Speech-language development as proceduralization and skill learning: Implications for assessment and intervention.

PURPOSE: This article considers how speech-language development can be viewed as proceduralization and skill learning. Viewing speech-language development in this way has important implications for the assessment and treatment of individuals with speech-language disorders. METHOD: Topics discussed are Ullman's (2016) distinction between the procedural and declarative memory systems, speech-language development as proceduralization and skill learning, and implications for assessment and intervention. CONCLUSION: Norm-referenced measures provide a good measure of deliberative speech-language processes whereas social conversations and discourses about familiar topics with familiar listeners provide the best indication of proceduralized speech-language processes. Intervention goals and planning need to consider which speech-language operations should be proceduralized and which ones will primarily require deliberative processing. Additional research and clinical application of these ideas are clearly needed to develop more precise criteria to define the line of demarcation between deliberative and proceduralized speech-language processes.

Prologue: Reading Comprehension Is Not a Single Ability.

Purpose: In this initial article of the clinical forum on reading comprehension, we argue that reading comprehension is not a single ability that can be assessed by one or more general reading measures or taught by a small set of strategies or approaches. Method: We present evidence for a multidimensional view of reading comprehension that demonstrates how it varies as a function of reader ability, text, and task. The implications of this view for instruction of reading comprehension are considered. Conclusion: Reading comprehension is best conceptualized with a multidimensional model. The multidimensionality of reading comprehension means that instruction will be more effective when tailored to student performance with specific texts and tasks.

Epilogue: Reading Comprehension Is Not a Single Ability-Implications for Assessment and Instruction.

Purpose: In this epilogue, we review the 4 response articles and highlight the implications of a multidimensional view of reading for the assessment and instruction of reading comprehension. Method: We reiterate the problems with standardized tests of reading comprehension and discuss the advantages and disadvantages of recently developed authentic tests of reading comprehension. In the "Instruction" section, we review the benefits and limitations of strategy instruction and highlight suggestions from the response articles to improve content and language knowledge. Conclusions: We argue that the only compelling reason to administer a standardized test of reading comprehension is when these tests are necessary to qualify students for special education services. Instruction should be focused on content knowledge, language knowledge, and specific task and learning requirements. This instruction may entail the use of comprehension strategies, particularly those that are specific to the task and focus on integrating new knowledge with prior knowledge.

Influence of prior knowledge and interest on fourth- and fifth-grade passage comprehension on the Qualitative Reading Inventory-4.

PURPOSE: In 2 experiments, we examined the influence of prior knowledge and interest on 4th- and 5th-grade students' passage comprehension scores on the Qualitative Reading Inventory-4 (QRI-4) and 2 experimenter-constructed passages. METHOD: In Experiment 1, 4th- and 5th-grade students were administered 4 Level 4 passages or 4 Level 5 passages from the QRI-4. Prior knowledge was assessed by key concept questions from the QRI-4. Interest was rated on a 5-point scale. In Experiment 2, 4th- and 5th-grade students were administered 2 passages from the QRI-4 and 2 experimenter-constructed passages. One general question was used to assess prior knowledge, and 3 measures were used to assess interest. RESULTS: Prior knowledge as measured by key concept questions on the QRI-4 or a general question had minimal impact on passage comprehension. More important, only one third of the prior knowledge questions on the QRI-4 were related to a comprehension question. When these question pairs were analyzed, having prior knowledge was still not predictive of comprehension performance. Interest level had minimal impact on comprehension performance. CONCLUSIONS: This study's findings raise concerns about the usefulness of prior knowledge assessments on the QRI-4. Interest had little impact on comprehension performance. Educational implications are discussed.

Improving clinical practices for children with language and learning disorders.

PURPOSE: This lead article of the Clinical Forum addresses some of the gaps that exist between clinical practice and current knowledge about instructional factors that influence learning and language development. METHOD: Topics reviewed and discussed include principles of learning, generalization, treatment intensity, processing interventions, components of language therapy, grammar goals, and goal prioritization for students with language and learning difficulties. CONCLUSION: The gaps that exist between current knowledge about learning, language development, and clinical practice often do not receive as much attention as the gaps in the evidence base that addresses the efficacy and effectiveness of language intervention practices and service delivery models. Fortunately, clinicians do not have to wait for future intervention studies to apply their knowledge of learning and language development to clinical practices.

Specific language impairment.

The acquisition of language is one of the most important achievements in young children, in part because most children appear to acquire language with little effort. Some children are not so fortunate, however. There is a large group of children who also have difficulty learning language, but do not have obvious neurological, cognitive, sensory, emotional, or environmental deficits. Clinicians often refer to these children as language disordered or language impaired. Researchers tend to refer to these children as specific language impaired (SLI). Children with SLI have intrigued researchers for many years because there is no obvious reason for their language learning difficulties. SLI has been found to be an enduring condition that begins in early childhood and often persists into adolescence and adulthood. The language problems of children with SLI are not limited to spoken language; they also affect reading and writing and thus much of academic learning. Knowledge of the characteristics of SLI should aid physicians, pediatricians, and early childhood specialists to identify these children during the preschool years and ensure that they receive appropriate services. With high-quality language intervention and literacy instruction, most children with SLI should be able to perform and function adequately in school and beyond.

Auditory training for children with auditory processing disorder and language impairment: a response to Bellis, Chermak, Weihing, and Musiek.

PURPOSE: We respond to Bellis, Chermak, Weihing, and Musiek's (2012) criticisms of the evidence-based systematic review of Fey et al. (2011) on the effects of auditory training on auditory, spoken, and written language performance of children with auditory processing disorder or language impairment. In general, we argue that the conceptualizations and methods on which our review was based were well motivated, and that our original conclusions are valid given the limited evidence that is currently available from clinical studies of auditory training with school-age children with auditory processing disorder or language impairment.

Pharmacological dosage concepts: how useful are they for educators and speech-language pathologists?

The first part of this response to Baker (2012) examines studies that have attempted to determine the optimum treatment intensity of reading interventions associated with a Response to Intervention (RTI) model of service delivery. In general, the findings indicated that differences in broad measures of intensity (duration and scheduling) did not result in differences in reading outcomes. These non-significant findings and Baker's excellent discussion of all of the factors that impact treatment outcomes led me to question how useful pharmacological dosage concepts are for educators and speech-language pathologists (SLPs). This commentary concludes by acknowledging that the more information available about the active ingredients of treatment episodes, the better able one will be to design effective and efficient interventions to improve speech, language, and literacy.

What speech-language pathologists need to know about auditory processing disorder.

PURPOSE: To consider whether auditory processing disorder (APD) is truly a distinct clinical entity or whether auditory problems are more appropriately viewed as a processing deficit that may occur with various developmental disorders. METHOD: Theoretical and clinical factors associated with APD are critically evaluated. RESULTS: There are compelling theoretical and clinical reasons to question whether APD is in fact a distinct clinical entity. Not only is there little evidence that auditory perceptual impairments are a significant risk factor for language and academic performance (e.g., Hazan, Messaoud-Galusi, Rosan, Nouwens, & Shakespeare, 2009; Watson & Kidd, 2009), there is also no evidence that auditory interventions provide any unique benefit to auditory, language, or academic outcomes (Fey et al., 2011). CONCLUSION: Because there is no evidence that auditory interventions provide any unique therapeutic benefit (Fey et al., 2011), clinicians should treat children who have been diagnosed with APD the same way they treat children who have been diagnosed with language and learning disabilities. The theoretical and clinical problems associated with APD should encourage clinicians to consider viewing auditory deficits as a processing deficit that may occur with common developmental language and reading disabilities rather than as a distinct clinical entity.

Auditory processing disorder and auditory/language interventions: an evidence-based systematic review.

PURPOSE: In this systematic review, the peer-reviewed literature on the efficacy of interventions for school-age children with auditory processing disorder (APD) is critically evaluated. METHOD: Searches of 28 electronic databases yielded 25 studies for analysis. These studies were categorized by research phase (e.g., exploratory, efficacy) and ranked on a standard set of quality features related to methodology and reporting. RESULTS: Some support exists for the claim that auditory and language interventions can improve auditory functioning in children with APD and those with primary spoken language disorder. There is little indication, however, that observed improvements are due to the auditory features of these programs. Similarly, evidence supporting the effects of these programs on spoken and written language functioning is limited. CONCLUSION: The evidence base is too small and weak to provide clear guidance to speech-language pathologists faced with treating children with diagnosed APD, but some cautious skepticism is warranted until the record of evidence is more complete. Clinicians who decide to use auditory interventions should be aware of the limitations in the evidence and take special care to monitor the spoken and written language status of their young clients.

Balancing certainty and uncertainty in clinical practice.

PURPOSE: In this article, I question how practitioners can balance the certainty and confidence that they can help their patients with the uncertainty that makes them continually question their beliefs and assumptions. METHOD: I compare the mechanisms of science and models of clinical practice that may help practitioners achieve the right balance between total acceptance of the status quo and an open willingness to explore and accept new ideas. CONCLUSION: Clinical practice, unlike science, has no independent self-correction mechanism that leads to consensus about best clinical practices. Evidence-based models provide principles and guidelines for clinical practice, but ultimately, clinical decisions may be influenced most by a practitioner's epistemology (belief systems) and propensity for rational thinking.

Solving the reading crisis--take 2: the case for differentiated assessment.

PURPOSE: The responses to my initial article (A. G. Kamhi, 2007) have raised serious questions about whether embracing the narrow view of reading is the best way to reduce the persistently high levels of reading failure experienced in today's schools. This afterword provides another attempt to offer a solution to this problem without the distraction of the narrow view of reading. METHOD: This second attempt to solve the reading crisis draws on the five responses in this clinical forum and other helpful comments from colleagues who responded to the initial article in The ASHA Leader. CONCLUSION: The way to eliminate high levels of reading failure is to differentiate word recognition from domain-general reading comprehension and specific subject knowledge in high-stakes assessments. This differentiation will focus attention on the true crisis in American education-knowledge deficiencies in the sciences, history, math, literature, and other subject areas that are important for success in the 21(st) century.

The case for the narrow view of reading.

PURPOSE: This prologue reiterates the case for the narrow view of reading as a solution to the persistently high levels of reading failure that occurs in our schools and provides a brief summary of the 5 response articles. METHOD: The arguments that support the narrow view of reading are presented and the respondents are introduced. CONCLUSION: Although the contributors to this clinical forum may have different views, we all are working toward a common goal: improving the literacy levels of children in our schools.

A meme's-eye view of nonspeech oral-motor exercises.

The ideas motivating the use of nonspeech oral motor exercises (NSOMEs) cluster into three memeplexes that reflect the rich history of oral motor and nonspeech activities in speech-language pathology; a bottom-up, discrete skill theory of learning; and common treatment practices. The lack of clinical guidance provided by research also plays a role in the use of NSOMEs. The essence of the oral motor memeplex is the history of oral motor activities in speech-language pathology and the often detailed coverage these activities receive in the most widely read textbooks and publications in our profession. The essence of the discrete skill memeplex is that complex behaviors, like speech production, can be broken down into discrete sequences of processes and behaviors, and the best instruction and intervention involves discrete skills training, bottom-up approaches, task analyses, and developmentally sequenced materials. The clinical practice memeplex reflects a set of common clinical practices that contribute to the use of NSOMEs. These factors include the desire to provide state-of-the art treatment, a preference for broad-based, eclectic treatment approaches, and diverse and engaging activities that offer opportunities for measurable success. There are so many reasons to use NSOMEs that the more interesting question may be why some clinicians (< 15%) do not use these activities.

Treatment decisions for children with speech-sound disorders.

PURPOSE: In this article, I consider how research, clinical expertise, client values, a clinician's theoretical perspective, and service delivery considerations affect the decisions that clinicians make to treat children with speech-sound disorders (SSD). METHOD: After reviewing the research on phonological treatment, I discuss how a clinician's theoretical perspective influences goal selection. Five perspectives are considered: (a) normative; (b) bottom-up, discrete skill; (c) language-based; (d) broad-based; and (e) complexity-based. The literature on treatment efficiency is then considered, followed by a discussion of service delivery factors, client values, and clinician factors. IMPLICATIONS: I believe like M. Ylvisaker (2004) that treatment decisions are influenced the most by the changes that occur in client behaviors. These changes must, however, be experimentally validated, which is not always easy to do. M. Ylvisaker suggests that validation could take the form of trial therapy, diagnostic teaching, or dynamic assessment, but it may also be important to show that the treatment provided, not some other variable, was primarily responsible for the behavioral change (A. Tyler, personal communication, January 11, 2006).

Epilogue: some final thoughts on EBP.

PURPOSE: In this afterward, I will offer some final thoughts on this clinical forum by considering a central question of EBP--how experimental validation is defined--to illustrate the difficulty involved in implementing EBP. METHOD: The comments draw on critical reviews I have received on my article in this forum and conversations I have had with professional colleagues about EBP. CONCLUSION: Like most scientific constructs, EBP is open to different interpretations. At their worst, these differences have the potential to polarize clinical practice. The hope, however, as Kent and Fey have expressed, is that articles and commentaries such as these will serve as the basis for discussion and even argument among clinicians and researchers as we attempt to define a philosophy and implementation of EBP suited to our profession.

A meme's eye view of speech-language pathology.

In this article, the reason why certain terms, labels, and ideas prevail, whereas others fail to gain acceptance, will be considered. Borrowing the concept of "meme" from the study of evolution of ideas, it will be clear why language-based and phonological disorders have less widespread appeal than, for example, auditory processing and sensory integration disorders. Discussion will also center on why most speech-language pathologists refer to themselves as speech therapists or speech pathologists, and why it is more desirable to have dyslexia than to have a reading disability. In a meme's eye view, science and logic do not always win out because selection favors ideas (memes) that are easy to understand, remember, and copy. An unfortunate consequence of these selection forces is that successful memes typically provide superficially plausible answers for complex questions.

Two paradoxes in stuttering treatment.

UNLABELLED: The premise of this article is that effective communication should be a central, overarching goal in the treatment of stuttering. Not focusing on communication may have some unintended negative consequences on treatment. The negative consequences are the result of two paradoxes that confront clinicians and clients: the listener paradox and the communication paradox. The listener paradox concerns the different ways that typical listeners and clinicians respond to stuttering. The communication paradox concerns the use of treatment procedures that may have negative consequences on communication. Clinicians and clients need to evaluate treatment procedures in terms of the effect they may have on communication. Understanding these two paradoxes and making effective communication the focus of treatment may improve the long-term treatment outcomes of people who stutter. EDUCATIONAL OBJECTIVES: The reader will learn about (1) why effective communication should be the central goal in the treatment of stuttering; (2) how the listener and communication paradoxes may negatively impact on communication; and (3) how understanding these paradoxes may improve the long-term outcomes of people who stutter and also improve the comfort level clinicians have in treating individuals who stutter.