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Language Impairment in a Child with Suspected Fetal Alcohol Spectrum Disorder

Table 14.3 Percentile rank and clinical interpretation of performance for each reasoning subskill of the Test of Problem-Solving, 3rd Edition (TOPS-3)

Subskill Percentile rank Interpretation of

performance

Making inferences 12 Below average—mild

impairment

Sequencing 35 Average

Negative questions 38 Average

Problem solving 32 Average

Predicting 14 Below average—

mild impairment

Determining causes 2 Below average—

moderate impairment

Total test 16 Borderline

Answer: h is correct. Diﬃculty in oral language comprehension may lead AJ to feel “lost” or confused when she either does not understand or cannot remember complex oral instructions. While students around her may be executing the tasks required of them in the classroom, AJ will not. This may give rise to a number of emotions that—if exacerbated by accumulating classroom demands—may manifest themselves in unwanted or aggressive behaviors. If AJ attempted to express her frustrations verbally, she may encounter diﬃculty in expressing her complex thoughts and feelings in a manner that can be understood by her teacher or students around her. If others indicate they do not understand her due to her impaired speech clarity, this may further exacerbate AJ’s emotional state and lead to further undesired behavior.

e is incorrect. There are numerous other standardized tests available to assess student skills and to corroborate and/or support clinical impressions.

3. If the laws in your state or province allowed for SLPs to make

diagnoses, would you diagnose this child with a language disorder? If not, why not? What information do you think is missing? a) Yes, because test results indicate below-average global

language abilities. I do not need additional information to make this diagnosis.

b) Yes, because test results indicate below-average expres-

sive language abilities. I do not need additional information to make this diagnosis.

c) No, because AJ’s verbal reasoning skills—higher-level abil-

ities required to navigate social situations—are borderline.

d) No, because a diagnosis of a language disorder requires

diﬀerentiating AJ’s language skills from her skills in other developmental domains. I need additional information from a comprehensive psychometric evaluation.

e) None of the above.

Answer: d is correct. For a language disorder to be diagnosed, language skills must fall at least 2 standard deviations below the mean of other domains of development as measured by intelligence or neuropsychological tests. That is, language skills alone must be significantly impaired compared to other domains of development. Otherwise, the language impairments

identified may be a part of a more global delay. If a language impairment is identified by an SLP, a diﬀerential diagnosis of language disorder must be ruled out by broader psychometric testing. Impairments in reasoning identified by an SLP must also be isolated to verbal reasoning (vs. visuospatial reasoning, for example) and further supported by both language-specific and global developmental testing to rule in language disorder.

4. Could AJ be diagnosed with FASD? Why or why not? Use the following website as your starting point: http://www.nofas. org.

a) Yes, she has FASD. No more information is needed to

make a definitive diagnosis.

b) Yes, she could have FASD, but more information is needed

from other domains of development to make a definitive diagnosis.

c) She is unlikely to have FASD given her history and clinical

profile.

d) No, she cannot have FASD given that she is already diag-

nosed with ADHD.

Answer: b is correct. Given the broad spectrum of FASD presentations and current best practice in the diagnosis of this disorder, language and verbal reasoning impairments are a piece of the puzzle. Other professions that need to be involved in the diagnosis can shed light on other domains of development that are not the purview of the SLP, such as developmental pediatrics, occupation therapy, and psychology. These professionals can, in turn, provide information regarding physical development and facial features, sensory and fine motor development, and intelligence, respectively.

a is incorrect. This answer assumes that only information documented by the SLP is suﬃcient to make this diagnosis. It is not.

c is incorrect. Many of the behaviors reported are present in children without FASD. However, these behaviors are also seen in children with FASD. Her behaviors and history alone cannot rule in or out FASD.

d is incorrect. It is a definitive statement that does not take into consideration that FASD and ADHD can be comorbid disorders.

14.5 Description of Disorder and Recommended Treatment

AJ’s areas of concern were primarily in expressive language at the word and sentence level. She also showed some diﬃculties in narrative retell, although this skill was not examined formally. Her Core Language Index placed her in the 8th percentile rank with a statistically significant discrepancy between her receptive and expressive language skills (18th and 5th percentiles, respectively). AJ’s literacy skills were moderately-toseverely impaired relative to children her age, and this was at least in part due to demonstrated diﬃculties with phonological awareness. Furthermore, AJ demonstrated diﬃculties in making inferences, predicting, and determining causes of events when given visual and verbal stimuli concurrently. Finally, her intelli-

Language Impairment in a Child with Suspected Fetal Alcohol Spectrum Disorder

gibility was aﬀected by several articulation and phonological processing errors that made her diﬃcult to understand in a quiet setting.

The following recommendations were made following the

evaluation.

●

Professional supports:

○

Speech-language therapy to focus on articulation and language skills. It was advised that the treating clinician target PROMPT motor speech hierarchy stages 4 and 5 (labiofacial and lingual movement), specifically.

○

Learning support in school: one-on-one pull-out support for specific impairments in addition to participation in classroom group learning activities.

○

Further psychometric evaluation to rule in/out a language or other learning disorder/disability and to assist with FASD diagnostic formulation.

○

Sharing of assessment results with AJ’s primary care physician to facilitate further supports, as needed.

●

Classroom environment:

○

Provide AJ with preferential seating close to her instructors.

○

Ensure AJ is facing the teacher during instructions.

●

Academic instruction and programming:

○

Reduce the use of rhetorical language.

○

Incorporate language instruction within the context of AJ’s preferred activities.

○

Provide opportunities for AJ to engage in oral sentence formulation activities.

○

Provide AJ with a “buddy” with whom she can exercise her narrative skills as they develop.

○

Use barrier games to encourage expressive language and theory of mind development.

○

Use picture cards or photographs to help elicit stories from AJ. Explicitly teach AJ the components of a story and have her practice story retelling either with picture cues or from memory.

●

Home environment:

○

When giving AJ instructions orally, ensure that AJ is facing the person giving the instruction, give instructions slowly, ensure comprehension of oral instructions by having her repeat them, and avoid the use of figurative or rhetorical language.

14.6 Outcomes

AJ presented with many strengths. She was a social girl who participated readily in the evaluation. In spontaneous speech recorded by her mother oﬀsite, AJ engaged in conversational turn-taking and provided spontaneous contributions and elab-

orations typical of a child her age in a casual setting. Furthermore, she displayed strengths in her ability to use visual and verbal information to sequence events, answer negative questions, and solve problems in a manner broadly similar to children her age. AJ presented with strengths in her ability to draw similarities among single spoken words, follow multiple-step, complex directions, and remember verbatim short statements spoken to her.

AJ’s family attended several speech-language therapy sessions targeting speech-sound production. During her attendance, she demonstrated perceptible success in the production of /s/ and /z/ in one- and two-syllable words in all word positions using the PROMPT method for tactile cueing and immediate auditory feedback of her utterances. However, this was not observed to generalize to the sentence level or made spontaneously. Unfortunately, therapy stopped after four sessions due to lack of resources and AJ was discharged to the care of her parents and school.

14.6.1 Key Points

●

FASD can manifest in several domains of development, including language, making it necessary to implement a multidisciplinary approach to its diﬀerential diagnosis.

●

Language and speech-sound impairments can more broadly impact children’s successful interactions with people in their environments. The eﬀects of these impairments can be observed in children’s behavior, which can vary from harmless indiﬀerence to verbal and/or physical aggression.

●

While an important part of a thorough evaluation, the clinical utility of standardized tests does not necessarily lie in the scores derived from them.

●

Although ideally all individuals with speech, language, or other impairments should receive the services they need, the unfortunate reality is that not all will receive them due to lack of resources.

Suggested Readings

[1] Astley SJ. Diagnostic Guide for Fetal Alcohol Spectrum Disorders: The 4-Digit

Diagnostic Code. Seattle, WA: University of Washington; 1994

[2] American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013

[3] Paul R. Language Disorders from Infancy through Adolescence: Listening,

Speaking, Reading, Writing, and Communicating. St. Louis, MO: Elsevier; 2012

[4] Reid N, Dawe S, Shelton D, et al. Systematic review of fetal alcohol spectrum

disorder interventions across the life span. Alcohol Clin Exp Res. 2015; 39 (12):2283–2295

Speech Rehabilitation following Cleft Palate Repair

15 Speech Rehabilitation following Cleft Palate Repair

Catherine Crowley and Chelsea Sommer

15.1 Introduction

Cleft palate can yield significant limitations to speech intelligibility. In addition, compensatory misarticulation can persist following surgical correction of the cleft. This case outlines the diﬀerentiation between cleft palate speech and compensatory misarticulation, as well as appropriate therapy approaches for this challenging population.

15.2 Clinical History and Description

MR, a 6-year-old English-dominant Spanish bilingual girl born with cleft of the hard and soft palate, underwent primary palate repair when she was 12 months old. From 12 months to 6 years of age, she produced typical cleft palate speech errors. At the age of 6, MR underwent secondary palate surgery to extend the velum to improve velopharyngeal closure. Concurrently, MR had myringotomy tubes placed due to recurrent middle ear infections. Conductive hearing loss is common in children with cleft palates, as the tensor veli palatini, the primary muscle responsible for eustachian tube opening, inserts into the soft palate. With a cleft, the tensor veli palatini cannot regulate air pressure and opening between the mouth and middle ear, making children with cleft palates more vulnerable to middle ear infections. cleft palate team who performed her surgery.

MR was referred by the head surgeon of the local

During the initial assessment, MR produced the /p/ sound in isolation at three diﬀerent times. This moment was captured on video and can be seen in ▶ Video 15.1. All other sounds except for /m/ were produced with incorrect placement (such as producing an /n/ by closing the lips) and often in an incorrect manner (such as producing a stop /t/ inste ad of a continuant /s/) and/or voicing (such as producing a /p/ as a /b/). MR also demonst rated the ability to imitate bilabial placem ent of the /p/ and /b/ after a few attempts using a multisensory approach with visual, tactile, kinesthetic, and auditory cu ei ng.

15.4 Questions and Answers for the Reader

1. Why was MR able to produce a /p/ sound only three times

during the evaluation?

a) To be able to consistently produce the /p/ sound, MR

would need a third surgery.

b) MR was stimulable for the high-pressure /p/ sound,

but she needed more therapy to produce consistent productions.

c) MR had the adequate structure following the surgery;

however, MR did not have adequate physiology for the /p/ sound.

d) MR had lip weakness and needed to work on lip

strengthening before she could produce the /p/ consistently.

15.3 Clinical Testing

In the evaluation of cleft palate patients, a clinician’s perceptual skills are the “gold standard” for assessment. included an oral examination; assessment of resonance; and assessment of all sounds in isolation, syllables, single words, and sentences. Oral mechanism examination revealed no fistulae and grossly adequate movement of the velum and articulators. Resonance was normal. With regard to speech, poor articulatory placement for all high-pressure sounds was observed. These “high-pressure,” or oral sounds, are sounds that require complete closure of the velopharyngeal mechanism so that the nasal passageway is occluded and all sound exits through the mouth. High-pressure sounds in English include /p, b, t, d, k, g, s, z/. Patients with cleft palate can produce nasal sounds, such as /m/, /n/, and /ŋ/ and low-pressure sounds, such as /w/, /l/, and /r/, which do not require full closure of the velopharyngeal port. In MR’s case, however, high-pressure, lowpressure, and even nasal sounds were replaced by typical errors in cleft palate speech, including pharyngeal fricatives, glottal stops, and nasal emissions. MR’s only consistently accurate placement was the bilabial, voiced nasal phoneme /m/ and all vowels.

Assessment

Video 15.1 Assessment and stimulability of high-pressure /p/ sound at initial consult. This is the first time the authors worked with this client. They assessed her speech sounds and probed for stimulability. MR was stimulable for the /p/ sound, as demonstrated in this clip.

Speech Rehabilitation following Cleft Palate Repair

e) MR’s surgery had not fully healed and would improve

even without speech therapy after a few more weeks of healing.

Answer: b is correct. By producing the /p/ sound correctly, MR demonstrated that the secondary palate surgery was a success and she could create adequate velopharyngeal closure. MR was only able to produce the /p/ sound three times in response to a multisensory approach to stimulate the sound. The elimination of compensatory errors, or “cleft palate speech,” involves motor learning and requires much practice and repetition to eliminate compensatory cleft palate speech errors.

a is incorrect. MR did not need another surgery following her secondary palate repair. MR needed more speech therapy. By producing the high-pressure /p/ sound only once during the initial evaluation demonstrates that she had adequate structure and function, and is not in need of another surgery, only speech therapy.

c is incorrect. MR had adequate structure and function after her secondary surgery as demonstrated by her production of the high-pressure /p/ sound, which indicated appropriate palatal function.

d is incorrect. Lip strengthening and other nonspeech oral motor exercises, such as horn blowing and straw sucking, are not evidenced based and will have no positive eﬀect on MR’sspeech.

e is incorrect. Once the surgeon confirms that the patient is ready for speech therapy, there is little healing left. More importantly, because MR did not have correct articulatory placement, that is, a bilabial placement, MR’s /p/ sound production is very unlikely to improve without therapy where she can learn correct placement.

2. Why did MR present with incorrect articulatory placement

for so many speech sounds, including all high-pressure sounds and also most low-pressure and nasal sounds? a) The levator veli palatini, the most important muscle in

velopharyngeal closure, could not function correctly for the low-pressure and nasal sounds.

b) In addition to the cleft palate speech errors with the high-

pressure sounds, MR’s speech had many phonological processes unrelated to velopharyngeal insuﬃciency.

c) MR had many speech errors that were consistent with

apraxia of speech.

d) Due to a conductive hearing loss, MR could not hear the

sounds correctly, and produced the sounds the way she heard them.

e) For MR’s case, the compensatory misarticulations aﬀected

virtually her entire sound system.

Answer: e is correct. Although a child with an unrepaired cleft palate can generally produce the nasal sounds and the lowpressure sounds, in MR’s case all but the /m/ and vowels were produced with inconsistent placement and mostly with incorrect manner and voicing. In MR’s case, the compensatory misarticulations aﬀected virtually her entire sound system, meaning that she had to relearn almost all sounds needed for speech with the exception of the /m/ and the vowels.

a is incorrect. Although the levator veli palatini is the most important muscle in velopharyngeal closure, this muscle has minimal involvement in the production of low-pressure and none with nasal sounds.

b is incorrect. MR did not demonstrate any phonological processes. Phonological processes are separate from cleft palate speech errors.

c is incorrect. Often children with cleft palate speech are misdiagnosed with apraxia, as they must relearn correct placement for sounds, resulting in inconsistent errors and groping as they work to relearn correct production for the mislearned sounds post–cleft palate repair. In this case, MR did not have apraxia of speech as vowel production was consistent and any inconsistent productions could be attributed to relearning correct production of sounds.

d is incorrect. While MR might hear sounds with distortions with a conductive loss, this is unlikely to cause classic cleft palate speech errors such as glottal stops and pharyngeal fricatives, and also unlikely to cause such poor placement of articulation for virtually all sounds.

3. Why did MR need another cleft palate surgery to address her

speech issues if she had her cleft palate repaired at an excellent hospital with an American Cleft Palate-Craniofacial Association ACPA–

Even the best surgeons have patients who need a secon-

dary repair for speech, even if the initial repair is flawless.

b) The hospital had a change in personnel and the surgeon

who did MR’s surgery was inexperienced.

c) MR received speech therapy from a speech-language

pathologist who did not have any understanding of how to address cleft palate speech.

d) MR’s mother failed to follow postoperative procedures

after the first cleft palate surgery, causing the velopharyngeal insuﬃciency.

e) MR did not have any health insurance to cover speech

therapy postsurgery.

Answer: a is correct. MR required another cleft palate surgery because after her primary palate repair she continued to display velopharyngeal insuﬃciency. Even the best cleft palate surgeons have patients who need a secondary palate surgery. The role of the speech-language pathologist is to work with the patient after the initial cleft palate surgery to determine whether t he speech errors are simply compensatory errors needing mor e speech t herapy or consistent with velopharyngeal ins uﬃciency, indicating the need for a secondary cleft palate surgery.

b is incorrect. While it is possible to have inexperienced or even less-than-competent surgeons on cleft palate teams, even the best cleft palate surgeon will have patients who need a secondary speech surgery, even when the first surgery was flawless. In MR’s case, she had an excellent and experienced surgeon do her first cleft palate repair.

c is incorrect. It is important that the speech-language pathologist has a full understanding of how to address cleft palate speech; however, without a secondary surgical intervention, MR’s velopharyngeal mechanism would not have functioned adequately. MR needed that surgery to have the anatomical and physiological ability to close the velopharyngeal mechanism and produce high-pressure speech sounds.

d is incorrect. MR’s mother went to all necessar y meetings for MR following her palate repair. MR’s velopharyngeal insuﬃciency was caused by her lack of tissue and muscle needed for velopharyngeal closure.

certified cleft palate team?

Speech Rehabilitation following Cleft Palate Repair

e is incorrect. Whether MR received speech therapy postsurgery has no impact on the fact that she needed a secondary speech surgery.

4. Would speech therapy have benefited MR even before she

had her secondary speech surgery at the age of 6 years? a) No. Without velopharyngeal closure, MR would never

have been able to produce any of the high-pressure sounds.

b) Yes. With high-quality multisensory speech therapy,

using nasopharyngoscopy feedback, MR could have had excellent production of the /p/ and /b/ phonemes.

c) Yes. Speech therapy could have focused on lip and tongue

strengthening so that after she had her surgery, she would require very little speech therapy.

d) Yes. Speech therapy could have focused on reducing her

hypernasality making her speech more intelligible.

e) Yes. Speech therapy could have focused on correct articu-

latory placement so she would require less speech therapy after the surgery.

Answer: e is correct. It is generally beneficial to receive speech therapy before surgery to improve speech outcomes after surgery. If MR had been receiving speech therapy before surgery, she would not be able to make the high-pressure sounds but would have good placement and manner. Therapy postsurgery could have focused on having the air and sound come through the mouth, something MR could not do without the speech surgery. Additionally, with good placement and manner of articulation, MR’s intelligibility would have been significantly better presurgery.

a is incorrect. Without velopharyngeal closure, MR would never have been able to produce any of the high-pressure sounds. Yet, speech therapy presurgery could have benefited MR by improving placement of articulation and intelligibility.

b is incorrect. High-quality multisensory speech therapy is helpful when providing feedback; however, without the secondary speech surgery, using only this method would not generate excellent production of the /p/ and /b/ sounds.

c is incorrect. Lip and tongue strengthening exercises would have had no impact on MR’s speech before or after surgery.

d is incorrect. Resonance is a function of the size and shape of the resonance cavity. Speech therapy cannot reduce hypernasality, where there is no change in the size or shape of the cavity. Only surgery can change the size and shape of the cavity.

in syllables, single words with no other high-pressure sounds followed by similarly constructed sentences, and, finally, conversation. Because cleft palate speech therapy requires drills and many repetitions, the therapy itself must be varied and fun to keep the child, and the family, focused and engaged.

In this case, each hierarchical step had diﬀerent, including multisensory, single-sound games, practicing the target sound in syllables, single-word cleft palate speech therapy games, and cleft palate speech storybooks that target voiced and voiceless cognates. ▶ Video 15.2 demonstrates how the cleft palate speech therapy hierarchy was implemented with MR. To optimize therapy outcomes, MR’s mother became a critical member of the therapy team acquiring the pertinent cleft palate speech therapy strategies MR was working on. Throughout the week, the mother worked with MR on repetition and drills to enhance motor relearning.

Therapy initially focused on appropriate placement of nasal sounds, as they are critical for the eventual placement of highpressure sounds. Once correct placement of the nasal sounds /m/, /n/, and /ŋ/ was achieved, /p/ was introduced as it is a bilabial, voiceless sound and thus less likely to engage the vocal folds to yield a glottal stop. MR could employ the bilabial /m/ to model appropriate placement for the /p/. With practice, the /p/ was relatively easy for MR.

In the cleft palate speech therapy hierarchy, clinicians should begin with discrimination of the compensatory error and the correct production so that the patient can perceive and understand the diﬀerence between the incorrect production and the correct target production. The next step is to work on the target sound in isolation. This means that the sound is targeted without a vowel after it (e.g., say “p” not “pa” as the prompt). Next, the clinician can combine the target sound with vowels in the “Acevedo Spoke.” In this approach (▶ Video 15.2), the target sound is in a circle in the middle of the page with spokes from the target sound to vowels around the outside of the page. The first combinations on the Acevedo Spoke involve the target sound in the initial position “pa, pe, pi, po, pu” followed by in

15.5 Description of Disorder and Recommended Treatment

MR had compensatory misarticulation secondary to velopharyngeal insuﬃciency. Prior to the secondary surgery, MR did not have the requisite anatomy and physiology for production of high-pressure sounds. The compensatory misarticulations formed as MR attempted to replicate the sounds she heard but that she could not make correctly because she had velopharyngeal insuﬃciency. Treatment involved moving sound by sound through the traditional hierarchy for cleft palate speech therapy discrimination, production of single sounds, the sound

Video 15.2 Hierarchy for cleft palate speech therapy. This demonstrates the speech therapy hierarchy to follow when working with a child who has had cleft palate speech.

Speech Rehabilitation following Cleft Palate Repair

the final position “ap”“ep”“ip”“op”“up” and then placing the target sound in the medial position surrounded by a combination of vowels “apa”“epe”“ipi”“opo”“upu.” Next, the clinician will move on to placing the target sound in words (in the initial, medial, and final positions). Following successful use at the word level, the clinician can use cleft palate speech therapy books, which can be found for free at leadersproject.org. Finally, the target sound should be practiced in spontaneous speech during conversation.

15.6 Outcome

Beginning 2 weeks after surgery, and with the approval of her surgeon, speech therapy was initiated approximately three times per week for 8 months. She also received school-based therapy twice per week. Over 8 months of therapy, MR improved from minimal intelligibility (20% for trained listeners and family members and 10% for others) to mostly intelligible speech even without k nown context (90% for trained listeners and family members and 75% for others). MR’s mother actively participated in the therapeutic process and continued to provide home practice and support. MR’s school-based speech-language pathologist collaborated with the university speech-language pathologist clinic team to ensure therapy speech goals were consistent and synergistic.

MR continues to have diﬃculty with the /k/ and /g/ sounds. MR can produce /k/ in seemingly more diﬃcult clusters such as “school” and the /ŋ/ placement is helpful as a placement transi- tion for words such as “pink” and “ringing.” The rationale underlying this success is likely related to the nasal /ŋ/ which is also a velar sound and the tongue is in the same place for production of /k/ and /g/. The final sounds to address will be /ʧ/, /∫/, and /ʤ/. Based on her progress to date, her prognosis for developing these sounds is good.

●

When a child can produce one high-pressure sound, the child has adequate velopharyngeal closure.

●

Screen for hearing; children with cleft palate often have a conductive hearing loss due to the improper insertion of the tensor veli palatini muscle.

●

Parental involvement in intervention is essential for success.

●

Eliminating compensatory cleft palate speech is a motor learning skill and needs to be practiced frequently throughout each day.

Suggested Readings

[1] Crowley C. Cleft palate practice books. Leadersproject.org. 2014. Available at:

http://www.leadersproject.org/cleft-palate-directory/cleft-palate-practicebooks/. Last accessed June 2016

[2] Crowley C. Cleft palate therapy word games. Leadersproject.org. 2016. Avail-

able at: http://www.leadersproject.org/english-cleft-palate-directory/cleftpalate-therapy-word-games/. Last accessed June 2016

[3] Crowley C, Baigorri M, Sommer C. Speech sound assessment and stimulabil-

ity. Leadersproject.org. 2016. Available at: http://www.leadersproject.org/ 2016/06/06/speech-sound-assessment/. Last accessed June 7, 2016

[4] Crowley C, Baigorri M, Sommer C, Acevedo D. What to do before the cleft pal-

ate is repaired to improve speech outcomes after surgery. Leadersproject.org.

2016. Available at: http://www.leadersproject.org/2016/05/30/strategies-before-the-cleft-palate-is-repaired/. Last accessed June 5, 2016

[5] Sommer C, Crowley C, Baigorri M, Acevedo D. Cleft palate speech therapy hi-

erarchy. Leadersproject.org. 2016. Available at: http://www.leadersproject. org/2016/05/30/cleft-palate-speech-therapy-hierarchy/. Last accessed May 29, 2016

References

[1] Peterson-Falzone SJ, Hardin-Jones MA, Karnell MP. Cleft Palate Speech. 4th

ed. St. Louis, MO: Mosby Elsevier; 2010

[2] Baylis A, Chapman K, Whitehill TL, The Americleft Speech Group.. Validity

and reliability of visual analog scaling for assessment of hypernasality and audible nasal emission in children with repaired cleft palate. Cleft Palate Craniofac J. 2015; 52(6):660–670

15.7 Key Points

●

Collaboration among all members of the interdisciplinary team ensures optimal outcomes.

Disorder, Diﬀerence, or Gap? A School-Age Disability Evaluation

16 Disorder, Diﬀerence, or Gap? A School -Age Disability Evaluation

Catherine Crowley and Casey Sheren

16.1 Introduction

This case describes a teenager previously diagnosed as “severely language impaired” based on a private, score-based evaluation. The emphasis is on the assessment of language and dialect acquisitional history and prior academic experiences to determine whether to characterize the deficits as a true language disorder or related to dialectal and/or academic issues.

16.2 Clinical History and Description

SD was a 13-year-old girl from a multilingual and multidialectal, low socioeconomic background. When SD was 7 years old, she and her younger siblings were removed from their biological mother and spent the next 4 years living in foster care. By fifth grade, SD had attended five diﬀerent schools and was exposed to Puerto Rican Spanish, African-American English, Spanish-influenced English, and code-switching, but had minimal exposure to Standard American English. At the age of 11, SD was adopted by two university professors. Standard American English was spoken at home and at school.

Shortly after adopting SD, her mother expressed concerns regarding her processing skills, as well as her expressive and receptive language. Specifically, she worried about SD’s vocabulary development and verb conjugations. She reported that SD demonstrated diﬃculty in school with text comprehension. Her performance on state tests was in the very lowest range.

Approximately 1 year following her adoption (age 12), SD underwent a score-based speech and language evaluation employing standardized assessment tools. Her performance on the Recalling Sentences subtest, a test of knowledge of syntax of Standard American English, suggested “significantly disordered language.”

This evaluation employed test scores in isolation without considering language and dialect, educational history, or instability of her home environment. The parents referred SD to a university-based clinic to address these deficits. After reviewing the initial report, reevaluation was indicated to consider SD’s sociolinguistic background and prior life experiences as well as linguistic and academic progress since initial evaluation.

of academic content. She noted that when SD first arrived at her new school as a sixth grader, she was hesitant to speak up when she did not understand something. Since then, though, SD’s teacher described “so much progress” and “great strides in writing.”

To examine SD’s acquisition of syntax, the Crowley and Baigorri School-age Language Assessment Measures (SLAM) subway assessment was administered (▶ Video 16.2). sented with a picture of a man whose shoe was caught in the subway door and posed with questions to elicit complex sentence structures and personal narrative. SD demonstrated ageappropriate ability to follow a line of questions, integrate and

Video 16.1 The teacher interview. SD’s seventh-grade teacher shares her perspective on the academic progress SD made since arriving at her new school.

SD was pre-

16.3 Clinical Assessment and Evaluation

In addition to an in-depth parent interview, SD’s primary seventh-grade teacher was interviewed (▶ Video 16.1). In addition, SD was observed in the classroom and samplings of recent schoolwork were obtained and reviewed. SD’s teacher previously worked in the inner city where SD grew up, making her a particularly reliable source of information. She explained that SD’s greatest weaknesses were vocabulary and comprehension

Video 16.2 Clinical interactions with the student. Two clips of the student responding to assessment questions during the author’s administration of her language evaluation.

Disorder, Diﬀerence, or Gap? A School-Age Disability Evaluation

organize her thoughts, and express these ideas employing appropriate Standard American English grammatical structure. For example,

Evaluator: What happened? SD: There was probably a big crowd and he didn’t get out, so

then his foot got stuck.

Evaluator: Did this ever happen to you?

SD: Almost. When we were going back to the apartment, it happened to my mom because she was swiping it the wrong way.

Evaluator: What would you do if this happened to you?

SD: I would probably start yelling. I know it would hurt.

As noted in the sample, SD had acquired many features of Standard American English. She used modal and conditional tenses (“I would probably” and “It would hurt”), Standard American English noun–verb agreement (“we were”), copula and auxiliary "be" forms (“there was” and “she was swiping”), and complex sentences including causation and temporal elements (“when,”“so then,”“because,” and “I know [that]”).

Review of the prior score-based evaluation revealed that SD fully acquired all aspects of Standard American English dialect over the past 18 months and considerable expansion of vocabulary. This information provided longitudinal information regarding language acquisition. For example, she described

thing to remember where you were, something precious to someone who got it”;a“committee” as “a whole group of people in deciding what to do”;a“negotiation” as “trying to work something out”;a“decade” as “a very long time”; and “award”

ou achieved in something, a reward, you get an award to

as “y show your eﬀort.” Her mother indicated that the family worked together building vocabulary with SD and her sister at breakfast and there is considerable focus in school as well.

Additionally, SD demonstrated metalinguistic understanding of language and an ability to use language to solve problems, make inferences, and compare and contrast. Further evidence of her linguistic skills included her quick understanding of humor and her ability to follow complex plots and character development in ongoing television shows (▶ Video 16.3).

Video 16.3 The parent interview. SD’s mother shares with the evaluator that SD is able to follow complex plots and character development in ongoing television shows.

16.4 Questions and Answers for the Reader

1. Why was the teacher interview part icularly salient in the diﬀerential diagnosis?

a) SD’s teacher is a close friend of SD’s adoptive family and has

had the opportunity to witness SD’sbehaviorandinteractions both in school and in informal, familial settings.

b) SD’s teacher herself is from the same linguistic back-

ground as SD and, therefore, can provide insight into whether SD’s communication represents a language difference or a true disorder.

c) SD’s teacher had done extensive linguistic research, look-

ing at dialectal diﬀerences between Spanish-influenced English, African-American English, and Standard American English and brings an important knowledge base to SD’s case.

d) SD’s teacher previously taught in the inner city where SD

grew up and, therefore, could provide information about how SD compared to other children of her same cultural and linguistic background.

Answer: d is correct. Because SD’s teacher had taught in the same community where SD grew up, she had an understanding of SD’s academic and linguistic experiences leading to more valid and reliable responses to the author’s questions.

a is incorrect. Because the teacher knew SD from school over the past 2 years, the teacher knew the family, but did not have a relationship with the family outside of school.

b is incorrect. SD’s teacher is a monolingual speaker of Standard American English. While she has insight into whether SD has a language diﬀerence or a language disorder, she is not from the same linguistic background.

c is incorrect. SD’s teacher did not do academic research on diﬀerent dialects of American English. However, as a result of her prior experience teaching in the diverse inner city where SD grew up, she was able to identify basic characteristics of Spanish-influenced English and African-American English.

1. Why did SD’s understanding of long-running television

shows with complex plots and characters influence the author’s conclusions?

a) SD’s watching television takes away from time when she

should be working to fill academic gaps through reading comprehension practice.

b) These skills demonstrate strong cognitive skills and

strong cohesive syntactical skills, as she used noun phrases and complex sentences to describe the stories.

c) SD is able to hear the television from a far distance, sug-

gesting that her hearing is within normal limits.

d) The characters in the television shows that SD watches

have diverse dialects of American English, which may be slowing the rate of her acquisition of Standard American English.

e) SD’s ability to follow complex plots in television shows

but not in novels suggests that her deficits are a result of a true language disorder.

Answer: b is correct. An understanding of complex plots and character development requires the ability to analyze, compare,

Disorder, Diﬀerence, or Gap? A School-Age Disability Evaluation

synthesize, problem solve, make inferences, make meaningful predictions, and other academic language skills. SD’s ability to express these concepts syntactically indicated high-level academic language skills.

a is incorrect. SD’s ability to describe plots and character development in complex, ongoing television shows provided another piece of evidence that her language skills were age appropriate and that her issues were related to academic gaps only.

c is incorrect. The information learned about SD’s language skills that related to her television watching did not relate to her hearing.

d is incorrect. There is no evidence that hearing diﬀerent dialects on a television show would slow the rate of her acquisition of Standard American English.

e is incorrect. Information from the parent about SD’s understanding of the television shows was especially valuable because it isolated SD’s language skills from her academic gaps. While weak language skills can aﬀect reading comprehension, in this case, SD demonstrated strong academic language skills, thereby oﬀering further evidence distinguishing a language disorder from pure academic gaps.

1. What conclusion can we draw from SD’s rapid acquisition of

Standard American English in the 18 months she was in her new school prior to speech-language evaluation? a) SD had previous exposure to Standard American English

in previous academic settings and home environments.

b) SD has a strong facility to acquire language and under-

stand metalinguistics.

c) SD’s new school has enabled her to be able to correct

the grammatical mistakes of her previous speech and language.

d) SD did a great deal of preparation for her subsequent eval-

uation, engaging in rigorous study sessions both at school and at home, to memorize the features of Standard American English.

e) SD actually did not acquire Standard American English,

supporting that she does have a true language disorder, in addition to language diﬀerences and academic gaps.

Answer: b is correct. SD’s ability to use modal and conditional tenses, Standard American English noun–verb agreement, copula and auxiliary "be" forms, and complex sentences including causation and temporal elements indicates that she rapidly acquired Standard American English in the 18 months she was in her new school. A student with severe language impairment, or even mild language impairment, would not demonstrate this level of linguistic and metalinguistic competence, especially after only such a short period of exposure to the new dialect.

a is incorrect. Prior to being adopted by her current parents, SD was exposed to Puerto Rican Spanish, African-American English, Spanish-influenced English, and code-switching, but had minimal exposure to Standard American English. Therefore, her acquisition of Standard American English cannot be attributed to prior exposure to the dialect.

c is incorrect. During SD’s initial speech and language evaluation, she did not exhibit “grammatical mistakes,” but rather language and dialect diﬀerences that represent characteristics of

rule-governed systematic dialects of American English. SD’s new school and home environments provided her with the exposure to Standard American English that she needed to acquire features of the dialect; it was not a matter of “correcting grammatical mistakes.”

d is incorrect. SD did not “prepare” or “study” for her second speech-language evaluation. Rather, she spontaneously acquired the features of Standard American English with adequate exposure to the dialect, which supports that she has the facility to learn language. The outcome of SD’s that SD previously lacked exposure to Standard American English, the sole dialect that was taken into account during that initial evaluation.

e is incorrect. SD’s performance revealed that she fully acquired Standard American English in the 18 months that she was exposed to it across all parameters of language, including syntax, morphology, semantics, and pragmatics.

1. What is one reason the private clinician who performed SD’s

first speech-language evaluation incorrectly diagnosed SD as having severe language impairment?

a) The clinician violated IDEA 2004, the Federal law on

special education, by relying on standard scores in a test

that was significantly biased against SD. b) SD did not cooperate fully with the evaluation. c) The clinician did not use a more appropriate standardized

test to diagnose SD. d) As a clinician in a private practice, the speech-language

pathologist did not have much experience with speakers

of dialects other than Standard American English and

should not be expected to know about other dialects. e) The clinician administered the test in Standard American

English but took into account SD’s language and dialect

acquisitional history.

Answer: a is correct. IDEA 2004 specifically states that evaluation materials cannot be racially or culturally biased. By failing to consider SD’s background, the evaluator came up with a diagnosis that was wrong, derived from seriously biased test materials. Evaluation materials that do not take into account a student’s cultural or linguistic background violate IDEA 2004, the Federal law on special education, as well as sound assessment procedures.

b is incorrect. Nothing in the evaluation indicated that SD

failed to cooperate.

c is incorrect. It is true that the clinician did not use an appropriate standardized test. But it is also unlikely that any standardized test exists that can take into account the impact of SD’s prior experiences, including the multiple changes in homes and schools, and the shifts in exposure between Spanish and English including several diﬀerent dialects of English.

d is incorrect. Although the clinician who did the pr ivate speech-language evaluation probably mostly sees speakers of Standard American English, a professional must be able to provide culturally and linguistically appropriate evaluations for all.

e is incorrect. Nothing in the initial score-based evaluation indicated that the evaluator took into account SD’s language and dialect acquisitional history. Failure to do so resulted in a seriously flawed diagnosis.

initial evaluation reflects

Disorder, Diﬀerence, or Gap? A School-Age Disability Evaluation

16.5 Diﬀerential Diagnosis

Upon review of both prior and current assessment, it was determined that SD presented with academic deficits as well as language diﬀerences, but certainly not a disorder or disability. SD demonstrated age-appropriate syntactic structures in Standard American English acquired, indicating a high level of language skills. She also demonstrated age-appropriate semantic knowledge through precise def initions of grade-level vocabulary words. Moreover, SD acquired metalinguistic skills and gradelevel academic language skills in her ability to make inferences, compare and contrast, analyze and synthesize complex ideas, and solve problems.

16.6 Recommended Treatment and Outcome

SD’s current school and teacher provided a stimulating environment, which was likely contributory to SD’s progress toward academic success. To supplement the exposure to high-level vocabulary at school, SD’s parents were encouraged to introduce new words into structured discussions meaningful to SD. To allow SD to maintain and express her diverse cultural identity, her parents were advised not to limit SD to speaking only Standard American English at home with her siblings. This diversity of language was thought to allay her concerns that she would “become white” when she “speaks white,” and support an additive model for continued acquisition of the new dialect.

16.7 Key Points

●

Diﬀerential diagnosis in speech and language requires more than measuring and reporting scores. Evaluators should consider influences of the student’s language and dialect acquisitional history in the analysis of linguistic abilities and have

knowledge of the variability and influences of morphology and syntax across those dialects and languages.

●

Parent and teacher interviews oﬀer valuable information about the student’s abilities across contexts.

●

Informed clinical opinion and direct observations are critical to gather evidence and gain a more holistic understanding of the student’s strengths and weaknesses.

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Remain up-to-date on the research and best practices for culturally and linguistically appropriate evaluations.