When choosing a specialist to address your child’s communication needs, there are many factors to consider. You need a professional who is skilled in making a differential diagnosis and selecting an appropriate treatment approach.
Treatment should reflect current research on brain development and the interconnected nature of speech, language, communication and thinking skills. Look for a professional who includes the family in ways that help you and your child enjoy the time you spend together.
SCREENING, EVALUATION AND DIAGNOSIS
Communication skills involve a huge variety of skills including using speech sounds, grammar, vocabulary, thinking, problem solving, social interaction and more. Many professionals can perform a screening; evaluation and diagnosis require advanced training.
Screening is a short procedure used for one purpose–– to decide if in-depth testing is recommended. A screening tool may be a parent questionnaire and/or a short set of tasks given to the child.
Screening tools do NOT decide if a condition exists. They only determine if there are enough indicators to recommend an evaluation.
There will always be some “false positives” because the screener is designed to pick up as many “possibles” as reasonable. Likewise, a screener may miss some children who later receive a diagnosis.
Many specialists are able to administer a screening tool for speech-language delay for toddlers and preschoolers. You don’t need to pay for this service, though. Reliable, free screening tools are available online to to help you decide if your child should be tested for a possible communication disorder.
The Ages and Stages Questionnaire – 3rd Edition (ASQ–3) for ages 2 months to 5 years looks at all areas of child development, including speech-language. It’s widely used by child development specialists and is now available free on the Easter Seals website.
The Smart ESAC for ages 9–18 months is effective for identifying children who need early intervention for communication skills. Completing the screener also gets you free access to the Social Communication Growth Charts from researchers at Florida State University.
You can take results of a screening to your health care provider to get a referral for therapy services paid for with insurance. In the US, though, you don’t need a physician referral to access public services.
For up to three years old, your child can receive early intervention services which are usually provided in the home. Check this list for contact information for services in your state or territory.
After age three, therapy and specialized preschool education are available from your local school district. Attach a copy of your child’s screening results to a note that includes this statement: “Based on my observations and the results of the attached screening, I’m requesting an evaluation to determine if my child qualifies for services.” Include the date and your signature.
For children ages three and up, you may have concerns about their speech sound development. Some sounds develop later than others, and some sounds have more effect on how understandable your child’s speech is. Use this chart to see what’s expected.
Evaluation is the process of using a set of tools to determine your child's current performance on communication tasks. Results of the evaluation are used to decide on a diagnosis.
No single test can provide all the information needed for an accurate diagnosis of a communication disorder. An evaluation may include a case history, parent interview, examination of the speech mechanism (mouth, breathing, voice, etc.), one or more standardized tests, a conversation sample and other observations.
An evaluation does more than answer the question, “Is there a disorder?” A full picture of your child’s strengths and challenges allows for well-informed decisions about the direction that should be taken in treatment. Examples of areas to consider include:
Speech: Does your child’s speech mechanism operate as expected so they can use all the movements needed for making all the speech sounds? Are there motor coordination issues that affect movements, or processing issues related to motor planning? Does speaking rate or phonetic context make it easier or harder for making some sounds? What is the percentage of consonants correct and how intelligible is connected speech?
Language: Does your child use the sentence length and grammar expected for their age? Do language differences follow a typical or unusual pattern? Is your child’s vocabulary restricted or robust? How does your child understand and use figurative language? Does your child use complex language structures? How does your child understand and use narrative and expository text structures? Could an augmentative/alternative communication mode enhance language development?
Social Communication: What functions of communication does your child express? Does your child interact with a variety of people using expected social conventions? How does your child understand and use nonverbal communication?
This sampling of questions reflects the broad, complex field of speech-language-communication. A skilled evaluator knows how to select the tools needed to target the areas of concern that were reflected in the screening results and report from parents.
A diagnosis names the condition that best explains all the features identified in the evaluation. A diagnosis should not be made based on the score of a single standardized test. As described in the previous section, an evaluation needs to gather evidence from a variety of sources.
Many professionals can administer a standardized test and report the scores. It takes additional background knowledge, training and experience to interpret the reasons a child obtains the reported scores.
Differential diagnosis is the process of eliminating or confirming some of the possible reasons for symptoms to come up with the best decision based on the collection of evidence. The clinician weighs the evidence, checks out hypotheses then draws a conclusion.
For example, there are many reasons that could cause a child to have difficulty making their speech sounds. There could be physical factors like weak muscles or the structure of the mouth. Processing issues can make it hard for a child to coordinate their sounds fast enough. A child with poor hearing can’t hear the difference between some sounds so does not form them correctly. Some children’s phonological (sound) system develops more slowly or in an unusual way for sometimes unknown reasons.
A differential diagnosis is important for planning the type of therapy that will best match the child’s learning needs. It’s not as simple as saying the child is not producing words so we will teach them to say words.
Build Strong Connections in the Brain
Brain imaging studies now give us evidence that how we teach a skill affects how well a child can use that skill. Brain imaging studies at the Harvard Center on the Developing Child have shown that children learn how to think and communicate best during meaningful social interactions with supportive adults.
Children who experienced supportive, responsive interactions throughout their daily activities were compared to children who did not have this experience. The children who learned during their daily back-and-forth interactions had different brain structures and better language and social interaction skills. Read more here.
Language and learning are interconnected in our brains; each depends on the other. When we hear a word spoken, several areas of the brain light up. To have a full understanding of words, we need to learn them in meaningful contexts so those connections are built in the brain.
Brain scientists propose that early intervention programs using interactive methods are effective for three reasons. (1) Young brains are “plastic” and more easily molded that older brains. (2) The positive social engagement and emotional support provided with naturalistic intervention improves important core deficits in social motivation, and (3) the enriched experiences promote the development of complex neural networks—the connections between parts of the brain.
Even when we’re working “only” on speech sounds, we need to recognize that speakers use thinking skills while talking. There’s a place for drill-and-practice to help a child become more automatic with using the sound. But right from the start, we need to use activities that help children be skilled speakers. They need to be able to do things like self-monitor their speech, evaluate their accuracy and self-correct as needed, recognize how one sound can change the meaning of what is said, and decide when and how to vary the way they speak. We get better transfer of the speech skills and better long-term results when thinking is embedded into speech therapy.
Select the Appropriate Treatment Methods
In the diagnosis section I talked about several reasons children have trouble using speech sounds. A skilled clinician needs to take that diagnosis into account to decide on an overall approach to treatment, and select specific methods that will help the child compensate for weaknesses.
For example, one child may not recognize some of the small differences between sounds that make a big difference in the meaning of words. Using a phonological approach can help the child correct several sounds at the same time. In contrast, another child might hear the sounds and know how they want them to sound, but they can’t make the movements accurately. This requires a different treatment approach that takes into account the reason they have trouble moving their speech muscles.
For young children who are just developing their language and thinking systems, the clinician needs to use treatment methods that put learning into meaningful contexts. Communication always needs to be a back-and-forth exchange, with language used for a variety of purposes.
If we pull out isolated skills for practice, they need to be immediately put back into context so they can be used meaningfully. We want children to be able to use the new information now, whenever and wherever it comes up in their life. They shouldn’t have to wait till later when somebody decides they are ready to be taught the next step.
I could go on with more examples but language development is such a huge area that I wouldn’t know where to stop. Let’s just say that there are many decisions to be made about what, when, where and how to teach language and communication. But all treatment needs to take into account that language learning requires active thinking—it’s not a drill and practice experience.
How to Decide on a Treatment Provider
There are several specialists who can administer screenings and standardized tests that look at aspects of communication. Some might provide treatment for certain skills. But there is only one professional whose training covers all the aspects of speech, language and communication your child needs for complete, accurate and effective evaluation, diagnosis and treatment.
Can you guess who that is? Of course you can! Speech-language pathologists have the training and experience needed to address your child’s speech-language-communication needs.
Don’t take just my word for it. Here’s a sampling from the American Speech-Language-Hearing Association of disorders and treatment methods used by SLPs: