On the Life-Saving Value of Clinical Assessments

Today, I’d like to elaborate on the importance of clinical assessments in speech-language pathology, especially as relevant to our older teen clients 14-18 years of age. Notice my choice of words in the title – “life-saving”. It is not an over-exaggeration or an attempt at sensationalism for clickbait.

For our clients with more subtle higher-order language deficits and concomitant mental health struggles, these assessments can represent a true lifeline and lead to appropriate and relevant therapy services. So today, I would like to illustrate via a specific case example, why clinical assessments truly matter!

In the recent past, I received a rather unique referral for a 10th-grade student with an average IQ, with a previous history of mostly exemplary performance on private neuropsychological, as well as most school-based educational and speech-language testing. While select previous testing implied that the student presented with difficulties in the areas of mathematics, executive functions, as well as self-regulation, both standardized language, and educational testing results showed stellar scores.

However, that wasn’t the parental experience with the adolescent in question. Their mother reported that they presented with significant difficulty comprehending grade-level texts and poor essay construction. She reported enormous struggles, tears, and tantrums over homework. Socially this teen misunderstood people’s responses during social interactions, which resulted in overreactions to the misperceptions. The parent also reported that the teen was very literal and unaware of how what they are saying is being perceived by their audience. Additional difficulties are reported to be inflexible thinking as well as poor emotional self-control.  Difficulty with social engagement via phone and texts has also been reported. The mother also reported that the teen was diagnosed with anxiety and depression due to ongoing academic and social struggles. And the singlehandedly most heartbreaking reported fact of all was that the above collective difficulties have driven the teen to the brink of suicidality!

The teen’s parents spent almost a decade searching for answers for their child and all they were receiving were average to above-average standardized testing results on the administered assessments. Consequently, when the student was referred to me as a “last resort” by a highly knowledgeable special education advocate, even she was uncertain whether I would be able to uncover any new, treatment-worthy information. Hence, the pressure was high to deliver results for functional treatment purposes.

I started the assessment process the way I always do. I reviewed the 4 parent-filled-out intakes, along with all available records to create an appropriate testing battery for this student. I tried to ensure that all selected standardized tests had the strongest psychometric properties and were very relevant for ruling out any foundational language deficits, which may be maintaining a hidden language disorder. Below is a list of administered standardized tests along with what difficulties they uncovered.

• The Listening Comprehension Test: Adolescent: Normative Update (LCT-A: NU)
  • Indicated deficits in the area of Main Idea Identification
• Multiple Meanings and Figurative Language subtests from the Clinical Evaluation of Language Fundamentals-5: Metalinguistics (CELF-5:M)
  • Did not identify deficits
• Test of Problem Solving-2 Adolescent (TOPS-2)
  • Identified deficits in the areas of Making Inferences, Problem Solving, and Determining Solutions
• Clinical Assessment of Pragmatics (CAPs)
  • Identified deficits in the areas of Awareness of Routine Social Language, interpreting and Reading Context Clues, Interpreting Irony and Sarcasm, as well as Reading and Using Nonverbal Cues
• 11 subtests from the Test of Integrated Language & Literacy Skills (TILLS)
  • Identified deficits in the areas of Vocabulary Awareness, Nonword Repetition, as well as Following Directions
• Gray Oral Reading Tests -5 (GORT-5)
  • Did not identify deficits
• Test of Written Language-Fourth Edition (TOWL-4)
  • Identified deficits in the area of Logical Sentence construction

Overall, the standardized testing results were already an improvement from past testing since they at least identified a clear pattern of difficulties in the areas of oral language, problem-solving, as well as pragmatic language, while gently hinting at potential written language deficits. However, based on the above results it was very clear that I needed to dig far deeper in order to determine how this student integrates her knowledge for discourse, reading comprehension as well as written composition purposes.

This is exactly where the administration of clinical assessment tasks has proven to be invaluable for this student!

Clinical task administration for the student included the following:

1. Discourse: Peer Conflict Resolution Task (Nippold, Mansfield, & Billow, 2007)
2. Reading Comprehension: Story of an Hour by Kate Chopin (Summarization and Analysis)
3. Written Composition: Persuasive Writing Prompt (Is it better to grow up in a small town or a big city?)

The results of the clinical assessment were very telling! In addition to the above-uncovered deficits, clinical assessment tasks revealed the following:

This student’s discourse abilities were immature for their age and were characterized by deficits in the areas of syntax (decreased sentence sophistication), semantics (fewer words used/less sophisticated words used, word finding difficulties), pragmatics (use of language for effective communication), verbal reasoning (difficulty making logical assumptions), as well as perspective taking abilities (insight into what someone may be thinking as well as whether someone is being truthful or deceitful).

Their reading comprehension difficulties were characterized by impaired ability to comprehend pragmatically related nuances of age/grade level texts including ambiguously phrased information, double meanings, irony and sarcasm, advanced figurative language, as well as grasp gestalt ideas and subtle messages of texts.   

Finally, the student’s writing composition difficulties were characterized by weaknesses in the area of essay composition including decreased literate vocabulary sophistication, thought formulation, coherence, and cohesion of content, as well as effective content organization (getting to the gist of the matter).

Knowing this information allowed me to create a comprehensive treatment plan on how to best address the above weaknesses functionally to allow this teen to thrive both socially and academically. It also validated the parents’ concerns that their child was indeed truly struggling, which were dismissed by many professionals over the years. Now, I am fully cognizant that this student would not qualify for services in a public school setting. Their deficits would not be viewed as ‘sufficiently severe’ to warrant school-based services. I fully acknowledge that. The school SLPs are stretched far too thin as they are! The parents are also very cognizant of that fact. They were quite happy to get recommendations for a private practice speech pathologist with a relevant area of specialty to treat their child. Unfortunately, until the completion of my assessment they could not do so because, despite their child’s significant social and academic struggles, all previous assessments have shown average standardized scores and did not identify academically and socially functional treatment areas. Now that my assessment has finally revealed deficit areas and provided them with a comprehensive treatment plan, they can finally move forward with appropriate intervention for their child.

I hope that in this post I had an opportunity to prove to you that clinical assessment tasks are a truly valuable and integral part of all assessments, especially those of students with more subtly displayed language and literacy deficits! I strongly encourage you to utilize them when you encounter students with subtle language deficit profiles, who do well on standardized tests.

So what is the best way to perform clinical assessments? Below are some useful links on this subject

How to Clinically Assess Narrative and Discourse Abilities?

1. Clinical Assessment of Narratives in Speech-Language Pathology*
2. The Importance of Narrative Assessments in Speech-Language Pathology
3. Analyzing Narratives of School-Aged Children
4. Identifying Word-Finding Deficits in Narrative Retelling of School-Aged Children

How to Clinically Assess Pragmatic Abilities?

1. Social Scenes for Assessment and Treatment Purposes
2. Assessment of Social Communication From Toddlerhood Through Adolescence*
3. Social Pragmatic Assessment and Treatment Bundle*
4. The Role of Pragmatic Language in Reading Comprehension and Written Expression: Focus on Assessment*

How to Clinically Assess Reading Abilities?

The most effective way is by asking a student to read a grade-level one page expository text and then asking them the following:

1. Identify the passage’s main idea
2. Summarize the passage
3. Answer abstract verbal reasoning questions
4. Define literate vocabulary words

Useful links:

1. Clinical Assessment of Reading Abilities of Elementary-Aged Children
2. Adolescent Assessments in Action: Clinical Reading Evaluation
3. Comprehending Reading Comprehension
4. Language and Literacy Assessment Tasks and What They Measure
5. Comprehensive Assessment of Elementary-Aged Children with Subtle Language and Literacy Deficits
6. The Role of Pragmatic Language in Reading Comprehension and Written Expression: Focus on Assessment*
7. Reading Fluency and Reading Comprehension Master Course*
8. The Science of Reading Literacy Certificate for SLPs*

How to Clinically Assess Writing Abilities?

For this purpose, I highly recommend the use of persuasive writing prompts for upper elementary and middle school students and the use of expository prompts for high-school-aged students.

1. Clinical Assessment of Elementary-Aged Students Writing Abilities: Suggestions for SLPs
2. Components of Qualitative Writing Assessments: What Exactly are We Trying to Measure?
3. Writing Assessment and Intervention Master Course*
4. Spelling and Morphology Master Course*

References:

1. Betz, Eickhoff, & Sullivan,( 2013) Factors Influencing the Selection of Standardized Tests for the Diagnosis of Specific Language Impairment. Language, Speech, and Hearing Services in Schools, 44, 133-146.
2. Bogue, E. L., DeThorne, L. S., & Schaefer, B. A. (2014). A psychometric analysis of childhood vocabulary tests. Contemporary Issues in Communication Science and Disorders, 41, 55-69.
3. Gray, S., Plante, E., Vance, R., & Henrichsen, M. (1999). The diagnostic accuracy of four vocabulary tests administered to preschool-age children. Language, Speech, and Hearing Services in Schools, 30(2), 196–206.
4. Nippold, M. A., Mansfield, T. C., & Billow, J. L.  (2007). Peer conflict explanations in children, adolescents, and adults: Examining the development of complex syntax. American Journal of Speech-Language Pathology, 16, 179-188
5. Norbury, C. F., Gemmell, T., & Paul, R. (2014). Pragmatics abilities in narrative production: a cross-disorder comparison. Journal of child language, 41(03), 485-510.