Language Difficulties Assessment

The terms language, speech, and communication are used interchangeably by most people. When children or adults are seen by a speech-language pathologist (SLP), however, each of these terms refers to specific behaviors that are assessed and treated differently.

Language is a symbolic code organized by rule-governed combinations that are socially shared. Children learn to use this symbolic code by being part of families and communities. This learning process continues when children go to school and learn to read and write and formally study language. Most children have no difficulty learning the code. They quickly and easily recombine words to talk with others (which can be likened to building structures with a Lego set). However, approximately 10% of all children have difficulty learning some aspect of the language code. In addition, some adults have had an experience, for example, a stroke or head trauma, that resulted in specific language impairment.

Speech is the spoken production of language. It is an oral neuromuscular process that shapes the sounds particular to each national language and allows verbal transmission of thoughts and ideas between people. The mouth’s structures and muscles shape the sounds, but the sounds being shaped are particular to specific symbolic language codes.

Communication, the most comprehensive of the three terms, involves the exchange of information between people. This exchange can be nonverbal, such as when the body, space, and eye gaze are used to convey information. It can be vocal, such as when those who are hearing impaired or using electronic equipment add their pitched voice, grunts, and so forth to the messages they are sending. It can be verbal, such as when information is exchanged by speaking to one another. Language is integral to communication because this symbol system is used to encode information and ideas. Therefore, while language need not be spoken, it is a pivotal aspect of communication.

Language, speech, and communication typically co-occur in everyday life. When considering atypical development or disease, injury, or illness that affects language, each person must be assessed and possibly treated differently. A life-span perspective about language assessment follows.

Birth to Age Three

Infants who are born with health problems, syndromes, or into living situations that place them socially at risk are eligible to receive early intervention services. The goal of these services is to prevent or reduce the effects of the biological or social conditions on development. Transdisciplinary teams provide services in homes and centers under an Individual Family Service Plan (IFSP). The family rather than the infant alone is considered the client.

Since the development of language is fundamental to communication and later learning, the SLP assesses emerging skills and formulates an intervention program. The focus of the assessment shifts between communication, speech, and language, depending on the developmental status of the infant. Common assessment tools include the Rossetti Infant and Toddler Language Scale, Receptive-Expressive Emergent Language Test, Sequenced Inventory of Communication Development, and MacArthur Communicative Developmental Inventories. These scales are criterion-referenced instruments that report age equivalencies. The first three provide information about infant understanding of communication and language, and determine how well the infant is communicating by using speech sounds, gestures, and language with others. The last instrument uses parent report to determine the range and depth of the infant’s vocabulary development.

Early Childhood

Early childhood extends from approximately 3 to 5 years of age. It encompasses the “magic” years of language development, so called because this is the single most dramatic period of language growth in the life span. Many children who receive speech-language therapy are first identified during this time of life. They are referred for assessment by physicians, who may use instruments such as the Denver Developmental Screening Test to identify concerns; by parents who do not think their child speaks enough or does not speak clearly; and by preschool educators who are concerned about language comprehension, attention, and other skills essential in the learning environment.

For assessment, children may be referred to early childhood programs, free-standing clinics, private practitioners, or university training centers. Regardless of setting, the formal and informal assessment tools used to determine the adequacy of language development will be similar.

Formal assessment usually involves the use of standardized tests, and provides a full range of normative scores. Some common assessment instruments are the Preschool Language Scale, Clinical Evaluation of Language Fundamentals-Preschool, Peabody Picture Vocabulary Test (PPVT), and Expressive Vocabulary Test (EVT). These tests cover a range of language skills. The PPVT and EVT are both vocabulary tests normed on the same cohort, which allow for comparisons between receptive and expressive skills. Vocabulary tests are also embedded in the other instruments as a part of the battery. Other assessment domains include the understanding and production of grammar (the way words are combined to make sentences), morphology (the way word parts are used, such as prefixes and suffices), semantics (how words and phrases create meaning), and pragmatics (awareness of others as having unique beliefs, desires, and mental states, and the social use of language).

Informal testing consists of observation, recording a sample of the child using language during play with a peer or family member, and charting communication patterns. Informal testing by the SLP provides a crosscheck on the standardized test results, since some children may do poorly on the more structured testing yet have adequate developmental language skills. The results of informal testing are reported descriptively and as age or developmental criteria comparisons. While this information may not be as easy to use as standardized test results, it is often better understood by parents and captures the everyday issues that resulted in the referral for evaluation.

School Age

It is assumed that children are developmentally ready to learn when they go to school. Language is a pivotal developmental skill that is used and further developed in classrooms. It also serves as the basis for reading and writing. Some children will continue the treatment begun in early childhood. Others may have been discharged from language therapy but need further assessment because they are having difficulty attending to or understanding language-based classroom activities or learning to read and/or write. Additionally, some children with no history of language problems will exhibit these problems and be referred by teachers. Regardless of a child’s history, the child’s present status of language-for-learning skills must be assessed.

Assessment of school-aged children is usually based on norm-referenced tests unless a school has a response to intervention (RIP) protocol in place. When an RIP action plan is activated, extra assistance is provided to the child. If the child responds, a full evaluation is not recommended. Those children who continue to have difficulties even with this extra assistance are referred for assessment. In a full diagnostic workup, developmental language skills will be checked, but the emphasis will be on language-for-learning. Some of the most frequently used standardized tests include the CELF, PPVT, and EVT cited earlier, as well as the Illinois Test of Psychological Abilities and Woodcock Language Proficiency Battery. In addition to developmental language skills, phonological awareness, reading, spelling, and writing skills are now assessed. The goal is to determine if there is an unresolved developmental language difference (for children up through Grade 3) or if the developmental language skills are adequate but the child is having difficulty taking these fundamental skills to a new context and transforming them into different language modalities (i.e., text based). The results of these tests are norm-referenced scores.

Informal assessment is included in a full diagnostic workup. This usually focuses on conversation skills, storytelling, and other pragmatic language skills that are best assessed when an interactive context is established. Results from these procedures are reported descriptively.

Adulthood

There are many diseases and conditions that can affect language functioning, speech, and communication in adulthood. Most problems are caused by some kind of neurological impairment. For young adults, language difficulties result most commonly from head trauma (e.g., a car accident, motorcycle accident, or bullet wound). As middle age approaches, there is increased risk of stroke or tumor, and these become even more likely as adults move into what are considered the older years. Some problems (such as stroke) are static; once the damage occurs there is no further loss of functioning. Other problems (such as Parkinson’s disease or Alzheimer’s disease) are progressive; impairment increases over time.

Language assessment in adults is critical for a number of reasons. First, the assessment results will contribute to a better differential diagnosis of the underlying condition or disorder. Second, assessment outcomes will be used to design a treatment program. Finally, test results will provide information that is critical to counseling the client and significant others about the nature of the specific language problems, the probable impact of these problems on daily functioning and quality of life, and the prognosis for change.

Language assessment for adults may be performed in a variety of settings, including acute care hospitals, rehabilitation facilities, freestanding clinics, and the client’s home. Virtually all assessments include informal observations of the person’s speech, language, and communication skills in everyday tasks and contexts. In some settings, because of time limitations, informal assessment may be the primary process used to identify the problem and develop treatment plans. However, there are a number of language assessment test batteries that can be used to examine all aspects of an adult’s language functioning. For adults with language problems following a stroke, the Western Aphasia Battery and Boston Diagnostic Aphasia Examination are examples of comprehensive batteries. Other tests evaluate language, but also examine other cognitive and perceptual skills impaired by neurological deficits. Examples might include the Ross Information Processing Assessment and the Cognitive Linguistic Quick Test. Still other tests focus on one small aspect of language functioning (e.g., reading, understanding of sentence-length materials, or naming).

Importance

Speech, language, and communication are complex behaviors. It is important to obtain an accurate assessment of language skills, deficits, and potential to determine the best way to improve language functioning. In addition, since language is such an important tool in counseling, it is critical to understand the person’s linguistic abilities and challenges and to make certain that support for communication is provided. Without language, children and adults cannot participate fully in the world around them.

References:

  1. Brookshire, R. H. (1997). Introduction to neurogenic communication disorders (5th ed.). St. Louis, MO: Mosby.
  2. Chapey, R. (Ed.). (2001). Language intervention strategies in aphasia and related neurogenic communication disorders (4th ed.). Philadelphia: Lippincott Williams & Wilkins.
  3. Haynes, W. O., & Pindzola, R. H. (Eds.). (1998). Diagnosis and evaluation in speech pathology (5th ed.). Boston: Allyn & Bacon.
  4. Owens, R. E., Jr. (2001). Language development: An introduction (5th ed.). Boston: Allyn & Bacon.

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