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February 20, 2023

An Often Overlooked Step: Comprehensive Evaluation in Speech, Language, & Literacy

Diagnostic Testing in Language.jpg

I think it’s safe to say that most everyone has had a headache, and for most headaches, taking your favorite over-the-counter pain medication offers much-needed relief. But, what happens when it doesn’t?

There are many different types of headaches, generally categorized under primary, where the headache itself is the condition, such as migraines and tension headaches, and secondary headaches, which are symptoms of another disease. A quick search on the Mayo Clinic website revealed 31 possible causes of secondary headaches, ranging in severity and prognosis, and treatable by at least eight

different medical specialists, including cardiologists, endodontists, infectious disease specialists, neurologists, ophthalmologists, otolaryngologists (ENT), oncologists, and psychiatrists. Hopefully, you have an experienced primary care doctor who can run some initial tests and point you in the right direction as the impact to your life in terms of stress, time, relationship, and money is significant. An accurate and timely diagnosis could mean the difference between life and death.

“Diagnosis” comes from the Greek roots “dia,” which means “apart (from another),” and “gignoskein,” which translates to “recognize.” From early Latin medical texts, we see that “diagnosis” evolved to mean “the recognition of a disease from its symptoms.” Oxford Languages offers a modern definition for “diagnosis” as “the identification of the nature of an illness or other problem by examination of the symptoms.” Medical diagnosis dates back thousands of years to several ancient civilizations found throughout the world, and it continues to have its place in modern society. As we can see from the headache example, without an accurate diagnosis, we don’t know if we need a root canal, a prescription for Tamiflu, or a time-dependent injection of tissue plasminogen activator (tPA) for an ischemic stroke, which by the way, must be administered within 4.5 hours of symptom onset to be effective. We need our diagnosticians to be accurate, thorough, thoughtful, efficient, and confident, and we want them to present a plan of action that not only corrects or mitigates the problem but does so in a cost-effective manner with as little time and effort as possible.


When it comes to communication disorders, we should expect nothing less. Without proper diagnosis in speech, language, and literacy, one could, at best, spend extra time and money addressing a skill that doesn’t remediate the underlying deficit, or at worst, reach the conclusion that a child is doomed to educational failure. For example, when a child is suspected of poor reading ability and we teach them to decode (i.e., sound out words), we may miss that the child's problem wasn't with decoding after all but rather with his understanding of what he was decoding. Without targeted language intervention, the skill of the therapist and the time and effort put into decoding won't matter. Just the same way that it isn’t effective to take daily pain medication in an attempt to alleviate a headache caused by high blood pressure. We recently learned about this type of headache from our dog’s veterinarian. Seven doctors and two specialties later, our furry family member is now feeling better, given appropriate treatment to lower his blood pressure.


In order to understand the importance of good diagnostics in speech, language, and litearcy disorders, you need to appreciate the complexity of the linguistic system and the underlying anatomy and physiology. Disorders of speech require a thorough understanding of the human body and what is involved in speech production. Knowledge of the English sound system and sequencing contingencies, along with the impact of various linguistic structures, is essential as is experience working with and distinguishing between disorders. The speech of a child with hearing loss presents very differently from the speech of a child with a motor speech disorder, even though both may have trouble saying /s/ some of the time. 


Assessing a child’s oral and written language is even more complex and involves the evaluation of all five areas of language (phonology, morphology, syntax, semantics, and pragmatics) across four domains – listening, speaking, reading and writing. This type of comprehensive assessment requires gathering careful case histories, asking thoughtful questions, choosing appropriate tests, administering tests following standardized procedures, understanding test limitations, observing the child in their daycare or school setting, gathering data from educators, analyzing performance and patterns of performance within and across assessments, completing extension testing which seeks to determine the supports necessary for the child to be successful at a given task, considering linguistic, social, and cultural differences, forming a professional opinion, and applying knowledge of current research findings to develop an appropriate plan for remediation. This plan should describe goals and objectives, necessary educational accommodations and curriculum modifications, therapy frequency, and prognosis. All of this information is then compiled into a comprehensible, written report which is delivered to parents and those professionals who work with and treat the child.


This process is not unlike the time spent drawing blood, undergoing imaging studies (e.g., CT or MRI scans), and completing other medical tests and procedures. You invest the time and money necessary for an accurate diagnosis. You rely on the expertise and collaboration of the professionals performing and analyzing the results. Unfortunately, medical expenses are covered in varying degrees, and this frequently impacts someone’s decision about whether to undergo various procedures. It is a sad but true fact that insurance coverage for the proper diagnosis and treatment of communication disorders is abysmal. When it comes to diagnostics, many insurance companies cover the equivalent cost for a single therapy session, which in some cases is 30 minutes long and reimbursed at a rate of $45. A comprehensive language evaluation takes between four and six hours of direct contact time with the child, another hour before and after the testing with the parents, an hour of school observation and review of teacher input, and then another 4-6 hours to score, interpret, collaborate, and write up the results. The good news is that a thorough diagnostic usually only needs to be completed once for most clients and for those who receive services longer-term, it’s usually once every three years. Many private therapists will arrange payment plans and work with you to provide the best outcome for you and your child. Targeted and dynamic assessments, which cost far less in time and money, can be administered more frequently as children meet their goals and objectives and progress toward age-appropriate communication abilities.


The need for accurate diagnostics is all around us, whether it’s an electrical problem with our cars, a leak in our homes, a software glitch that results in a computer freezing up, an afternoon headache that appears day after day, or difficulty learning to read. You want to find someone who carefully assesses the situation, diagnoses the problem, and provides a plan to correct it. While the upfront costs of time and money may seem prohibitive, careful diagnostics are crucial for accurate and successful outcomes when dealing with complex systems. In the long run, you may find that you save money, time, and frustration for both you and your child.


Here are links to a few blog posts from a well-respected SLP regarding the case for comprehensive evaluation.

     1. This one discusses the need for comprehensive assessment for children with subtle language and literacy needs.

     2. In this one, she lays out four very different scenarios and how comprehensive assessment led to different conclusions from the presenting concern.

     3. This one explains the differences between neuropsychological testing and comprehensive language evaluation and makes a case for the need for both.

Finally, the American Speech-Language-Hearing Association (ASHA) has information for families on health insurance and coverage for speech/language needs, as well as action steps to try to obtain coverage.

ASHA on Private Health Plans

ASHA on Health Insurance & Care Options

January 9, 2023

The Science of Reading? Reading Wars? What does it all mean?

The Science of Reading represents what we know about how children learn to read and what instructional approaches are effective. Our knowledge stems from a vast, diverse, and cross-disciplinary body of evidence-based research. Hundreds of studies, on and in multiple languages with expert contributions from the fields of linguistics, cognitive psychology, speech-language pathology, neurology, and education make up this body of research.

Structured literacy approach to reading

The “Reading War” historically pitted proponents of “phonics” against those who choose a “whole language” approach. The Reading War is not new and has been ongoing for decades. Terms, approaches, and theories change over time. Sometimes they are based on science, and sometimes they are not. Narrow views lead to further dissent among the differing camps. The current war involves “Structured Literacy” vs. “Balanced Literacy.” Before I delve into what each of those theories espouses, it’s important to understand additional background information that has brought us to this critical juncture in reading instruction.

In 1997, Congress assembled the National Reading Panel, a group of 14 people -- educational administrators, parents, teachers, college representatives, and reading scientists -- for the purposes of identifying the best ways to teach children to read. The panel reviewed the existing research on reading acquisition, and on April 13, 2000, they produced a report from which the “5 Pillars of Reading Instruction” were introduced. Those “5 Pillars” included Phonemic Awareness, Phonics, Fluency, Vocabulary, and Comprehension. The panel determined that effective reading instruction should seek to develop these five areas in order to produce good readers. It did not recommend specific reading programs, but instead provided a framework of the skills linked to the development of good readers. Some questions were answered, and many questions were raised that provided direction for future research. The National Reading Panel disbanded upon the writing of the report. The executive summary of that report can be found here:


In 2001, Dr. Hollis Scarborough, a leading researcher in spoken and written language acquisition, published the most famous visual representation of the skills underlying reading ability. The Reading Rope highlights two primary areas -- word recognition and language comprehension -- each with numerous “strands” or skills that develop and eventually work in unison to produce a skilled reader. Word Recognition includes the strands of phonological awareness, decoding, and sight recognition. Language Comprehension includes the strands of background knowledge, vocabulary, language structures, verbal reasoning, and literacy knowledge. Dr. Scarborough created the Reading Rope to illustrate the complexity and interdependencies of reading acquisition, as well as the need to teach skills concurrently rather than sequentially. The Reading Rope is based on a solid foundation of published, peer-reviewed research. You may find the Reading Rope graphic along with a wonderful explanation on the International Dyslexia Association website:


In 2014, in an effort to simplify and unify the terms describing the necessary elements of good reading instruction, the International Dyslexia Association suggested using, “Structured Literacy.” Structured Literacy endorses the need for instruction in these six areas -- Phonology (sound system of the language), Sound-Symbol Association (alphabetic principle), Syllables (how sounds are combined to form words), Morphology (sounds and sound combinations that carry meaning, such as -s for plural or -ed for past tense), Syntax (how words are combined in sentences), and Semantics (meaning of the text). Structured Literacy espouses the systematic, cumulative, explicit, and individualized instruction of these six skills. Structured Literacy aligns with Dr. Scarborough’s framework of reading acquisition and contains the components of both “phonics” and “language.” Additional information on Structured Literacy can be found here:

“Balanced Literacy” is a theory of teaching reading and writing that was developed in the 1990s to sit between the “phonics” and “whole language” camps. It was designed to “balance” teacher-led instruction and student exploration by incorporating elements, such as comprehension, vocabulary, fluency, phonics, and phonemic awareness, into the different instructional models -- whole group (e.g., Interactive Read Aloud), small group (e.g., Shared Reading, Guided Reading), and one-on-one instruction. While some elements of phonics and phonemic awareness are taught, Balanced Literacy primarily focuses on the meaning of the presented text. Unfortunately, current research shows that this approach, while working for a subset of students, does not work for most, who instead require systematic and explicit instruction in word-level reading skills. For an easy-to-understand explanation about the differences between Structured Literacy and Balanced Literacy, please refer to the Iowa Reading Research Center Blog:


What the Science of Reading tells us is that most children (about 80%), given explicit and direct instruction in the components of reading, can successfully learn to read. We know that reading is complex. It requires direct instruction, flexibility, creativity, and often an approach tailored to an individual student’s needs. Reading programs, of which there are many, that are aligned with the “Structured Literacy” framework and are taught by trained and qualified personnel will result in the largest proportion of skilled readers within a classroom. If you consider appropriate instruction as the starting point, 20% of all children will still encounter reading challenges at school and require additional support. Extremely conservative estimates suggest that with additional and individualized support three quarters of that 20% (or 15% of all children) will develop into proficient readers and one quarter (or 5% of all children) will require intensive instruction. We also know that half of all children encountering reading difficulty exhibit concurrent language deficits that require direct remediation by a speech-language pathologist. In fact, in practice, many therapists find that nearly all children with reading deficits demonstrate some language needs.


And if you haven’t listened to the podcast, “Sold a Story,” now may be the time.

December 26, 2022

Phonological Processes, Phonological Process Disorder, & the Relation to Early Reading

Phonological disorders in speech and reading

"Eye ayee oo a eye a aya uh," said a 3-year-old client, while playing with a toy firetruck.

"Your daddy used to drive a fire truck," I responded.

Children who are learning to speak often employ simplification patterns as a way to manage complex sound production or sound combinations. These patterns of simplification are known as phonological processes. Most people are familiar with the more common patterns, such as gliding where /w/ is used in place of /r/ and /l/. A child may say, “Wook at the siwy wabbit” for “Look at the silly rabbit.” Other common patterns include cluster reduction (adjacent consonants are simplified to the initial consonant in a cluster) such as “tain” for “train” or “pant” for “plant,” weak syllable deletion (the unstressed syllable in a word is omitted), such as “ephant” for “elephant” and “bufy” for “butterfly,” and reduplication (the stressed syllable in a word is repeated in place of the weak syllable), such as “baba” for “bottle” and “wawa” for “water.”

A phonological process disorder is a type of speech sound disorder. It is typically diagnosed when a child continues to employ phonological processes or simplification patterns longer than is developmentally appropriate or when the child displays patterns that do not follow the typical developmental path. Some patterns, such as initial consonant deletion, where the first sound of a word is omitted (e.g., “at” for “cat” or “ook” for “book”), can greatly impact a child’s ability to be understood, as can the child’s use of multiple patterns at the same time. Research in phonological development provides information on what phonological processes are usually employed and when typically developing children abandon the various simplification patterns for more adult-like speech. These developmental norms help speech-language pathologists determine the need for and timing of treatment.

Children who enter school with a phonological process disorder often experience a delay in the development of early reading skills. Which of these children will go on to a later diagnosis of dyslexia is not so straightforward. What we do know is that a child with a phonological disorder runs a greater risk of displaying reading difficulty at age 8 than those children who do not. More importantly, children diagnosed with a phonological process disorder in addition to a language disorder, difficulty with attention, memory, and/or processing speed, and those with a family history of reading impairment display the greatest risk for significant reading difficulties by the end of second grade.

The bottom line for me, as an SLP, is that early intervention of speech sound disorders is critical to provide the best scaffolding for reading acquisition, especially if a child presents with any additional risk factors for dyslexia. While researchers have worked hard over the past 25 years to identify reliable predictors of dyslexia, they have yet to determine a single cause. This is likely due to the fact that dyslexia is a complex neurobiological disorder. A quick search on the incidence of dyslexia will yield estimates ranging from 5% to an incredible 20% of the population. With this many school-aged children being diagnosed, research into the identification of pre-cursors is critical - and thankfully, ongoing.

One more important note, a phonological process disorder is NOT the same as phonological processing or phonological awareness skills, which are critical for reading acquisition. The neurobiological underpinnings may be responsible for the development of each, however, one does not equal the other.

For more information on speech sound disorders, please visit the American Speech-Language-Hearing Association:

Click here for a great developmental chart and descriptive information on phonological processes:

December 14, 2022

My child can't say R. Why is R so hard?

R is hard. Learning to say R.

Can I share a secret? Many SLPs dread working on R. The thing about R is that it’s not just one sound. R is strongly influenced by the sounds around it, especially vowels. So, while vowels are typically acquired early in the developmental process, R and its 7 variants are often among the last. Something else that makes R challenging is the fact that R can sound correct to our ears even though tongue shape, position, and muscle tension can vary significantly from person to person. SLPs work to elicit R by focusing primarily on two placement variations; however, the path to successful elicitation can sometimes be quite complex, requiring flexibility, ingenuity, and an in-depth analysis of the child’s productions. This is why an SLP who is comfortable with R is your best bet when looking for someone to help remediate it in your child.

Another point to consider is that while your child may develop R without intervention as late as age 8 or the end of second grade, those children who produce R with distortion will benefit from early intervention.

How do I know if my child needs speech therapy?

An SLP can guide you to find the right answer for your child. The good news is that R can be worked on at any age and early intervention is quite successful.

December 6, 2022

At what age should my child be able to say his or her sounds?

This is a great question and one of the most common questions parents ask. Below is a fantastic visual that was created and can be found here:

McLeod, S. (2012). Summary of 250 cross-linguistic studies of speech acquisition. Bathurst, NSW, Australia: Charles Sturt University. Retrieved 12/6/2022 from

It is based on a systematic review published in 2020 in a peer-reviewed journal. It’s an open-access article for those of you interested in digging deeper:

Crowe, K., & McLeod, S. (2020). Children's English consonant acquisition in the United States: A review. American Journal of Speech-Language Pathology.

Basically, 90% of English-speaking children in the United States should be able to say the sounds listed under their age plus those under the ages below them.


United States Treehouse Chart.jpg

For example, by age 3 years, most children (90%) should be able to say the following sounds:

  • /t/ as in “toy,”

  • /k/ as in “cat,”

  • /g/ as in “go,”

  • /ng/ like at the end of the word “running,”

  • /f/ as in “foot,” and

  • /y/ as in “yes.”

And, they should also be able to produce those listed under age 2:

  • /p/ as in “papa,”

  • /b/ as in “boy,”

  • /d/ as “dog,”

  • /m/ as in “mine,”

  • /n/ as in “no,”

  • /h/ as in “hat,” and

  • /w/ as in “water.”

If you have concerns about your child’s ability to say their sounds, speak with a speech-language pathologist (SLP) at your child’s school, through a local hospital, or with one at a local private practice. While articulation therapy can be successful at any age, it is often easier and more efficient to address difficulties sooner before habits become second nature.

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