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 Intervention

The Importance of Social Competence

Social communicative competence is an important aptitude for children to possess because it allows them to interpret social situations and productively interact with their peers and others (i.e., to engage in play, resolve conflict, etc.). Social communication skills are supported by the child’s executive functions, language abilities, and social cognitive processes. Timler, Vogler-Elias, and McGill (cited below in the Additional Resources) discuss two outcomes which social communication interventions should target in order to be effective:
• Enhancement of language and social skills (with a particular focus on pragmatics)
• Generalization of social skills during authentic interactions with peers

Timler et al. describe 4 intervention contexts (from most to least naturalistic) in which social communication can best be targeted, which include:

  1. Environmental arrangement
  • Intervention in this context has typically occurred within preschool classrooms
  • This context involves arranging the classroom to include social toys (i.e., dress up clothes, board games, etc.) and centers to promote cooperative and pretend play
  • Through this arrangement, children with a range of social skills will have more opportunities to interact with each other in a natural context
  • The effectiveness of interventions in this context may be reduced in non-inclusive settings (i.e., children with disabilities segregated from typically-developing peers)
  1. Teacher-mediated intervention
  • This form of intervention focuses on increasing the classroom teacher’s use of verbal strategies which will promote peer interactions (i.e., “redirect” strategy where teachers encourage children to redirect requests from the teacher to a peer)
  • This method can increase peer interactions, after providing teachers with a relatively small amount of professional development on verbal strategies (however, teacher buy-in is necessary in order to see results!)
  1. Peer-mediated intervention
  • This type of intervention focuses on having the SLP recruit typical and pro-social peers to interact with children with social communication difficulties
  • Previous studies have shown that when children with social communication problems attempt to initiate interactions with typical peers, they are more likely to be rejected or ignored by these typical peers
  • Thus, in this case the typical peers are trained and receive “intervention”
  • The increased interaction between the trained peers and children with social communication problems is meant to provide the latter group with more opportunities to develop social communication skills
  • This method has primarily been used with children with ASD and has showed positive outcomes in terms of higher response rates by children with ASD and higher initiation rates of typical peers
  1. Clinician-mediated intervention
  • This mode of intervention involves individual or small group sessions with the child with social communication difficulties
  • Intervention components include:
    – Direct instruction
    – Modelling of desired behaviours
    – Role-play
    – Corrective feedback and praise to shape and reinforce skills
  • Timler et al. note that intensive instruction and concentrated practice, including opportunities where children can learn “when” and “how” to use social skills (i.e., contexts like peer group entry, cooperative play groups, conflict resolution, etc.), is crucial to help children acquire social skills
  • Typical peers can still be used in this form of intervention, however they do not receive training and are instead involved to allow the child with social communication difficulties to practice his/her newly acquired skills

I think that each of these contexts can create an effective framework to develop a child’s social communication skills. However, I feel that some important considerations when selecting an intervention context include:

  • After observing classroom dynamics, does the class seem to include children with a diverse range of social skills (i.e., are there pro-social children which could be selected for a peer-mediated intervention)?
  • Does the teacher appear to have the motivation to apply verbal strategies in the classroom (i.e., would you feel confident that a child’s social communication skills could improve with teacher-mediated intervention alone)?
  • What type of prompting hierarchy may be needed to have the child work towards independently and effectively using social communication skills (i.e., starting with a visual cue, a verbal prompt in the form of a direct request, a verbal prompt in the form of a direct model, etc.)?
  • Is the child able to self-monitor their use of the targeted skill or does self-monitoring need to be explicitly taught?

For more information, check out these additional resources:
Adams, C., Gaile, J., Lockton, E., & Freed, J. (2015). Integrating language, pragmatics, and social intervention in a single-subject case study of a child with a developmental social communication disorder. Language, Speech, and Hearing Services in Schools, 46(4), 294.

Timler, G. R., Vogler-Elias, D., & McGill, K. F. (2007). Strategies for promoting generalization of social communication skills in preschoolers and school-aged children. Topics in Language Disorders, 27(2), 167-181.

Winner, M. G. & Crooke, P. J. (2009). Social Thinking: A developmental treatment approach for students with social learning/social pragmatic challenges. Perspectives on Language Learning and Education, 16(2), 62-69.
https://www.socialthinking.com/Articles?id=3d555633f16f4396a5f0c22987bb9951
• This article presents great information on social communication development and the ILAUGH Model of Social Thinking

https://www.youtube.com/user/TDSocialSkills
• This YouTube channel provides several videos about social skills.

http://www.pbis.org/school
• This site provides information on promoting social competence at a school-wide level

Social Communication Intervention Project (University of Manchester)
http://research.bmh.manchester.ac.uk/scip/projectoverview
• This website provides information about a social communication intervention program which addresses the interactions between social understanding, language pragmatics, and language processing.