Chapter 20
Diagnostic Guidelines
Amy Glaspey
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Introduction
• Purposes of assessment
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Establish presence/absence of a disorder
Characterize the nature of the disorder
Document change over time
Document response to treatment
Observe transfer of skills to new contexts
(generalization)
• This chapter describes
– Components of assessment for diagnostic purposes
– Assessment during treatment
– Video clips: 3-year-old with phonological disorder
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Diagnostic Assessment
Components of a diagnostic assessment:
• Client history
• Standard assessment
• Dynamic assessment
• Connected speech sample with phonetic inventory
and intelligibility
• Structural-functional evaluation (with supplemental
motor screening)
• Phonological awareness
• Hearing screening
• Supplemental measures
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Client History
Sidebar 20.1 Sample questions that clinicians may ask a parent or
caregiver with a child with suspected speech delay
What are your concerns regarding your child’s speech and language?
Did any complications occur during pregnancy or birth?
Has your child met developmental milestones?
When did your child say his/her first words?
Has the child experienced any health or medical concerns?
Does the child have a history of ear infections?
Has the child had a recent hearing screening?
How is the child performing in school?
How is the child interacting with peers?
How well do others understand the child’s speech?
Do you have any concerns about academic achievement?
Is there a family history of speech, language, or reading problems?
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Client History: Cultural Factors
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Questioning may be perceived as invasive
Who is the family spokesperson?
Religious beliefs
Language proficiency of parent/caregiver
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Standard Assessment
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Standardized tests come with all materials (pictures, objects) and norms tables
Usually elicit single word productions
Evaluate speech sounds in relevant word positions (initial, medial, final)
Advantages
– Target word is known
– Comparison to other children of the same age/sex can support decision about treatment
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Disadvantages
– Lack of ecological validity
– Can be misinterpreted; a child’s accuracy on single words may be higher than in conversation
– Does not capture small changes
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Tests differ in purpose (articulatory accuracy vs. phonological processes).
Examples:
– Articulation
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Goldman-Fristoe Test of Articulation-Second Edition (Goldman & Fristoe, 2000)
Arizona Articulation Proficiency Scale-Third Edition (Fudala, 2000)
– Phonological patterns
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Hodson Assessment of Phonological Patterns (HAPP) (Hodson, 2004)
– Both articulation and phonological patterns
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Clinical Assessment of Articulation and Phonology (CAAP) (Secord & Donahue, 2002)
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20V1 Standard assessment using the Hodson Assessment of
Phonological Patterns
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Dynamic Assessment
• Measures the type of support needed by the
child to produce sounds/patterns successfully
• Complementary to standard assessment
• Criterion-based (what does this child need to
produce the sound/pattern successfully?)
– Stimulability
• Model – imitation
• Sound in syllable
• Sound in isolation
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Dynamic Assessment cont’d
• Adaptability
– Scaffolding
– Levels of modeling, cueing, prompting
– Levels of linguistic complexity
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Table 20.2 Glaspey Dynamic Assessment of Phonology (GDAP). A 15-point
scale of speech adaptability. Note that a low score is better and shows that
the child needs less scaffolding to produce a target.
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• Advantages of dynamic assessment
– Helps the clinician gather more detailed information about the
child’s abilities and needs
– Allows the clinician to track a child’s progress more carefully
• Disadvantages of dynamic assessment
– Scores may depend on the clinician’s ability to motivate the
child and administer the cues
– Takes more time
• Administering both standardized and dynamic assessment
results in a more comprehensive view of the child’s abilities
20V2 Dynamic Assessment. The Glaspey Dynamic
Assessment of Phonology (GDAP)
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Connected Speech Sample
• Conversation or story from wordless picture book
• The clinician listens to the sample and identifies
types of errors in the child’s speech
– Segmental errors?
– Deletions of parts of words?
– Only basic syllable shapes?
• Connected speech can be analyzed for
– Independent phoneme inventory
– Relational phoneme inventory
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Connected speech can also be used for various accuracy measures (see
Chapter 2 for details on how to compute these measures)
• Segmental
– Percent Consonants Correct
– Percent Vowels Correct
– Percent Phonemes Correct
• Whole word
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Syllable shape accuracy
Inventory of syllable shapes
Whole Word Accuracy
Phonological Mean Length of Utterance
Proportion of Whole Word Proximity
Proportion of Whole Word Variability (# different ways a child
produced a word/# total times the child produced the word)
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• Intelligibility
– No universally accepted measure of intelligibility exists
• Estimate of % intelligible: very subjective
• % words glossable: influenced by listener familiarity
• Children’s Speech Intelligibility Measure, Wilcox & Morris (1999): Recorded
single word imitations judged by an unfamiliar listener
• Rating scales
– Measure of intelligibility may not be appropriate for severe disorders
• Speech samples may be glossed incorrectly
• Difficult to measure progress because the child has low intelligibility for a long
time
• Cannot compare pre/psst data because content of the speech sample cannot
be controlled
– Solution: collect speech sample from a closed set of words (e.g.,
wordless picture book)
– Collect more than one measure of intelligibility
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1. No noticeable differences from normal.
2. Intelligible though some differences
occasionally noticeable.
3. Intelligible although noticeably different.
4. Intelligible with careful listening although
some words unintelligible
5. Speech is difficult to understand with many
words unintelligible
6. Usually is unintelligible.
7. Unintelligible.
Source: Strand & Skinder (1999)
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1. Speech is unintelligible.
2. Speech is usually unintelligible.
3. Speech intelligibility is difficult.
4. Speech is intelligible with careful listening.
5. Speech is intelligible, although noticeably in error.
6. Sound errors are occasionally noticed in continuous speech.
(Source: Bauman-Waengler, 2000)
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20V3 Connected Speech Sample
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Phonological Awareness
• “[A]n awareness of sensitivity to speech sounds and
the ability to manipulate the sound structures (i.e., the
syllables and phonemes) in words” (Hart Paulson &
Moats, 2010 p. 52)
• Deficits put children at risk for problems with written
language later
• Phonological processing skills include
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Rhyming
Alliteration
Blending
Segmenting
Nonword repetition
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Structural-Functional Examination
• Structures: symmetry, anomalies
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Lips
Teeth
Mandible/maxilla
Hard/soft palate/uvula
Pharynx
Tonsils
• Function
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Lips
Tongue
Palate
Diadochokinetics
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Hearing Screen
• Pure tones at 20 dB SLP
– .5, 1, 2, 4 KHz
• Why?
– The role of otitis media with effusion in the
development of speech is unclear
– Impaired hearing at age 18 to 21 months resulted
in a 10 to 21 fold risk increase for speech disorder
later (Shriberg, Friel-Patti, Flipsen, & Brown, 2000)
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Supplemental Assessment
• If the child presents with unusual speech
production difficulties, it may be necessary to
obtain supplemental measures. Some
examples are:
– If motor speech difficulties are suspected, the
motor system should be evaluated further, e.g., to
test for apraxia of speech
– If the clinician suspects that the language system
is impaired, receptive and especially expressive
language abilities should be tested.
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Completing the Evaluation and Making
a Diagnosis
• A comprehensive set of data has been collected. Next step: Diagnosis
• Does the child have a speech sound disorder or not?
• If yes: differential diagnosis
– Consider all potential candidates
– Select the candidate that best fits the child’s profile
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Articulation (consistently misarticulated) errors
Phonological (pattern-based) errors
Or both
If phonological errors:
– Delay or disorder?
– Consistent or inconsistent?
• From supplemental testing
– Motor-based speech disorder
– Receptive and/or expressive language
• How severe is the disorder?
• What effect does the disorder have on the child’s daily life?
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From Diagnosis to Treatment
• No intervention necessary
– The data show that the child’s speech is within normal limits for age and sex
– The data show that the child’s speech errors are slightly delayed compared to
typically developing children
• Intervention recommended
– There is a moderate to severe delay
– There is evidence that the child’s speech is not following typical trajectories
and most likely will not self-correct
• The clinical context
– Depending on available resources, the SLP must show
• Standard scores lower than 1.5 SD below the mean (or lower)
• A certain number of speech sounds across classes must be in error
• Next step: selecting a treatment approach that has been shown to be
effective and that is appropriate for the type of speech disorder described
in the assessment
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Connections
• This chapter: Process of gathering and interpreting information
when a child is referred for an initial evaluation because of concerns
regarding her or his speech production
• Chapter 2: Detailed overview of tools for describing and measuring
children’s speech abilities for clinical as well as research purposes
• Chapters 4, 5, and 6: Various aspects of speech development in
typically developing, English-speaking children, providing a
reference against which to compare disordered development
• Chapter 7: Acquisition of prosody and ways to assess it.
• Chapter 22: Pathway from diagnosis to treatment selection, design,
and implementation; also: use of assessment throughout treatment
to document progress and probe for generalization
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Concluding Remarks
• Assessment is also a regular component of
treatment to track
– Daily/weekly progress
– Generalization probes
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