are below; the full list of briefings is available HERE):

How to Spot Controversial Practices? 

In her 2012 post entitled: “10 Questions To Distinguish Real From Fake Science“, Dr. Emily Willingham wrote that “science consumers need a cheat sheet … when considering a product, book, therapy, or remedy”. She advised consumers to consider some of the following criteria:

  • Consider the source
  • Determine their agenda
  • Do they use highly emotionally charged language or meaningless jargon?
  • Are they relying on testimonials vs. evidence?
  • Are they claiming to be exclusive?
  • Do they mention words like ‘conspiracy’?
  • Is their treatment promising to cure multiple unrelated disorders?
  • What does the money trail reveal?

The truth is that there’s a lot of pseudoscience out there and as such it is very important for both parents and professionals not to fall into its trap.  In 2012, Dr. Gregory Lof presented the following poster at the ASHA’s Atlanta Convention:  “Science vs. Pseudoscience in CSD: A Checklist for Skeptical Thinking” to “help clinicians evaluate claims made by promoters of products or services to help determine if they are based on scientific principles or on pseudoscience”. An interactive version of the checklist is available HERE, and for the summary based on the checklist,  written by Mary Huston,  fellow SLP and author of the Speech Adventures, click HERE. 

So what do pseudoscientific practices/claims look like?

  • People place heavy emphasis on beliefs and opinions vs. data, when it comes to therapeutic claims
    • SLPs: “You are wrong! I’ve seen ________ work with my clients!”
    • Parents: “Who cares about your research this _______worked for us so HOW DARE YOU question it?
  • The presented data is based on “expert opinions”, testimonials, and isolated case studies
    • “These ridiculously expensive ‘speech sticks’ at $120 a pop worked for us, Yay!”
  • Data is disseminated via self-published books, popular press, proprietary websites lacking research sections, as well as non-peer reviewed conferences.
    • You might want to review the list of predatory publishers HERE, review the guide of how to spot a bogus scientific publication HERE,  and if you ever find yourself reading anything on this website, I suggest you close your laptop as fast as you can and possibly put it into another room for a while (Read Why – HERE).
  • Treatment sounds like a magic potion since it works on a wide range of disabilities, appeals to fears and wishful thinking, preys on the desperate and uses hyperboles (“miracle cure”)
  • Use of disdainful comments against researchers because “only clinicians do real clinical work”coupled with over reliance on clinician’s experience and subjective judgment since it’s the “best way” to determine effectiveness
    • “I’ve found ___________ to be highly effective with gazillion clients”.
  • Lack of change in practices despite a veritable mountain of evidence to the contrary
    • “Your child NEEDS oral-motor exercises, NOW, for his speech to get better”
  • New terms are created to mask use of disproven pseudoscientific practices

Why do we keep believing when all the evidence points to the contrary?

Because our brains become emotionally attached to ideas. This is further supported by the construct of two biases.

Confirmation bias – our tendency to look for/interpret information in a way that confirms our beliefs by “cherry picking” the evidence that supports what we believe in and ignoring the evidence that argues against it.

Disconfirmation bias – when facing with evidence which directly contradicts our beliefs we will criticize and reject it because we do not want to be wrong.

So now let’s get back to talk about the title of this post: “What’s the harm in that?” 

While I am accustomed to seeing the variation of this statement on parent forums, I was surprised when I learned that it’s popping up quite often in some unexpected places such as during IEP meetings or during doctor visits (as reported to me by some of my client’s parents).

So I wanted to take this opportunity to explicitly point out what the harm in these alternative practices could be, ranging from the obvious to the hidden.

For starters some of these ‘therapies’ could kill!

  • Over the years there has been a number of reports regarding deaths from controversial autism treatments including chelation and GcMAF injections.

Even if they don’t kill you they can cause some nasty side effects!

  • To illustrate, Nourish Life Speak Nutrients, which were prescribed to children to “increase their language output or to make them speak better”, were so loaded with vitamin E (way above the legal amount), that a number of children who were taking them experienced significant seizure activity.

It’s going to cost you!

They create false hope!  

They can create a sense of  bitterness and hopelessness!

  • Ever spoken to parents who have tried every alternative treatment possible and have subsequently given up? If you haven’t, I assure you it’s not a pleasant or productive conversation.  At best you will hear a lot of vitriol and accusations and at worst they may actually start a forum thread or a website bashing effective treatments such as speech language therapy because of their negative experiences.  When you believe that you have tried everything and it’s still not helping, you feel defeated and lost and as a result tend to attack blindly anyone who attempts to assist you because you’ve stopped perceiving it as assistance but rather as just another scam.

They delay effective research-proven treatments! 

They affect self-esteem and self-efficacy! 

  • Now enough about parents and professionals. Let’s actually take a moment to talk about effect of these alternative practices on the most important people in question: the children who are on the receiving end of it! Let’s talk about all the negative effects that can be incurred by them by undergoing these useless treatments time after time.  And no I am not actually talking about the hugely dangerous treatments, which can cause physical harm or awful side effects.  I am talking about the relatively benign treatments of “vision therapy”, “memory training”, etc.
  • To illustrate, I work with are very bright 11-year-old boy with significant reading deficits and an extensive history of reading disabilities in the family.  This boy’s deficit is in the area of reading, there is no doubt about it! He knows it and it’s very acutely aware of it.  However, at the advice of well-meaning professionals he was taken to a behavioral optometrist, who told his mother that his issues with reading are due to visual processing deficits (despite the fact that his ophthalmologist ruled out any vision difficulties and declared his vision to be 20/20).    It was then recommended that he undergo a costly vision therapy program in order to improve his “visual processing”.  Guess, what his first words were, when I saw him in my office for reading intervention?  ‘I went to the doctor who told me that I have problems in my eyes and that I need to stop reading!  So I can’t do any more reading because of my eye problems.’   Imagine how he will feel when after several months of costly therapies there will be no functional improvement in his reading skills, since the only thing which can improve his reading abilities is the actual targeted reading instruction!
  • Our students are very acutely aware when something is not working. Just like us they get increasingly frustrated after being dragged from one professional to another, after ‘suffering’ through one controversial treatment after another with no respite in sight.  Imagine what havoc it begins to wreak on their self-esteem and their self-efficacy (belief in own abilities to complete tasks and reach goals), when they keep undergoing these treatments without any improvement? All the negative self-talk they will use? Here are just a few statements I’ve heard over the years: “I am so stupid”; “There’s something wrong with my brain”, “I am not good at this, etc.) Instead of building them up these alternative therapies and treatments will not just tear them back down but may potentially cause behavioral and psychiatric effects to boot.

There you have it: that’s what the harm is!  The toll of these quack practices can be very significant and can go far beyond the financial.  So the next time someone utters the statement: “What’s the Harm in That?” consider the above information in order to make the informed decisions regarding the treatment for the most vulnerable parties involved: the children in your care!

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It’s a Fairy Tale (Well, Almost) Therapy!

I’ve always loved fairy tales! Much like Audrey Hepburn “If I’m honest I have to tell you I still read fairy-tales and I like them best of all.” Not to compare myself with Einstein (sadly in any way, sigh) but “When I examine myself and my methods of thought, I come to the conclusion that the gift of fantasy has meant more to me than any talent for abstract, positive thinking.”

It was the very first genre I’ve read when I’ve learned how to read. In fact, I love fairy tales so much that I actually took a course on fairy tales in college (yes they teach that!) and even wrote some of my own (though they were primarily satirical in nature).

So it was a given that I would use fairy tales as a vehicle to teach speech and language goals to the children on my caseload (and I am not talking only preschoolers either). Continue reading It’s a Fairy Tale (Well, Almost) Therapy!