Posted in Assessment, Cognition & Executive Function, Special Populations

Special Populations: Navigating Diagnoses

I think one of the most interesting parts of finally practicing as an SLP will be having the opportunity to work with children who have speech and language concerns as just one part of a broader disorder or disability. Some of the disorders that we learned are commonly co-morbid with developmental language disorder (DLD) include:

Attention Deficit Hyperactivity Disorder (ADHD)
Primary symptoms of ADHD include inattention, hyperactivity, and distractibility.
• Although ADHD and DLD have similar prevalence rates, awareness of ADHD is much greater and only ADHD rates are being tracked in healthcare service data.
• Studies have shown that children with ADHD show increased maze behaviour during conversation.
• Executive function and continuous performance measures do not clearly differentiate DLD from ADHD due to concerns around their validity (i.e., some children with ADHD will not have executive function deficits).
• Informant ratings (i.e., from parents, teachers, etc.) of the child’s attention, impulsivity, and defiance appear to be more useful measures for differentiating ADHD from DLD (especially when language-loaded items are removed from analysis).

Auditory Processing Disorder (APD)
Children with APD tend to have difficulties processing information and speech in noise.
• When differentiating children with APD and DLD, Ferguson et al. (cited below in Additional Resources) found that the following measures did not differentiate the two disorders:
– Structural language
– Social/pragmatic
– Attention ratings (item analysis suggested possible qualitative differences)
– Speech intelligibility in quiet or noise (despite being the most commonly reported symptom of APD)
– Intelligence (verbal or nonverbal)
– Reading
• Thus, Ferguson et al. concluded that the child’s diagnosis of APD or DLD was determined based on the referral route (i.e., referred to an audiologist vs. a speech-language pathologist)

Autism Spectrum Disorder (ASD)
ASD is characterized by impairments in social communication and social reciprocity, and by the presence of restricted interests and repetitive behaviours.
• DLD can occur co-morbidly with ASD, but ASD cannot occur co-morbidly with social communication disorder (SCD).

Social (Pragmatic) Communication Disorder (SCD)
SCD is defined by a primary deficit in the social use of nonverbal and verbal communication.
• Individuals with SCD may be categorized as having difficulty in using language for social purposes, appropriately matching communication to the social context, following rules of the communication context (e.g., turn-taking), understanding non-literal language (e.g., jokes, idioms, metaphors), and integrating language with nonverbal communicative behaviours.
• Sufficient language skills must be developed before higher-order pragmatic deficits can be detected, so a diagnosis of SCD should not be made until children are 4–5 years of age.
• DLD can occur co-morbidly with SCD, but SCD and ASD are mutually exclusive disorders (the presence of one means the other cannot occur co-morbidly).
• SCD may be considered by some as the “middleman” on a continuum between DLD and ASD

This graphic created by Dr. Lisa Archibald demonstrates some of the shared characteristics between DLD and the above-mentioned disorders. Difficulties with pragmatic and social communication skills (i.e., identifying nonverbal communication markers, following conversational rules, etc.) are present in all of the disorders, which I think highlights how a very diverse variety of skills influences an individual’s ability to be socially competent (i.e., executive functions like attention, language, ability to process information, etc.).

disorders

For more information, check out these additional resources:
Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54(1), 211-227.

Redmond, S. M. (2016;2015;). Markers, models, and measurement error: Exploring the links between attention deficits and language impairments. Journal of Speech, Language, and Hearing Research, 59(1), 62.

Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: A research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41.

CanChild’s Autism Classification System of Functioning: Social Communication
https://www.canchild.ca/en/resources/254-autism-classification-system-of-functioning-social-communication-acsf-sc

The Communication Matrix
https://communicationmatrix.org/Matrix/About#forPractitioners
• An assessment tool for children who are not speaking or writing to communicate

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Posted in Assessment, Perspectives from the Field

Perspectives from the Field: A Private Practice SLP’s Take on Assessment

I recently spoke to a private practice SLP with great insights regarding the assessment process. Due to this SLP’s extensive experience in the field prior to working in private practice (some of her previous experience includes working in the school board, at the Geneva Centre for Autism, as part of a preschool speech and language initiative, in acute and long-term care facilities, etc.), the information she shared with me was based on many years of experience working with a diverse population of clients.

Before seeing the child and parent, this SLP conducts a phone screening to gather information when she receives a new referral. This is especially helpful in cases where the child’s L1 (Native of first language) may not be English, so that she can learn about the child’s exposure to English and other language(s) as well as the child’s expression style (i.e., communicates in L2 but understands L1) prior to the assessment. She will occasionally use parents as translators (when the parents have good mastery of English, and after providing careful instruction regarding what the parent can and cannot say to the child) during the assessment of bilingual/multilingual children, but will note this in the report since there could be issues with reliability using this method. Sometimes she will conduct informal observation during language-based play for most of the first visit with the child, in order to determine which areas need to be investigated further using the appropriate standardized test(s). However, she mentioned that tests like the CELF-4 (or even using a few of the subtests of the CELF) are helpful to get an idea of a wide variety of language skills.

One important consideration which impacts this SLP’s assessment process is the family’s financial resources (i.e., if a family has limited insurance coverage for SLP services, and cannot afford to pay for more services beyond this coverage). For this reason, the SLP stated that she approaches assessment as “diagnostic therapy” – similar to what we have been discussing in class as ‘dynamic assessment’. I think this is a good strategy to ensure that too many hours and dollars aren’t spent on assessment, since many parents bring their children to my course partner’s private practice because their child is not receiving/did not receive direct intervention in the school board (the SLP mentioned that many school board SLPs in the GTA only provide consultation and Tier 1 or Tier 2 intervention).

The SLP also stressed the importance of observing children during assessment because these observations can reveal valuable information beyond raw scores. For example, if you asked a child to complete a written sample in two minutes and the child only produced two sentences, this may have been due to motivation (child quickly wrote two sentences and then was looking around and fidgeting for the rest of the time) rather than actual difficulties with production (child took two minutes to slowly write out each word in the sentences), or vice versa. Beyond observation, she mentioned that we should listen and ask children what they find difficult too, because sometimes they are able to effectively describe why they find a certain task or skill difficult.

Posted in Assessment

Dynamic Assessment: What is it & how do I use it?

I mentioned dynamic assessment a bit in one of my previous posts about culturally & linguistically appropriate assessment, but I felt there was much more to be discussed in terms of what dynamic assessment actually is and how it is used. Dynamic assessment (DA) is an interesting mode of assessment because unlike standardized assessment tests which involve the interpretation of quantitative scores, DA focuses on analyzing a child’s thinking and learning process during tasks. Based on how much support the child needs during the assessment and how they proceed through the tasks, the clinician using DA can make inferences about what strategies or intervention methods would be best for the child.

Some methods for the dynamic assessment of language include: 

1) Testing the limits:

  • This involves determining the highest level at which a child can respond, using a series of probes and elaborated feedback or verbalization.
  • Unlike simple feedback (simply indicating whether an answer is correct), elaborated feedback includes feedback about why a child’s response was correct or not and an explanation of the principles involved in the task (i.e., “The reason that Tommy was sad, not happy, was because in the story it said…”).
  • Verbalization involves asking children to describe the question or task and how they arrived at their answer (i.e., “How did you know that Tommy was sad in the story?”).
  • The administration of a test can also be modified to focus on generating questions which will help a child understand how they are thinking about a test question (i.e., “What would happen if…”, “How did you know that?”, etc.) and enable their awareness of the targeted skill(s).

2) Graduated prompting:

  • Graduated prompting involves using a hierarchy of predetermined prompts (from minimal prompting to maximal prompting) to determine the child’s readiness to learn specific targets.
  • Prompts should vary in the level of contextual support they provide.
  • Predictions can be drawn about the child’s response to intervention by looking at their responses to the test procedures and new tasks.
  • Below is an example of a hierarchy which may be used for the dynamic assessment of sentence structure (DASS), provided by Hasson et al. (cited below in the additional resources).
dass
Table taken from Hasson et al. (2012), cited below.

3) Test-teach-retest:

  • This method begins with the “test” or evaluative component to determine the area(s) where a child needs more support.
  • The “teach” component involves the examiner teaching the child the principles of the task. This provides an opportunity for the child to learn from the examiner.
  • Finally, the “retest” component typically involves the re-administration of a task in the area of focus (i.e., if reading comprehension was targeted, a new reading passage will be presented to the child). This provides an opportunity for the child to reveal their competence to the examiner and provides insight into how the child responded to the “teach” step.

Dynamic assessment can be a great approach to assessment because it encourages a focus on the “process” behind tasks. Modifications and flexibility during assessment can help ensure that a child understands the tasks and expectations. It also informs clinicians on the stimulability and readiness of a child to begin intervention tasks. I think this form of assessment would be especially helpful when working with “difficult to test” populations (i.e., bilingual children, children who use AAC, children with behavioural challenges, etc.), since other assessment methods (i.e., standardized assessment tests) may not best assess the competences of these children.

For more information, check out these additional resources:

De Lamo White, C., & Jin, L. (2011). Evaluation of speech and language assessment approaches with bilingual children. International Journal of Language & Communication Disorders/Royal College of Speech & Language Therapists, 46(6), 613.

Gutierrez-Clellen, V. F., & Pena, E. (2001). Dynamic assessment of diverse children: A tutorial. Language, Speech, and Hearing Services in Schools, 32(4), 212-224.

Hasson, N., Dodd, B., & Botting, N. (2012). Dynamic assessment of sentence structure (DASS): Design and evaluation of a novel procedure for the assessment of syntax in children with language impairments: Dynamic assessment of sentence structure (DASS). International Journal of Language & Communication Disorders, 47(3), 285-299.

Spencer, T. D., Petersen, D. B., & Adams, J. L. (2015). Tier 2 language intervention for diverse preschoolers: An early-stage randomized control group study following an analysis of response to intervention. American Journal of Speech-Language Pathology/American Speech-Language-Hearing Association, 24(4), 619.

Posted in Assessment

Culturally & Linguistically Appropriate Assessment

Many schools in Ontario and Canada now have a culturally diverse population of students, which means that speech-language pathologists need to consider how to provide assessments which are culturally and linguistically fair. In the case of students referred for assessment who are English Language Learners (ELLs), SLPs will need to consider the child’s expressive and receptive knowledge in both their Native language and English to determine how to proceed with the assessment.

These are some questions I had when learning about how to conduct a culturally and linguistically appropriate assessment. I think the answers provide ways that SLPs can make assessment fair for all students:

What is a “silent period” and is it normal?
A “silent period” is a common second-language acquisition phenomenon. It occurs when children are first exposed to a second language, and focus on listening and comprehension. During this period children are often very quiet and speak little in order to focus on understanding the new language. According to the American Speech-Language-Hearing Association, the younger the child, the longer the silent period tends to last (older children may remain in the silent period for a few weeks to a few months, while preschoolers may be relatively silent for a year or more).

Can I still use norm-referenced standardized tests to assess ELLs?
Yes, but interpret the results with caution and supplement the test with other assessment tools. The child’s scores compared to the norms would also be invalid (since certain items on the test may be culturally or linguistically specific to North America/English), and thus the tests could not be used to gain conclusive quantitative data. However, they may give an SLP some preliminary information about the areas where a child may excel or need more practice. It is important to supplement standardized tests with other information, such as a language sample, observation of the child in the classroom, a review of the child’s classwork, information about the child’s expressive and receptive abilities in English and/or other languages from teachers and parents, etc.

White & Jin (cited below in the Additional Resources) discuss a variety of assessment procedures which can be used with bilingual children, including the following:
• Dynamic assessment, which commonly involves a test-teach-retest format, can be a good option for assessing bilingual children. This type of assessment integrates both assessment and therapy simultaneously, to provide information on the child’s level of performance and the impact of intervention on performance, to shed light on the strategies which would best support the child’s learning.
• Criterion-referenced (CR) measures, or measures of the child’s level of performance on a particular skill, can also be good alternative to norm-referenced standardized measures. CR measures tend to be informal (i.e., language sampling, probing, etc.) and allow the clinician to use materials which are familiar to the child, thus reducing cultural and linguistic bias.
• A sociocultural approach to assessment, although more time-consuming and intensive, takes a holistic view of the child’s developing speech and language skills in the context of their social and cultural environment.
• The RIOT procedure is one representation of the sociocultural approach, which includes the following components:
Review all documentation, client records, clinical history and educational records.
Interview parents, teachers, and relevant others to glean the child’s language history, family dynamics, interactions, cultural differences, etc.
Observe the child in multiple settings with a variety of different people.
Test all languages which the child speaks using (modified) formal and informal assessments (i.e., language sampling, dynamic assessment, etc.).

What should I say to bilingual parents or parents of ELLs in terms of Native language (L1) vs. English language use?
• Parents should know that learning two languages at home (i.e., English and a Native language like Hindi or Mandarin) does not cause confusion or a language problem in young children
• Children with language delay can also learn two languages (without the languages being kept separate, i.e., only L1 at home and only English at school), and will not become more delayed if they hear or learn two languages (However, speech and language difficulties will be heard in both languages)
• Even if a child has a language delay, parents should still continue to use both their L1 and/or English, to increase the child’s opportunities to talk, play, and get to know friends and family members who speak either language
• If the parents are not fluent or comfortable speaking in English, they should speak and read books with the child in L1 to ensure the child still has exposure to good language models

In terms of language use, what might I expect of children who are learning two languages?
Hoff & Core (cited below in the Additional Resources) provide some “need to know” facts about the language development of bilingual children:
• A measure of total vocabulary provides the best indicator of young bilingual children’s language learning capacity.
• Bilingual children can have different strengths in each language.
• Learning two languages takes longer than learning one. Thus, on average, bilingual children lag behind monolingual children in single language comparisons.
• The quantity and quality of bilingual children’s input in each language influence their rates of development in each language.

It is normal for children learning a second language to:
• Use one language more than the other
• Mix words from both languages in the same sentence (aka “code-switching”)
• Make mistakes in the new language until they learn all the rules
• Lose language skills and fluency in their L1 as they learn English (in order to prevent this, parents should be encouraged to reinforce and maintain L1 by using it at home, even if the child chooses to respond in English)

For more information, check out these additional resources:
De Lamo White, C., & Jin, L. (2011). Evaluation of speech and language assessment approaches with bilingual children. International Journal of Language & Communication Disorders / Royal College of Speech & Language Therapists, 46(6), 613.

Eriks-Brophy, A. (2014). Assessing the language of Aboriginal Canadian children: Towards a more culturally valid approach. Canadian Journal of Speech-Language Pathology and Audiology, 38(2), 152-173.

Hoff, E., & Core, C. (2015). What clinicians need to know about bilingual development. Seminars in Speech & Language, 17;36;(2), 089-099.

Language Background Questionnaires in Different Languages:
http://nhlrc.ucla.edu/nhlrc/data/questionnaires

Intelligibility in Context Scale in Different Languages:
http://www.csu.edu.au/research/multilingual-speech/ics

University of Alberta’s Child English as a Second Language Resource Centre:
https://www.ualberta.ca/linguistics/cheslcentre

Red Flags for Speech-Language Impairment in Bilingual Children:
http://leader.pubs.asha.org/article.aspx?articleid=2578642&utm_source=asha&utm_medium=enewsletter&utm_campaign=leaderlive110216

Bilingualism in Ontario
http://www.botte-boot.com/
A website with information and a blog about bilingualism in Ontario, created by a speech-language pathology faculty member at Laurentian University

Posted in Assessment, Perspectives from the Field

Perspectives from the Field: Speaking to a School Board SLP (Part II)

I recently spoke to an SLP in the Peel District School Board about her thoughts on assessment. Assessment and intervention varies across school boards, so I was interested to hear about what the approach is like in Peel.

On the “standard assessment”…
The SLP mentioned that the following tests and tools are typically used in an assessment battery:
• Peabody Picture Vocabulary Test (PPVT)
• Expressive Vocabulary Test (EVT)
• Clinical Evaluations of Language Fundamentals (CELF)
• A reading and/or writing assessment (i.e., Phonological Awareness Test)
• An informal spelling test
• A review of writing samples (i.e., past assignments the child has completed)

A full language assessment can take 8-10 hours, and thus the SLP stated that it is important to carefully consider when it is or is not appropriate to complete an extensive, formal assessment. She also stated that she likes that the CELF is comprehensive in the sense that it “covers a little bit of everything”.

On assessing English language learners (ELLs)…
The SLP explained that she works with a diverse population of students where bilingual and multilingual students are the norm at her schools, rather than the exception. Many of these children have enough exposure to English that they can be tested using standardized tests such as the CELF. However, in the case of children who are not as proficient in English, she explained that she will often administer the CELF, but will not report the child’s percentile scores. Instead, she interprets the CELF results as a “starting point” in her assessment. She observes the child in the classroom, reviews the child’s class work, and consults with teachers and parents about the child’s strengths and weaknesses to gather more information for her assessment. She stated that even without standardized test results, she is still able to set intervention goals to target for these children based on the abovementioned sources of information.

I think this highlights the importance of assessment beyond standardized tests, since there may not always be a test or set of norms which is best suited for each child, especially when working with children from a highly diverse background of cultures and languages. Standardized tests are important, but usually need to be supplemented with other information in order to fully understand the child’s capabilities.

Since this SLP works in a diverse school board, she has the advantage of being able to access translators when a child and/or the child’s parents do not know very much English. Thus, information can still be reliably gathered from the child and their parents. This resource may be more difficult to acquire in a school board where encountering multilingual children is less common.

On writing effective assessment reports…
I also wanted to get the SLP’s thoughts on the “Strategies and Recommendations” section of the assessment report, since we discussed the issues surrounding generic or redundant recommendations (i.e., Almost identical/vague recommendations across both the psychoeducational assessment report and the speech and language assessment report) in class. The SLP agreed that strategies included in assessment reports are often too generic to be meaningful for educators. She mentioned that she tries to address this issue by recommending apps, programs, or workbooks to teachers (i.e., Explode the Code phonics program) because teachers often prefer hands on materials. I think this is a great approach because both teachers and parents can then have tangible resources to help the child develop their speech and language skills.

Expect some future blog posts where I delve deeper into assessment tests, tools, and resources!