Resource: Specifics About Speech-Language Assessments for Internationally Adopted Children

Bilingual speech therapist, Tatyana Elleseff, MA, CCC-SLP, has produced four, in-depth blog posts at smartspeechtherapy.com about screening for and differentiating among common disorders of internationally adopted children.

Every prospective adoptive parent and adoptive parent should read these entire posts to self-assess their child and to discuss the specific tests with their school or therapist, if necessary.

Early Speech-Language Assessment

The full post is at A case for early speech-language assessments of adopted children in the child’s birth language [2/23/11]

Specific steps excerpted below:

For children ages 0-3:

“Depending on a country, the youngest age children become available for adoption is 7-9 months and depending on length and complexity of the adoption process, may become legally adopted by 12 months of age or older. My first concern with this group (+/-1 – 3 years) is the child’s feeding and swallowing abilities. Difficulties may range from immature feeding skills (e.g., immature chewing abilities) to a more severe failure to thrive, to even structural or functional deviations of the swallow mechanism, which may require detailed imaging tests and subsequent dysphagia therapy. In some rare instances, more serious discoveries were made during those initial speech and language assessments such as presence of vocal webs and submucous clefts, conditions which actually required surgical intervention.

Another concern with this age range are the child’s speech and language abilities or I should say lack of thereof. In the case of younger children (15-18 months), the “red flag” is a complete absence of words, jargon, babbling or general lack of any sound production during both – their early development and the parent bonding pre-adoption period during which the parents intensively interact and communicate with the child. In older children (2.5-3 years of age) the “red flag” is the general absence of phrases and/or words in their birth language, which is a strong indication that assessment is merited.

Finally, with this age group, any form of abnormal social interaction should be thoroughly investigated. Many children who have resided in very deprived institutional environments may present with a pattern of autistic-type behaviors. In reaction to emotional trauma, loss of primary caregiver, isolation in hospital cribs, and lack of stimulation, some children may develop symptoms often found in autistic children and may exhibit limited communicative intent in the absence of speech (make limited gestures, vocalizations, eye contact, etc). As a result, an early speech and language assessment in conjunction with other testing (neurological, psychological, etc) may shed light on whether the child presents with a form of institutional autism or true autistic spectrum behavior.

Unfortunately, internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Knowing the above, oftentimes it is important to determine a degree of delay (severe vs. mild), and if it’s not that clear (especially if the child is under 3 years of age and the parents don’t speak the child’s birth language or are not familiar with typical developmental milestones) than a safer choice would be an initial speech and language assessment in the child’s birth language which can determine the type and degree of delay and make recommendations regarding the necessity of further services.

It is also important to highlight that a child’s mastery of the birth language is a good predictor of the rate of learning the new language. Many professionals make an error of assuming that internationally adopted infants and toddlers will not be affected by cross-linguistic interference because the children have just begun to learn the birth language at the time of adoption, before the attrition of birth language occurred. However, due to a complex constellation of factors, language delays in birth language transfer and become language delays in a new language. These delays will typically persist unless appropriate intervention is provided. For older children (3 years +), the delays will be very recognizable and will likely be part of the child’s adoption record but for younger children an early speech and language assessment may be the first step on the way to appropriate language remediation.”

For ages 3-16 years:

“(although it is important to note that most adopted older children will be in the range of 3-12 years, while adoption of children 12+ is somewhat less common).

Here, most speech and language delays will be more acutely pronounced and as a result far more recognizable. As mentioned above they will also probably be clearly documented in the child’s adoption records. With this age-range there are a number of concerns ranging from poor articulation to language delay to social pragmatic communication impairments.

So how do professionals and parents decide which child merits early assessment?

With regard to articulation, it’s important to keep in mind that if the child is limitedly intelligible in their birth language, they will continue making similar error patterns in English unless they receive appropriate intervention. So assessment is definitely merited.

Similarly, if at the time of adoption, a preschool or school age child presents with delayed language abilities in their birth tongue (e.g., inability to answer “wh” questions, speaking in phrases vs. sentences, etc) then no matter how quickly they will gain basic English proficiency, it is reasonable to expect that similar difficulty will be encountered in English with respect to academically based tasks. In other words they may gain basic skills fairly appropriately but then present with significant deficits acquiring higher level listening and speaking abilities required for long-term academic success.

Another reason why it’s important to assess a child in the birth language in the first few weeks post arrival has to do with their pragmatic language skills or the appropriate use of language. Pragmatic language ability is the ability to appropriately initiate conversations, maintain and terminate topics, appropriately narrate stories, understand jokes and sarcasm, interpret non-verbal body cues, all of which culminate into the child’s general ability to appropriately interact with others in a variety of social settings.

As mentioned above, many children who have resided in deprived institutional environments may present with a pattern of unusual social behaviors, be socially withdrawn, or present with poor ability to socialize with others. Thus, the longer is the period of time the child spends in the institutional environment the greater is the risk of social pragmatic deficits. Unfortunately, this important area of language often receives merely cursory attention.

To illustrate, in recent years I have assessed a number of adopted children, who were 5-7 years post adoption, and had never previously received any speech and language services. Once brought to US they quickly gained English language proficiency and did not seemingly present with any of the “red flags” described above.

The reason these children were referred for intervention so many years later was because “seemingly overnight” they developed numerous difficulties. Oh, they were still getting good grades and presented with adequate vocabulary skills. But both parents and educators were getting concerned that these children were acting very immature for their age, had problems socializing with other children, presented with difficulty understanding figurative language, could not understand non-verbal conversational and social cues, couldn’t coherently express their thoughts, and presented with significant difficulty understanding and retelling stories.”

“Interestingly, when questioned further, all interviewed parents revealed that the above difficulties had existed from the get-go albeit in a milder form in their child but in the presence of appropriate receptive and expressive skills these difficulties were not deemed worthy of assessment/ intervention. Had these children received early assessment when these problems were first noticed, the outcome (degree of impairment; duration of therapy) might have been entirely different.” [emphasis Rally]

“So, do all newly adopted children require early speech language assessments? Not, at all. However, understanding the “red flags” for each age group will be helpful for both parents and professionals when they make their decision to refer a newly adopted child for a an early speech-language assessment.

As always, if parents or related professionals would like to find more information on this topic, they should visit the ASHA website at www.asha.org and type in their query in the search window located in the upper right corner of the website.”

Observations of the Face and Mouth (Orofacial)

The full post is at Orofacial Observations of Internationally Adopted Children: Recommendations for Parents and Non-Medical Adoption Professionals [11/22/11]

Excerpt:
“Fact is that oftentimes internationally adopted children arrive to US with a host of undetected disorders and deficits. Lack of detection is further increased in children adopted from economically developing countries or from hard to access insular regional orphanages, where they may fail to receive consistent and appropriate medical care, or where overcrowded conditions coupled with staff shortages may cause for deficits to be missed or unrecognized.

Consequently, oftentimes it is the parent(s) who are the first individuals to observe something different or unusual regarding their child’s facial features, oral structures, or any other appearance anomalies.

While many parents, of course, are not professionally trained in recognizing physical signs and symptoms of serious disorders, it is important to note that detection of unusual features is not as difficult as it sounds.

Here are some basic guidelines:

Does your child’s face look symmetrical or do you see any obvious signs of weakness (paralysis) on either side of the face (particularly evident when the child smiles and one side of the face droops or doesn’t move).

Do you find that your child’s features look odd or unusual in any way? Examples may include, but are not limited to: unusually wide or narrow set eyes, unusually set ears, virtual absence of a nose bridge, excessively thin upper lip, flatness of a groove above the lip, and so on (although with respect to facial appearance one needs to be very careful and account for differences in normal facial variation among various ethnic groups).

Do you notice any unusual spots, nodules, or openings on your child’s face or body or in his/her mouth?

In what condition is your child’s mouth? Is there excessive tooth decay? Do you see an unusual absence of teeth (in older children), or unusual bite (open bite, cross bite, etc)? Is there excessive drooling?

Does your child have a usual voice or unusual cough in the absence of a documented illness?

If you do, then it would be a good reason to consult with a pediatrician specializing in international adoptions, to see whether your observations merit a referral to a specialist (e.g., neurologist, orthodontist, etc).

I realize of course that parents are not trained professionals, but they are observant individuals! Moreover, there is a great likelihood that they are actually the first people to spend a prolonged period of time with the child. There’s an even greater likelihood that they are the first people to actually “see” the child vs. the orphanage staff who may have fulfilled the child’s basic needs (feeding, diapering, etc) but who in reality may have actually spent very little face to face time with the child.

Furthermore, parents should not worry whether something that may see may not be a cause of concern. What if it is and is not addressed? That is why it is so important to share your concerns with relevant medical professionals. It is up to them to investigate further whether your observations merit additional follow ups. If you are concerned, bring it up! You never know! You may paving the way to timely diagnosis and relevant intervention provision for your adopted child.

References:

• Golper, L (2009) Medical Speech Language Pathology: A Desk Reference. Clifton Park, NY: Delmar Cengage Learning
• Shipley, K, & McAfee, J (2008) Assessment in Speech Language Pathology: A Resource Manual. 4^th Ed. Clifton Park, NY: Delmar Cengage Learning”

Social Pragmatic Language Deficit

The post can be found at  What are social pragmatic language deficits and how do they impact international adoptees years post adoption? [3/14/11] and is pasted below:

“Scenario: John is a bright 11 year old boy who was adopted at the age of 3 from Russia by American parents. John’s favorite subject is math, he is good at sports but his most dreaded class is language arts. John has trouble understanding abstract information or summarizing what he has seen, heard or read. John’s grades are steadily slipping and his reading comprehension is below grade level. He has trouble retelling stories and his answers often raise more questions due to being very confusing and difficult to follow. John has trouble maintaining friendships with kids his age, who consider him too immature and feel like he frequently “misses the point” due to his inability to appropriately join play activities and discussions, understand non-verbal body language, maintain conversations on age-level topics, or engage in perspective taking (understand other people’s ideas, feelings, and thoughts). John had not received speech language services immediately post adoption despite exhibiting a severe speech and language delay at the time of adoption. The parents were told that “he’ll catch up quickly”, and he did, or so it seemed, at the time. John is undeniably bright yet with each day he struggles just a little bit more with understanding those around him and getting his point across. John’s scores were within normal limits on typical speech and language tests administered at his school, so he did not qualify for school based speech language therapy. Yet John clearly needs help.

John’s case is by no means unique. Numerous adopted children begin to experience similar difficulties; years post adoption, despite seemingly appropriate early social and academic development. What has many parents bewildered is that often times these difficulties are not glaringly pronounced in the early grades, which leads to delayed referral and lack of appropriate intervention for prolonged period of time.

The name for John’s difficulty is pragmatic language impairment, a diagnosis that has been the subject of numerous research debates since it was originally proposed in 1983 by Rapin and Allen.

So what is pragmatic language impairment and how exactly does it impact the child’s social and academic language abilities?

In 1983, Rapin and Allen proposed a classification of children with developmental language disorders. As part of this classification they described a syndrome of language impairment which they termed ‘semantic–pragmatic deficit syndrome’. Children with this disorder were described as being overly verbose, having poor turn–taking skills, poor discourse and narrative skills as well as having difficulty with topic initiation, maintenance and termination. Over the years the diagnostic label for this disorder has changed several times, until it received its current name “pragmatic language impairment” (Bishop, 2000).

Pragmatic language ability involves the ability to appropriately use language (e.g., persuade, request, inform, reject), change language (e.g., talk differently to different audiences, provide background information to unfamiliar listeners, speak differently in different settings, etc) as well as follow conversational rules (e.g., take turns, introduce topics, rephrase sentences, maintain appropriate physical distance during conversational exchanges, use facial expressions and eye contact, etc) all of which culminate into the child’s general ability to appropriately interact with others in a variety of settings.

For most typically developing children, the above comes naturally. However, for children with pragmatic language impairment appropriate social interactions are not easy. Children with pragmatic language impairment often misinterpret social cues, make inappropriate or off-topic comments during conversations, tell stories in a disorganized way, have trouble socially interacting with peers, have difficulty making and keeping friends, have difficulty understanding why they are being rejected by peers, and are at increased risk for bullying.

So why do adopted children experience social pragmatic language deficits many years post adoption?

Well for one, many internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Children in institutional care often experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which has long lasting negative impact on their language development including the development of their pragmatic language skills (especially if they are over 3 years of age). Furthermore, other, often unknown, predisposing factors such as medical, genetic, and family history can also play a negative role in pragmatic language development, since at the time of adoption very little information is known about the child’s birth parents or maternal prenatal care.

Difficulty with detection as well as mistaken diagnoses of pragmatic language impairment

Whereas detecting difficulties with language content and form is relatively straightforward, pragmatic language deficits are more difficult to detect, because pragmatics are dependent on specific contexts and implicit rules. While many children with pragmatic language impairment will present with poor reading comprehension, low vocabulary, and grammar errors (pronoun reversal, tense confusion) in addition to the already described deficits, not all the children with pragmatic language impairment will manifest the above signs. Moreover, while pragmatic language impairment is diagnosed as one of the primary difficulties in children on autistic spectrum, it can manifest on its own without the diagnosis of autism. Furthermore, due to its complicated constellation of symptoms as well as frequent coexistence with other disorders, pragmatic language impairment as a standalone diagnosis is often difficult to establish without the multidisciplinary team involvement (e.g., to rule out associated psychiatric and neurological impairment).

It is also not uncommon for pragmatic language deficits to manifest in children as challenging behaviors (and in severe cases be misdiagnosed due to the fact that internationally adopted children are at increased risk for psychiatric disorders in childhood, adolescence and adulthood). Parents and teachers often complain that these children tend to “ignore” presented directions, follow their own agenda, and frequently “act out inappropriately”. Unfortunately, since children with pragmatic language impairment rely on literal communication, they tend to understand and carry out concrete instructions and tasks versus understanding indirect requests which contain abstract information. Additionally, since perspective taking abilities are undeveloped in these children, they often fail to understand and as a result ignore or disregard other people’s feelings, ideas, and thoughts, which may further contribute to parents’ and teachers’ beliefs that they are deliberately misbehaving.

Due to difficulties with detection, pragmatic language deficits can persist undetected for several years until they are appropriately diagnosed. What may further complicate detection is that a certain number of children with pragmatic language deficits will perform within the normal range on typical speech and language testing. As a result, unless a specific battery of speech language tests is administered that explicitly targets the identification of pragmatic language deficits, some of these children may be denied speech and language services on the grounds that their total language testing score was too high to qualify them for intervention.

How to initiate an appropriate referral process if you suspect that your school age child has pragmatic language deficits?

When a child is presenting with a number of above described symptoms, it is recommended that a medical professional such as a neurologist or a psychologist be consulted in order to rule out other more serious diagnoses. Then, the speech language pathologist can perform testing in order to confirm the presence of pragmatic language impairment as well as determine whether any other linguistically based deficits coexist with it. Furthermore, even in cases when the pragmatic language impairment is a secondary diagnosis (e.g. Autism) the speech language pathologist will still need to be involved in order to appropriately address the social linguistic component of this deficit.

To obtain appropriate speech and language testing in a school setting, the first step that parents can take is to consult with the classroom teacher. For the school age child (including preschool and kindergarten) the classroom teacher can be the best parental ally. After all both parents and teachers know the children quite well and can therefore take into account their behavior and functioning in a variety of social and academic contexts. Once the list of difficulties and inappropriate behaviors has been compiled, and both parties agree that the “red flags” merit further attention, the next step is to involve the school speech language pathologist (make a referral) to confirm the presence and/or severity of the impairment via speech language testing.

When attempting to confirm/rule out pragmatic language impairment, the speech language pathologist has the option of using a combination of formal and informal assessments including parental questionnaires, discourse and narrative analyses as well as observation checklists.

Below is the list of select formal and informal speech language assessment instruments which are sensitive to detection of pragmatic language impairment in children as young as 4-5 years of age.

1. Children’s Communication Checklist-2 (CCC–2) (Available: Pearson Publication)
2. Test of Narrative Development (TNL) (Available: Linguisystems Publication)
3. Test of Language Competence Expanded Edition (TLC-E) (Available: Pearson Publication)
4. Test of Pragmatic Language-2 (TOPL-2) (Available: Linguisystems Publication)
5. Social Emotional Evaluation (SEE) (Available: Super Duper Publication)
6. Dynamic Informal Social Thinking Assessment (www.socialthinking.com)
7. Social Language Development Test -Elementary (SLDT-E) (Available: Linguisystems Publication)
8. Social Language Development Test -Adolescent (SLDT-A) (Available: Linguisystems Publication)

It is also very important to note that several formal and informal instruments and analyses need to be administered/performed in order to create a complete diagnostic picture of the child’s deficits.

When to seek private pragmatic language evaluation and therapy services?

Unfortunately, the process of obtaining appropriate social pragmatic assessment in a school setting is often fraught with numerous difficulties. For one, due to financial constraints, not all school districts possess the appropriate, up to date pragmatic language testing instruments.

Another issue is the lack of time. To administer comprehensive assessment which involves 2-3 different assessment instruments, an adequate amount of time (e.g., 2+ hours) is needed in order to create the most comprehensive pragmatic profile for the child. School based speech language pathologists often lack this valuable commodity due to increased case load size (often seeing between 45 to 60 students per week), which leaves them with very limited time for testing.

Further complicating the issue are the special education qualification rules, which are different not just from state to state but in some cases from one school district to the next within the same state. Some school districts strictly stipulate that the child’s performance on testing must be 1.5-2 standard deviations below the normal limits in order to qualify for therapy services.
But what if the therapist is not in possession of any formal assessment instruments and can only do informal assessment?

And what happens to the child who is “not impaired enough” (e.g., 1 SD vs. 1.5 SD)?

Consequently, in recent years more and more parents are opting for private pragmatic language assessments and therapy for their children.

Certainly, there are numerous advantages for going via the private route. For one, parents are directly involved and directly influence the quality of care their children receive.

One advantage to private therapy is that parents can request to be present during the evaluation and therapy sessions. As such, not only do the parents get to understand the extent of the child’s impairment but they also learn valuable techniques and strategies they can utilize in home setting to facilitate carryover and skill generalization (how to ask questions, provide choices, etc).

Another advantage is the provision of individual therapy services in contrast to school based services which are generally attended by groups as large as 4-5 children per session. Here, some might disagree and state that isn’t the point of pragmatic therapy is for the child to practice his/her social skills with other children?

Absolutely! However, before a skill can be generalized it needs to be taught! Most children with pragmatic language impairment initially require individual sessions, in some of which it may be necessary to use drill work to teach a specific skill. Once the necessary skills are taught, only then can children be placed into social groups where they can practice generalizing their skills. Moreover, many of these children greatly benefit from being in group or play settings with typical peers and/or sibling tutors who may facilitate the generalization of the desired skill more naturally, all of which can be arranged within private therapy settings.

Yet another advantage to obtaining private therapy services is that there are some private clinics which are almost exclusively devoted to teaching social pragmatic communication and which offer a variety of therapeutic services including individual therapy, group therapy and even summer camps that target the improvement of pragmatic language and social communication skills.

The flexibility offered by private therapy is also important if a parent is seeking a specific social skills curriculum for their child (e.g., “Socially Speaking”) or if they are interested in social skill training that is based on the methods of specific researchers/authors (e.g., Michelle Garcia Winner MACCC-SLP; Dr. Jed Baker PhD, etc), which may not be offered by their child’s school.

There are many routes open for parents to pursue when it comes to their child’s pragmatic language assessment and intervention. However, the first step in that process is parental education!

To learn more about pragmatic language impairment please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find a professional specializing in assessment and treatment of pragmatic language disorders in your area please visit http://asha.org/proserv/.

References

Adams, C. (2001). “Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder.” International Journal of Language and Communication Disorders 36(3): 289-305.

Bishop, D. V. (1989). “Autism, Asperger’s syndrome and semantic-pragmatic disorder: Where are the boundaries?” British Journal of Disorders of Communication 24(2): 107-121.

Bishop, D. V. M. and G. Baird (2001). “Parent and teacher report of pragmatic aspects of communication: Use of the Children’s Communication Checklist in a clinical setting.” Developmental Medicine and Child Neurology 43(12): 809-818.

Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autism, 3, 371–396.[

Brackenbury, T., & Pye, C. (2005). Semantic deficits in children with language impairments: Issues for clinical assessment. Language, Speech, and Hearing Services in Schools, 36, 5–16.

Burgess, S., & Turkstra, L. S. (2006). Social skills intervention for adolescents with autism spectrum disorders: A review of the experimental evidence. EBP Briefs, 1(4), 1–21.

Camarata, S., M., and T. Gibson (1999). “Pragmatic Language Deficits in Attention-Deficit Hyperactivity Disorder (ADHD).” Mental Retardation and Developmental Disabilities 5: 207-214.

Ketelaars, M. P., Cuperus, J. M., Jansonius, K., & Verhoeven, L. (2009). Pragmatic language impairment and associated behavioural problems. International Journal of Language and Communication Disorders, 45, 204–214.

Ketelaars, M. P., Cuperus, J. M., Van Daal, J., Jansonius, K., & Verhoeven, L. (2009). Screening for pragmatic language impairment: The potential of the Children’s Communication Checklist. Research in Developmental Disabilities, 30, 952–960.

Miniscalco, C., Hagberg, B., Kadesjö, B., Westerlund, M., & Gillberg, C. (2007). Narrative skills, cognitive profiles and neuropsychiatric disorders in 7-8-year-old children with late developing language. International Journal of Language and Communication Disorders, 42, 665–681.
Rapin I, Allen D (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). : Academic Press”

ADHD vs. Auditory Processing Disorder

The post can be found at Differential Diagnosis of AD/HD and Auditory Processing Disorders in Internationally Adopted School Age Children [6/6/11] and is pasted below:

“Scenario: Corinne is an adorable 8 year old girl with an infectious smile, who has been adopted from Russia at the age of 15 months. She sits quietly by the bookshelf; completely absorbed by the book in her lap, while her distraught mother is quietly telling me in the hallway why Corinne has come to visit me today. Corinne has numerous listening difficulties. She is very inattentive and frequently mishears verbal messages. She is very distractible and tends to act impulsively at home and in school. She has trouble organizing her verbal output when speaking and is constantly forgetting what has been told to her, even if it was only moments ago. Corinne has never had a speech and language assessment before, but she does have a documented diagnosis of ADHD, for which she is currently taking medication. The trouble is that this medication does not seem to be helping Corinne one bit. She is just as distractible, impulsive and inattentive as she was before. Not only that, but this is not the first medication or the lowest dosage that Corinne has been taking for her ADHD. According to Corinne’s mother, Corinne’s medications and dosages have been adjusted multiple times by several doctors, but so far it hasn’t really affected anything. Corinne’s parents’ are at their wit’s end! Corinne is desperately struggling with her studies despite working very hard and getting a lot of help at home, but she is doing so poorly – that her school has been hinting very strongly that Corinne ought to be held back in 3rd grade.

Sadly, Corinne’s case is far from unique. The incidence and prevalence of AD/HD (the slash is used to denote both subtypes with and without the hyperactivity component) in internationally adopted children is very high and continues to be on the rise.

What further complicates the situation is lack of valid statistical data. At this time there are no reliable statistics to cite! However, parents of internationally adopted children and those professionals who work with this unique population know just how frequently this label is used. AD/HD prevalence in internationally adopted children is so highly alarming that it begs a number of important questions:

• “What criteria are currently used for diagnosing AD/HD in internationally adopted children?”

• “Are other disorders with similar symptoms being ruled out before the diagnosis of AD/HD is made?”

Attention Deficit/Hyperactivity Disorder is one of the most commonly diagnosed disorders of childhood. As a speech language pathologist, who works in a pediatric psychiatric hospital setting, I see many children, including a large number of internationally adopted children, who have the diagnosis of AD/HD in conjunction with other comorbidities including psychiatric disorders as well as speech-language and learning deficits.

However, after the initial screening and assessment period when these children are seen by our multidisciplinary team (psychiatrist, psychologist, nurse, occupational and speech therapists, as well as a learning specialist) in a number of cases, the AD/HD diagnosis is ruled out.

It is very important to understand that the core symptoms of AD/HD: inattention, hyperactivity, and impulsivity are also the core symptoms in a variety of other disorders, which need to be ruled out in order for the diagnosis of AD/HD to be confirmed with reasonable accuracy.

The above “core symptoms” are observed in a number of disorders:

• Sensory Processing Dysfunction

• Auditory Processing Disorder

• Mental Retardation

• Hearing Deficits

• Mood Disorders

• Sleep Disorders

• Seizure Disorders

• Acquired Traumatic Brain Injury

• Autistic Spectrum Disorders

• Language Disorders

• Nonverbal Learning Disorder

• Yeast Overgrowth

And this list is by no means exhaustive.

Since I am a speech language pathologist, in this article I would like to focus on a diagnosis that is most frequently mistaken or may co-occur with AD/HD, which is auditory processing disorder (APD), also referred to as Central Auditory Processing Disorder (C/APD).

Auditory Processing Disorder (APD) is technically not one disorder but a number of disorders, which affect the processing and use of auditory information at the level of the Central Nervous System (CNS). A child with APD has normal hearing but has trouble recognizing, processing and/or interpreting auditory information.

The reason why it’s not just a name for one disorder is because according to the 2005 ASHA’s CAPD Technical Report, auditory processing difficulties may affect a number of abilities such as “sound localization and lateralization; auditory discrimination; [and/or] auditory pattern recognition.”

Additionally, the difficulties could be with the “temporal aspects of audition, including temporal integration, temporal discrimination (e.g., temporal gap detection), temporal ordering, and temporal masking; auditory performance in competing acoustic signals (including dichotic listening); and auditory performance with degraded acoustic signals” (ASHA, 2005, CAPD Technical Report).

These technical terms translate into some of the following auditory processing difficulties for the child:

1. Difficulty processing auditory information efficiently

a. Child may require increased processing time to respond to questions

b. Child may present like they are ignoring the speaker

c. Child may request the speaker to repeat presented information several times

d. Child may not be able to follow long sentences

e. Child will have difficulty keeping up with class discussions in group settings

f. Child’s poor listening abilities under noisy conditions may be interpreted as “distractibility”

2. Difficulty maintaining attention on presented tasks

a. Frequent loss of focus

b. Difficulty completing assignments on their own

3. Poor Short Term Memory – difficulty remembering instructions and directions or verbally presented information

4. Difficulty with phonemic awareness, reading and spelling

a. Poor ability to recognize and produce rhyming words

b. Poor segmentation abilities (separation of sentences, syllables and sounds)

c. Poor sound manipulation abilities (isolation, deletion, substitution, blending, etc)

d. Poor sound letter identification abilities

e. Poor vowel recognition abilities

The combination of above factors may result in generalized deficits across the board, affecting the child’s social and academic performance:

• Poor reading comprehension;

• Poor oral and written expression

• Disorganized thinking (e.g., disjointed narrative production)

• Sequencing errors (recalling/retelling information in order, following recipes, etc)

• Poor message interpretation

• Difficulty making inferences

• Misinterpreting the meaning of abstract information

Auditory processing difficulties frequently coexist along with AD/HD. So a child may have both diagnoses AD/HD and APD. However, the child may also be accidentally misdiagnosed with one, instead of the other, or may even have a different diagnosis entirely, which is why a differential diagnosis is absolutely crucial!

How to initiate an appropriate referral process if you suspect that your school age child has auditory processing difficulties?

If your child is exhibiting any of the above mentioned symptoms, it is very important to address the cause of the problem. Even though AD/HD and APD may have similar core symptoms, the management of both disorders is quite different. Management of AD/HD may require a number of interventions including behavioral management, medication, and language therapy vs. APD which may require language intervention only, since behavior therapy and stimulant medications used to control AD/HD do not improve the symptoms of APD! (Tillary et al 2000)

The differential diagnosis of auditory processing disorder falls under the auspices of an audiologist. However, because many of AD/HD and APD symptoms overlap and manifest as language difficulties, before a referral to an audiologist is made, a speech language pathologist is often consulted first to determine the presence and/or extent of language difficulties that affect the child’s listening comprehension, short term memory, attention to verbal messages, and so on.

A speech language pathologist may also be consulted before the audiologist, if the symptoms in question pertain to a younger child (e.g., 4-5 years of age). Most auditory processing batteries can only be administered partially when a child is minimally 5 years of age (e.g., SCAN-3C; Pearson Publications) and comprehensively when a child reaches about 7 years of age, due to the differences in speed of brain maturation in children. In contrast, a speech language pathologist can determine much earlier if a child presents with difficulties which may later be diagnosed as APD. In fact one recent test that came out in 2010, the Auditory Skills Assessment (ASA), available from Pearson Publications, screens children as young as 3;6 years of age for early auditory and phonological skills.

As the result of the above guidelines, some parents have asked me in the past: “If an auditory processing disorder is suspected but only fully diagnosed at 7, does it mean that we have to wait until that age to confirm the diagnosis and only then initiate language therapy?” Absolutely not!

If the assessment indicates that intervention is merited, the speech pathologist can begin addressing specific deficits (e.g., understanding verbal messages, following complex directives, etc), long before the diagnosis of auditory processing disorder can be made, since our aim is to treat the presenting symptoms and not a specific label!

Furthermore, even after an audiologist confirms the presence of an auditory processing disorder, in the vast majority of cases, the child will be sent back to the speech language pathologist for treatment since treatment of auditory processing deficits falls under the auspices of a speech language pathologist.

Thus, early detection (e.g., ages 4-5) frequently facilitates successful treatment, remediation, and/or mitigation of symptoms. Early treatment may also decrease symptom severity (e.g., mild-moderate auditory processing disorder vs. severe auditory processing disorder) by the time the child is tested by an audiologist at an older age (e.g., age 8).

After the initial referral is made, and depending on the nature of deficits (e.g., attention, processing, phonological awareness, memory, etc) a speech pathologist may chose to use a number of language testing instruments, sensitive to various auditory processing components.
Below are just several of the popular screening and testing instruments which may be used by a speech language pathologist in order to determine whether a referral for a comprehensive auditory processing assessment battery with an audiologist is merited.

• The Listening Inventory (TLI) (2005) available from Academic Therapy Publications

• Differential Screening Test for Processing (DSTP) (2006)*

• Dynamic Screening for Phonological Awareness (DSPA) (2010)*

• Test of Auditory Processing Skills-3 (2005)**

• The Listening Comprehension Test-2 (LCT-2) (2006)*

• The Listening Comprehension Test Adolescent (LCT-A) (2009)*

• Phonological Awareness Test -2 (PAT-2) (2007)*

• Comprehensive Test of Phonological Processing (CTOPP) (1999)**

• Lindamood Auditory Conceptualization Test-3 (LAC-3) (2004)**

*Denotes instruments available from Linguisystems
** Denotes instruments available from multiple publishers such as Linguisystems, Pearson Publications, and/or Super Duper Publications

Please note that a speech language pathologist does not have to use the above tests in order to refer the child for an auditory processing assessment battery. He/she can select the testing subtests from a number of commonly used language testing instruments such as Clinical Evaluation of Language Fundamentals-4 or Test for Auditory Comprehension of Language-3 (Pearson Publications) in order to test the affected areas of difficulty (e.g., listening comprehension, following directions, etc).

So, the SLP will test the child’s language abilities in order to determine if their testing results are indicative of deeper auditory processing deficits. If they are, and the child’s age is appropriate, then the child will need to see an audiologist who will first perform a routine hearing test to rule out hearing impairment and then, if the hearing is normal, the audiologist will administer the auditory processing testing battery.

What is the role of audiologist in the assessment of auditory processing disorders?

• An audiologist is the ONLY professional who diagnoses auditory processing disorders.

• An audiologist is the ONLY professional who is responsible for describing auditory processing deficits diagnosed during the above assessment.

• The audiologist is EXPECTED to suggest treatment and management strategies for school and home accommodations, which are specific to the child’s unique deficits.

• An audiologist MAY provide auditory processing remediation to the child but TYPICALLY he/she will refer the child to a speech language pathologist for further treatment.

• Subsequent to receiving auditory processing intervention, the child will go back to the audiologist (usually after 1 year) in order to receive an auditory processing reassessment battery.

• The child may continue to receive yearly reassessments until the audiologist determines that further assessments/treatments are no longer necessary.

Audiological testing battery differs from speech language testing battery. Most audiological tests are administered in sound-proof booths and involve the attention and response to signals/tones in addition to attention and response to recorded words, word pairs, and sentences (in contrast to live voice) in the absence and presence of background noise. Based on presenting symptoms an audiologist will determine what combinations of tests need to be administered.

After testing is completed it is very important that parent request that the audiologist outline confirmed deficits, suggest treatment hierarchy with goals and objectives as well as make recommendations for school and home accommodations which will be specific to the child’s unique deficits.

This is especially important because much of the terminology used by audiologists may not be familiar to many school based speech language therapists much less parents who are attempting to interpret the report. Therefore, it is important that an audiologist clearly explain what the deficits are and what needs to be done.

This is necessary in order to avoid confusion regarding the meaning of terms as well as to avoid generalized and unnecessary interventions. For example, the deficits pertaining to term “tolerance fading memory” should be explained as difficulties with speech interpretation in the presence of background noise as well as difficulty with short term memory. Moreover, it is also important to caution parents that the generic recommendation of an FM system (frequency modulation system) is not applicable to all children with auditory processing deficits but only to those who have been accurately diagnosed with auditory sensitivity and/or auditory distractibility. Similarly, not all parents of children with auditory processing disorders need to rush out to purchase “Earobics” (www.earobics.com) or “Lindamood-Bell” (www.lindamoodbell.com) software programs especially because these phonological awareness programs and their levels of difficulty may not be necessarily applicable to many children with APD symptoms.

Parents should also be wary of recommendations heavily emphasizing specific costly software or remediation programs (to the exclusion of all other interventions), since not all recommendations are based on scientific research and evidence. Therefore it’s very important to research the efficacy and effectiveness of these products and programs on the ASHA (American Association of Speech Language and Hearing Science) website.

I also want to reemphasize again that even after the diagnosis of C/APD has been confirmed, it may be necessary to revisit the child’s remaining symptoms once more in order to reassess the continued applicability of AD/HD diagnosis and use of medications as well as to rule out the presence of additional comorbidities.

On such occasions, I have found that The Listening Inventory (TLI) screening instrument is a very helpful tool for making additional referrals. This questionnaire, which can be filled out by parents AND teachers in as little as 15 minutes, has the users rating the child’s difficulties in 6 areas: linguistic organization, decoding/language mechanics, attention/organization, sensory/motor, social/behavioral, and auditory processes. After all the statements are rated and the index scores are calculated, many parents are often surprised by the results. Oftentimes the difficulties they interpret as being social behavioral may actually be the result of sensory/motor impairments, which require an assessment by an occupational therapist.

This is why the multidisciplinary approach to identification, differential diagnosis, and management of disorders like AD/HD and/or C/APD is so important. Just one individual assessment, be it psychological, occupational, or audiological, CANNOT reliably determine accurate diagnosis to the exclusion of all others, especially when the diagnostic criteria is based on generalized symptomology (symptoms fit several diagnoses).

To learn more about auditory processing disorders please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find professionals specializing in assessment (audiologist) and treatment (speech language pathologist) of auditory processing disorders in your area please visit: http://asha.org/proserv/.

References

• American Speech-Language-Hearing Association. (2005). (Central) Auditory Processing Disorders [Technical Report]. Available from

www.asha.org/policy

.

• Lucker, J.R. (2007). History of Auditory Processing Disorders in Children. In D. Geffner and D. Ross-Swain, Auditory Processing Disorders for Speech-Language Pathologists San Diego: Plural Publishers.

• Tillery et al. (2000) Effects of Methylphenidate (Ritalin) on Auditory Performance in Children With Attention and Auditory Processing Disorders. Journal of Speech Language and Hearing Research 43, 893-901 “

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