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conflicting assessments: SLT v everyone else

32 replies

kissingfrogs · 08/02/2011 23:00

Dds latest SLT assessment today shows only minor language difficulties (vocab, auditory memory, word retrieval). Emphasis on minor.

We're awaiting another EP assessment. The last one a year ago showed significant gap beyween cognative and language abilty (eg verbal comprehension 5th percentile, non verbal reasoning 97th).

These new reports are going to make the difference between intervention and non intervention.

Other professionals (TOD, SENCO,SENCO co-ordinator, teachers) have all recognised that dd has a language difficulty which is not apparent until you get to know her as she is very clever at concealing it (being bright, using diversion tactics etc).

The SLT might think alls well because dd can answer basic questions like how old she is, her teacher's name, but dd can not grasp concepts (abstracts esp) because you can't verbally explain them without loosing her and u can't tell how much she understood because she can't hold a conversation. Minor? Dd isn't a toddler, she's in YR1. It's not flaming minor when your child says she doesnt like school because "I'm different, I talk different."

So, my question is: am i right in thinking that these SLT assessment procedures focus on grammar, vocab & phonology but do NOT recognise that though a child may be reasonably competent in these they still may have a language difficulty (semantics, pragmatics, conversational disability)?

If so, what assessments can they do to test this (on a 5.5yr old)?

OP posts:
lisad123isasnuttyasaboxoffrogs · 08/02/2011 23:05

we have a wonderful SALT who does pick up on these things, BUT I know not all do.
Do you have a SALT specialist in communication difficulties? We have one in our area but she deals with children with ASD, so not sure if they cover other areas too.
Have you discussed this with your salt?

kissingfrogs · 08/02/2011 23:19

The SLT was in two minds whether to refer to another SLT who has a specialism in language disorders, though agreed to do this. Is there a difference in one who specialises in language disorders and one who specialises in communication difficulties (or is the same thing and just a question of using different terminology)?

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kissingfrogs · 08/02/2011 23:33

This SLT has a specialism in hearing impairment. She said dds language was typical of mild-moderate hearing loss. In contrast, the senco co-ordinator of sensory team and dds teacher of the deaf (60+ yrs experience between them) said the exact opposite.
Confused

The lines: "in comparison with the children I usually see..." and "DD is very different to what I was expecting" made me think she came with certain preconceptions.

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wasuup3000 · 08/02/2011 23:41

Yep you need a specialist in whatever your child's difficulty is.
My son has ASD amongst other things - pre diagnosis we saw a general SaLT who's conclusion was mild delays and speech sound difficulties.
This affected the diagnosis by delaying it until we had other expert opinions.
A recent NHS ASD SalT has just recently told us that she disagrees with the general SaLT and agrees with CAMHS who made his diagnosis, after school obs and the ADOS test, on my request for a 2nd opinion as the paeds in our area are useless at listening to parents.
We wish that we knew that we could have asked for the specialist SaLT earlier.

kissingfrogs · 08/02/2011 23:53

It's all so frustrating isn't it?
The SLT said that dds word retrieval difficulties were due to lack of vocabulary. Yet, when she gave me examples, I pointed out that dd knows some of these words. So it might be a case of lack of vocab sometimes, but that doesn't account for words she definitely knows.

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working9while5 · 08/02/2011 23:54

Your daughter needs to be assessed using a formal standardised/psychometric assessment e.g. CELF-4 (5-8).

What assessment has been used?

goingroundthebend4 · 09/02/2011 06:26

yes ds was tested on the cleft scale recentley for receptive and expressive and it did show he has problems in receptive with concepts and even with simple things like tomorrow and yestersay in front of and behind

expressive well he never got of starting blocks as unable to test

but defintley need better salt its only since ican first tested him and now in speech unit as he ever been formley testsed

Talkingtot · 09/02/2011 09:16

As a parent - go with your gut feeling. Push for a 2nd opinion. Any decent SLT will should readily accept your wish for a 2nd opinion. As speech & language therapists we often only get snapshots of children and only rarely get the whole picture. Good luck. Lisa :-)

ArthurPewty · 09/02/2011 11:29

This reply has been deleted

Message withdrawn at poster's request.

TotalChaos · 09/02/2011 12:21

can relate to this, my 6 year old got discharged from NHS SALT over a year ago as he was testing within normal range (on CELF 4), even though IMO it wasn't picking up his conversational difficulties. Am going to get a private SALT opinion. Think there are other assessments, such as a pragmatics profile that can be done by SALT, know it's been discussed on here previously.

kissingfrogs · 09/02/2011 20:17

working had a Pre-School CELF last October. Showed scores within normal limits except sentence structure & recalling sentences (5 & 6 score). Yesterdays asessments were: TROG result 32nd percentile, RAPT result 3.5-4yr level, 9RWFT result 4.8yrs. Hence SLT verdict of minor difficulties.

These tests were done with picture stimuli. I'm wondering if the reason why dd does worse in real life (as opposed to doing a test under test conditions) is that
(a)conversation does not come with picture stimuli
(C) classroom is not 1-1 in a quiet room

also conversation is unpredictable, quick paced, requires ability to infer etc etc.

These tests show that dd should really not have as much of a problem as she does have. I'm baffled and feel like giving up. Dds teacher says to keep plugging on as she's sure one of these departments - EP, SLT will come up with some funding.

totalchaos it's disheartening isnt it. I too may go down the same road and try a private SLT, but for now I think I've had enough of these assessments.

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TotalChaos · 09/02/2011 20:24

Omg when i posted on here after ds was discharged from salt i posted word for word what you did about why i felt ds did so well at the tests! I have got hanen talkability book to go through which will hopefully help me work on social and convo skills. Shortly before ds was discharged from salt he went to group therapy to a narrative group which was v helpful as a lot of focus on question words

kissingfrogs · 09/02/2011 20:46

It's comforting to know that you can relate to my experiences and vice versa.
If it wasn't for dds teacher, TOD etc supporting me in getting recognition & help for dd I would be thinking I was an over anxious mother because these assessments do make me question my own judgement.

This raises the question: should these standardised SLT assessments be broader in scope, or more specific in certain areas, and should sub-tests be offered to explore discrepencies? What do the SLTs who work with these tests actually think about them? Do they have confidence that the results are conclusive and indisputable or do they see room for improvement?

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kissingfrogs · 09/02/2011 21:36

leonieDelt just read a previous post of yours re private assessment. Very interesting. I need to start saving!

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working9while5 · 10/02/2011 00:59

The procedure for all assessment is supposed to be that results are analysed with reference to function e.g. reports from people around the child, observation in settings etc.

Mostly, the tests are not that bad to be honest. There are a wide range of subtests on the CELF-4, for example, that are linked to research on which domains are most impaired in different disorders. It's a much more involved test than the Preschool CELF, actually, which really suffers from a lack of an extended speaking task (though this is not particularly fantastic on the CELF-4 either). There are adjusted norms for ASD and HI (you might want to check the relevant stats were used).

In terms of CELF-4 not picking up on conversational difficulties, there is no real reason it would. It is a language assessment, its purpose is not to analyse conversation. For a great many children, structural language will be impaired alongside conversation but in spectrum disorders this is not always the case (and isn't necessary for a spectrum diagnosis etc). If the CELF-4 assessment protocol was followed as per the manual, and combined with a full observation/consultation with other professionals etc and additional testing using other measures where appropriate, there shouldn't be an issue.

With reference to HI, it would make a lot of sense if there was a gap between performance on an assessment in a 1:1 with structure/visual support and "real life". I'm not a specialist in this area, but you might want to discuss pursuing assessment for auditory processing difficulties/disorder if results are "normal" in a quiet/structured environment. On the other hand the score in the RAPT is not that great if done at the age of 5! Don't accept age equivalents, only standard scores. A score of 5/6 on the subtest you mentioned is below the lower end of normal (range 7-12) so does indicate difficulties.

The other question you have to ask is what are school doing now about this? If the results are showing that she can perform quite well in 1:1 structured situations and/or with visuals, what visuals are they putting in place? How are they planning and differentiating schemes of work with reference to quality first teaching for all/targeted support for identified children? Have they identified what support they need from SLT with reference to this - ToD could certainly do this? Sometimes there can be a "wait and see" approach with reference to funding - but actually, that can be a non-issue. Say your daughter has a statement, tomorrow, with SLT twice a week.. she will still spend most of her time in class which is where a lot of the support needs to be, with appropriate adjustments made for full iclusion. A private SALT/second opinion from another NHS SALT looking solely at her performance in class/these issues identified by other professionals may help pick up areas where support could be more targeted/training could be offered, but even intensive 1:1 isn't going to necessarily make the difference you need it to. Not saying it wouldn't help, but if I were you, I would like to know what is being done NOW by those who identify her issues in class and how THEY are going to chase it up (vs leaving it up to you).

Unfortunately, many SLTs today do not have hands-on experience of this type with children and young people which can skew their understanding of how results "look" in real life. Many SLTs are expected to be educational consultants without having worked in schools on an ongoing/intensive basis and without compulsory training on literacy and the demands of the curriculum (though many do pursue this themselves). In a certain sense, many SLTs are not fit for purpose. God knows I wasn't when I qualified. I don't think I had even had adequate training on interpreting psychometric (standardised) assessments and only truly grasped the full implications at MSc level (and I got a first in my undergrad!).

In this country, the typical package of support for children with speech, language and communication needs doesn't mesh well with the potential of the profession. There is nowhere NEAR enough time to do an adequate assessment in most posts/roles - even doing a full CELF-4 is pushing it, let alone also observing and undertaking further measures as described above. We have weak follow-through by the professional bodies on this, who lay down guidelines on things like training/clinical supervision/caseload size but won't comment if you alert them to the fact that instead of a caseload of 60, you have one of 220! The NHS has all this stuff about "patient care" and "patient safety" and "improving patient experience" but commitment to actually meeting the evidence base is poor in terms of resourcing. There is a massive gap between research level evidence in SLT and what happens on the ground and it is nearly all resource based.

In reality in many clinical/school consultative posts, you get used to working a certain way and, actually, you can't offer intensive interventions even if you want to so you have to dilute. This affects your skill development. Again, behind the scenes, there are many campaigning for better.. but we are not seen as a priority in NHS organisations because - to put it bluntly - our clients won't die if we don't offer quality care.

There are so many issues.. but if your daughter needs help, persist.

I would also press for quite an indepth narrative assessment, something like the Strong Narrative Assessment Procedure (SNAP) to look at language structure in extended speaking tasks.

I will stop now, though I'm sure I could say more!

working9while5 · 10/02/2011 01:03

By the way, in an academic context, issues with vocab/auditory memory and word retrieval are not minor issues.

There are significant implications for inclusion here.

I hope there was a recommendation that curriculum vocabulary was planned to be pretaught? This is something that might make a big difference to her learning NOW.

It also sounds like she needs some support with verbal reasoning.

That's before you even START on the conversational stuff.

TotalChaos · 10/02/2011 12:24

thanks for your detailed and thoughtful posts, 9-5, v. useful. Feel with my DS we are slipping through the gaps - that he's just about good enough with language (and is doing q. well academically) without support from school - but he still comes over as being a bit, well, naive and inarticulate at times. really have to go down private route I think.

kissingfrogs · 10/02/2011 13:11

working I was so hoping you would respond. Excellent information there, that really helps.
I had specifically asked SLT for an assessment of conversation - extended speaking. I was also a bit dismayed that she had no knowledge of dds previous EP report. The brief results she emailed me prior to report have a postscript of: these assessments are not standardised on children with a hearing loss. I am hoping that as she was bought in due to her specialism in HI that the full report will be adjusted with relevant stats for HI.

Absolutely agree with what you've said re 1:1 v the real issue of where dd spends most of her time - in class.
A bid has been made for a radio aid, it's taking time...I sense that the problem here is funding as dd is "only" mild/moderately deaf (the reason told to me in last school as to why she didn't get one)so is likely to be classed as least-in-need. Dds teacher has told me she wants more info on strategies in class as she feels that current IEP targets are a bit woolly.

I'm going to contact the SLT re her referal to collegue with language speciality and this time I will be firmer that I dont want another standardised test - dd needs it to be specific to extended speaking.
You can but try.

At least thanks to your advice I feel better informed. Wish you were dds SLT.

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goingroundthebend4 · 10/02/2011 13:14

thank you working

Intresting as ds was tested on the preschool cleft scale and came back as untestable due to no actual words available on the expressive and on receptive he was scoring mostly around 3.8

So giving the fact he is a year 1 pupil and was 5.4 when tested should they used the other cleft tests .Is their a point when they are meant to use them with the childs age

Becuase i am then guessing his score for recetive be even lower

Davros · 10/02/2011 13:40

How many times have I heard (and experienced first hand) that SLTs have a different opinion to everyone else? Nothing changes.

goingroundthebend4 · 10/02/2011 13:47

hmm reading am i right that ds was tested incorrectley ? mind not that the scores could get much worse

dolfrog · 10/02/2011 16:35

This could be the first signs of Auditory Processing Disorder (APD)
APD is a listening disability, which can include having problems with word recall, poor auditory memory, and following verbal instructions
The Medical Research Council first recognised APD in 2004, and the current assessment centre is at Great Ormond Street Hospital (via a GP referral after the age of maturation (over 7 - 8 years of age when children stop growing out of these problems)

APD in young children can be a genetic issue, in which their may be some family history of similar issues, or APD can be acquired via severe ear infections such as Otitis Media with Effusion (Glue Ear).
you might like to have a look at the Auditory Processing Disorder in the UK (APDUK) web site.

According to the Medical Research Council 10% of the child population may have some degree of APD.

working9while5 · 10/02/2011 18:23

goingroundthebend4, there is overlap up to 6 I think so either test can be used. Generally speaking if you were concerned a child would score very badly on the CELF-P you would use this so as to get meaningful data with reference to norms (as it is also standardised on children up to 6). The Celf-4 (5-8) tests different areas which are sensitive predictors of language impairment in this age range but they are at a higher level iyswim, so if you are scoring in the lowest percentiles on the CELF-P, it is unlikely you would be able to attain a score on the CELF-4. This means that you might struggle to pick up subtle discrepancies between different areas as all subtests would be in the lowest rankings. Using the CELF-P makes it more likely that these discrepancies can be identified. Hope this makes sense..

Kissing, I think that a different specialist would be better placed to offer what you are looking for and I hope you get additional information this way that is useful for your dd. I would still be pressing the teacher for info on what she is doing to chase up her concerns/what steps she is taking/what she is doing. When a parent complains there can be a sudden bout of people pointing fingers in other directions, but as your dd's teacher, if she feels that the IEP targets are not appropriate or that she needs support/further info, she really needs to do something about it vs blaming it on a particular professional. I have seen all varieties of professional (SLT, Paed, Teachers, Paeds) pull the "oh but I can't do my job til they do theirs" card. Every professional needs to take responsibility for the children in their care. If she doesn't know what to do in class, she needs to find out by whatever means necessary but that shouldn't really involve YOU having to chase up the information for her. If she thinks that the strategies are rubbish/not useful etc, she needs to assert that and advocate on your dd's behalf and she also possibly needs to be more explicit about her needs e.g. really spell out what she has tried and where she is stuck and needs help.

Of course, I don't know your dd's teacher and she could be outstanding and have really educated herself on your dd's needs and be doing everything she can to include her in the environment etc.. but I would want to know everything that is being done in whole class teaching/small groups/1:1 to address specific needs as they arise (regardless of involvement of other professionals) anyway as it's good to know...

kissingfrogs · 10/02/2011 18:36

Dolfrog dds TOD mentioned possibility of APD.
GP referal: you're having a laugh! My GP wont refer dd anywhere as he says he doesnt believe in "labels". His very words. Won't be seeing him again. Fortunately he's not the only GP in the world.
Getting an accurate professional assessment of dds areas of difficulty will help support future referals such as the one you mention.

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goingroundthebend4 · 10/02/2011 19:41

thank you working that makes complete sense and now i understand why

as we all knew expressive that he was still having trouble as can only make nouns and m and h sounds and even knew theres areas with receptive problems though intresting when signing added in his receptive does pick up though still far below normal