I supervise multiple Speech Pathologists with entry to advanced levels of experience at any given time. They are vibrant, intelligent, capable therapists and they adore treating their clients. They are successful. But when it comes to evaluating a new client, the majority of those super SLP’s will exhibit hesitation. Even when given extensive birth and developmental information and/or other professional opinions, the question of whether they are able to diagnose comes to the foreground. They are generally less anxious about kids with probable articulation and language disorders. Yet when presented with a child given characteristics of autism, apraxia, dysarthria, cerebral palsy, and feeding disorders to name a few, they doubt themselves and their training. I hear the same questions, “What test should I use?” ” What should I do if the kid will not sit down?” “How am I supposed to evaluate an 18 month old?” ” What should I do with a child with a diagnosed sensory processing disorder.” I’ve seen more than one evaluation during which both the parents and the therapist looked like “deer in headlights.”
Why? From what I’ve observed (and experienced) it directly relates to the fact that we are generally taught to administer standardized assessments to diagnose communication disorders.The majority of Speech Pathologists I know have no problem pulling out a standardized articulation or language test and giving it. It is short and sweet. It has norms. It’s easy. It takes the leg work out of diagnosis; the expert researchers did it for you. Insurance companies want scores, school districts want scores. We have a list of articulation tests to choose from that we score in order to obtain a diagnosis . Once we have a diagnosis, we can pick from thousand books with therapy activities to treat. We pick random worksheets, for example, from said “R” treatment books and away we go.
But is a score always valid? Can a child perform within normal limits and still be communicatively impaired? Does a generic activity from a workbook garner results? We’ll come back to those questions.
But first, what about other disorders, those we were thought to think of as the Mt. Everest’s of the evaluation process? Increasingly, our clients are not easy. When I was in graduate school the incidence of autism was 1 in 1500 live births, today it is 1 in 96. Communication disorders on the whole are on the rise.For most therapists, evaluating “those” kids is daunting. Why? Because there is no fail safe approach. There is no standardized test. Diagnosis involves skilled observation, parent interview, and interdisciplinary chit chat. The speech therapist is called to use all of her (his) clinical training to pull forth a valid communication diagnosis. You have to know the right questions to ask. It is not short and sweet.
A working knowledge of play skill developmental norms, oral motor norms, global language skills, etc is imperative. You may be able to use a checklist or test, but you must know if it is it normed and valid. And if it is not the clinical data you have obtained should specifically outline strengths and challenges of your client in relation to the expectations of a child their chronological age (there are some exceptions). Remember that even a popular and widely available standardized test doesn’t guarantee its validity. Sorry to burst your comfort bubble, but its true. I can tell you which tests score high and those that score low, those that have no inter-rater reliability. Don’t know what that is? If not you should. Challenge yourself to “can” the “easy button” and help your client from Day One with a valid diagnosis. A valid diagnosis will drive ethical best practices treatment.
Great diagnosticians know developmental norms. They observe whole bodies, not just the mouth. They and look and listen. I am not saying a therapist who uses a standardized tool is bad. I’m not suggesting Master’s Level SLP programs are turning out inadequate therapists. I applaud the level of training we receive. After 75 graduate hours we better have it! Our intense training covers the nature of speech, language, hearing, and communication disorders and differences; and (in most programs) swallowing disorders. We can recite the etiologies, and characteristics whether anatomical/physiological, acoustic, psychological, developmental, and/or linguistic or cultural in nature.
We eat and breathe:
- articulation
- fluency
- voice and resonance, including respiration and phonation
- receptive and expressive language (phonology, morphology, syntax, semantics, and pragmatics) in speaking, listening, reading, writing, and manual modalities
- hearing, including the impact on speech and language
- swallowing (oral, pharyngeal, esophageal, and related functions, including oral function for feeding; orofacial myofunction)
- cognitive aspects of communication (attention, memory, sequencing, problem-solving, executive functioning)
- social aspects of communication (including challenging behavior, ineffective social skills, lack of communication opportunities)
- communication modalities (including oral, manual, augmentative, and alternative communication techniques and assistive technologies)
We must complete a minimum for 400 clock hours of supervised clinical experience in the practice of speech-language pathology before getting certified.
Whew! Like you, I got theory up the wazoo in grad school. But the bridge between theory and practice was left up to me. I had no professors give me a tried and true treatment plan for any disorder I now treat. Most persued research and taught both their own work and the work of various other researchers, those they liked at least. Those they disagreed with either were left out or discredited.
We were exposed to a variety of treatment settings, approaches, and therapists in our practicums and CFY’S. Some of you had great mentors, others did not. I was lucky enough to have a professor that refused to leave her hospital position and taught in her “spare time.” She was always full of “secrets to therapy success” and for lack fo a better way to state it, was “diagnosis happy.” She emphasized looking versus listening, using both observation and standardized assessments, and insisted upon individualized treatment plans. The more involved the client, the more energized she became. That I’ve been told is the exception rather than the rule.
But even given my intense diagnostics training, I fell back on standardized tests my first several years in the field! I doubted my skills and my confidence as a therapist was taxed when asked to perform evaluations. Most SLP’s use a “cookbook” approach to diagnostics and treatment. Perhaps its because the bridge from theory into practice is tough. We know definitions, we know characteristics. And then we are faced with a precious human being and his/her family. We are not only a diagnostician and a support, we can be a source of hope or of angst. Given the level of engagement it is understandable that we err on the side of what we have been taught is valid. We pull out the flip book, the crads, the worksheet. We take the road always taken.
Standardized assessments when valid, although essential for their breadth of research information, have their limitations. If as a Speech Therapist you can not evaluate a child without a flipbook or checklist in front of you, you will be limited in your diagnostic capability. Believe me when I say learning to look, listen, compare, and collaborate will liberate you and make you an expert diagnostician and treatment specialist.
As a community of SLP’s, we must adjust our methods of evaluation and treatment. Revel in the fact that you can learn more about a client by observing them, by listening and looking, in 30 minutes than in multiple hours of standardized testing. Stop frantically transcribing what you hear into a protocol( while questioning if your phonetics are accurate) and start looking at your kids. Know your developmental norms, oral motor norms, and consult with Physical Therapists, Occupational Therapists, and Nutritionists about what to expect at any given age and use that as a comparative norm.Learn the latest treatment methods. Challenge what you know daily. By stepping outside the box you will become the expert.
Your first Challenge:
Think “outside of the box” with the following client.
” Johnny,” age 12, exhibits an “r” distortion in connected speech. He can achieve an auditorially sound “r’” in the initial position of words only. He has received speech therapy for the last five years, twice weekly for thirty minutes.
He is new to your school / practice and is expressing a profound distaste for ongoing therapy. With encouragement he agrees to undergo one last “evaluation” to help him understand why he cannot produce an “r.”
Do you :
A) Call his parents and dismiss him from your caseload because he “is lazy” and unwilling to do the necessary drills
B) Perform an Oral Motor Assessment looking at function/ strength related to speech production of “r”
C) Assess jaw height in relation to position needed for accurate “r” production
D) Continue with auditory discrimination/ placement drills based on multiple prior standardized assessment results
E) Re-administer your preferred standardized articulation assessment
Let me know what you would do!
Subscribe to the newsletter for tried and true tips related to this case!
