An Often Overlooked Step: Comprehensive Evaluation in Speech, Language, & Literacy
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. https://www.smartspeechtherapy.com/comprehensive-assessment-of-elementary-aged-children-with-subtle-language-and-literacy-deficits/ 2. In this one, she lays out four very different scenarios and how comprehensive assessment led to different conclusions from the presenting concern. https://www.smartspeechtherapy.com/special-education-disputes-and-comprensive-language-testing-what-parents-attorneys-and-advocates-need-to-know/ 3. This one explains the differences between neuropsychological testing and comprehensive language evaluation and makes a case for the need for both. https://www.smartspeechtherapy.com/neuropsychological-or-language-literacy-which-assessment-is-right-for-my-child/ 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 assist you in obtaining coverage.