Chapter 9 – Discussion
9.4 Assessment practices of SLPs working in paediatric TBI
9.4.1 Factors influencing assessment practices in clinical practice
9.4.1.3 Different assessment practice across clinical settings
Areas of communication assessed were similar for inpatient or community
settings. One difference was in the area of word finding, which was an area more
likely to be assessed in an inpatient setting. Word finding difficulties are viewed as a
specific and common linguistic deficit after TBI (Ewing-Cobbs & Barnes, 2002;
Hough, 2008), therefore SLPs may specifically screen for this in an inpatient setting.
The Renfrew Action Picture Test (RAPT; Renfrew, 2003) was reportedly used more
commonly in an inpatient setting. This tool is quick to administer, which might be a
reason for its application in that setting. While the TOPS (Huisingh et al., 2005) was
both infrequently used and had overall lower satisfaction ratings, SLPs working in an
inpatient setting reported increased satisfaction ratings in relation to this tool,
particularly with regard to their goal setting and intervention planning. The TOPS
(Huisingh et al., 2005) evaluates six aspects of critical thinking, those being making
inferences, sequencing, negative questions, problem solving, predicting, and
determining causes. In an inpatient rehabilitation setting, this structure of the test
may provide valuable therapy tasks to aid the SLP in designing a therapy program.
These results do provide valuable information to the SLP looking to identify potential
tools to use in an inpatient setting as opposed to a community one and would also
allow the SLP to think more broadly of other tools to use. Popular and frequently
used tests such CELF-4 and the PPVT (Dunn & Dunn, 2007) were used as
frequently in either setting, suggesting repetitive use, and depending on the time
results. As part of best practice, repetitive assessment should identified as
something to avoid in clinical practice due to practice effects (Heilbronner et al.,
2010). Improvements in performance on retesting should be due to a true change in the individual’s ability rather than the result of previous exposure to the same or
similar measure.
9.4.1.4 Different assessment practices across SLP’s years of experience
Surprisingly a discourse assessment, ERRNI (Bishop, 2004) was utilised
more frequently by SLPs with less years of experience. As it was published in the
last decade, use by newer graduates may be due to its inclusion in speech pathology
curricula. The ERRNI (Bishop, 2004) provides scores about content, recall, mean
length of utterance and comprehensionand other discourse assessments may not
provide this information as comprehensively. This assessment would be worth
pursuing in studies of paediatric TBI with future investigations evaluating the clinical
utility of this tool as well as validity and reliability for this clinical population.
9.4.2. Summary
In summary this is the first international study to explore assessment practices of
SLPs working in paediatric TBI. This group of SLPs routinely assessed receptive and
expressive language, with some variability in the frequency with which they reported
assessing functional communication. Consistent with the US study by Frank and
colleagues (1997) the CELF and PPVT remain prevalent in clinical practice. The use
of the CELF-4 was high and consistent throughout the major English-speaking
The CELF-4 was rated highly on criteria such as, its ability to identify
strengths and weaknesses and assist with goal setting, raising questions of how
models such as ICF (World Health Organization, 2001) are applied in clinical
practice with tools that are predominately word and sentence level tasks,
representing an impairment level assessment. Other tools rated highly for both
criterion included the ERRNI (Bishop, 2004), CCC-2 (Bishop, 2003a) and the CASL
(Carrow-Woolfolk, 1999). Factors influencing clinical practice included country, with
use of discourse, and functional communication differing between the SLPs from the
various countries. Assessment tools such as the RAPT (Renfrew, 2003) and TOPS
(Huisingh et al., 2005) may have more clinical utility in an inpatient setting, but some
of the popular tools such as the CELF-4 are possibly being repeated in an inpatient
and community setting.
9.5 Clinical Evaluations of Language Fundamentals Fourth Edition (CELF-4) 9.5.1 Tabulation of core language, index scores and supplementary tools
The Clinical Evaluation of Language Fundamentals Fourth Edition (CELF 4;
Semel et al., 2003) was the most frequently used standardised assessment by SLPs
working in paediatric TBI and DLI. This assessment had the highest rating of satisfaction owing to its ability to highlight strengths and weaknesses in a child’s
communication skills as well as assist in goal setting and intervention planning.
The core language (CL), receptive language (RL), and expressive language
(EL) index scores were the most routinely tabulated index scores by SLPs working in
paediatric DLI and TBI. As outlined in Figure 1.4, Chapter 1, SLPs use the CELF-4 to
EL to describe the language disorder. There was variability between SLPs in both
paediatric TBI and DLI regarding whether further tabulation of the language content
(LC), language structure (LS), and language memory (LM) index score was
conducted. SLPs infrequently examined the underlying clinical behaviours of the
language disorder, those being the working memory (WM) index score,
supplementary tests phonological awareness (PA), word associations (WA), and
rapid automatic naming (RAN). Nor were the observational rating scale (ORS) or
pragmatic profile (PP) frequently used to evaulate how the disorder affected
classroom performance.
There was only one difference in the frequency of tabulation between SLPs
working across TBI and DLI, and this was with WA, with SLPs working in TBI more
likely to tabulate this supplementary test. The WA test has been a tool used by neuropsychologists’ to evaluate cognitive outcomes (Rabin et al., 2005). The authors
of the CELF-4 suggest using the WA test when clinicians suspect cognitive
difficulties in the child with executive function, working memory, and attention and
specify TBI as a clinical group for which it should be used. The authors also suggest
that WA provides additional information about vocabulary knowledge.
SLPs working in paediatric TBI are using the WA from the CELF-4 to identify
underlying clinical behaviours of the language disorder, which is how this is
described in the manual and in Figure 1.4. This is consistent with assessment
practices of neuropsychologists (Rabin et al., 2005) who also assess WA. This
therefore raises clinical questions about how these results may be interpreted
between an SLP and neuropsychologist and how this may inform clinical decision-
making and whether there is unnecessary duplication of assessments.
attention, processing speed, and working memory (Rabin et al., 2005), which all
provide further information regarding the cognitive abilities of the child. The results of
this study suggested that WM index score is infrequently administered in clinical
practice even though WA is suggested by Semel et al. (2003) to be of benefit in the
assessment process for children with WM difficulties. What remains to be found is
whether this subtest is tabulated in conjunction with the WM index score or if they
examined and interpreted in isolation.
Interestingly, given the increased focus within an assessment on pragmatic
skills and participation in everyday context (Owens, 2014), the use of the ORS and
PP was low and those supplementary tools were the least likely to be used in clinical
practice by SLPs working in TBI. Further understanding of the barriers to its use in
clinical practice is necessary. The CELF-4 provides impairment-based measures as
well as measures on how language and communciation affects performance outside
the clinical context, which has been highlighted as providing additional clinical
information for the SLP (Bishop & McDonald, 2009; Massa, Gomes, Tartter,
Wolfson, & Halperin, 2008). The results of this study would suggest that SLPs are
not currently utilising all aspects of the CELF-4.
General measures of RL and EL, like that presented in the CELF-4, are not
sensitive to the communication challenges of a child with a TBI (Ewing-Cobbs &
Barnes, 2002; Liégeois et al., 2013; Turkstra, 1999). Furthermore, subtle language
difficulties are more appropriate areas to assess (Dennis & Barnes, 1990; Hallet,
1997). The CELF-4 has not yet been validated for use on the paediatric TBI
population, and the EL index score has been reviewed, with results suggesting it
showed weak construct validity (Turkstra et al., 2005b). With this in mind, it needs to
administered and tabulated scores for paediatric TBI as with the DLI or whether
other aspects of the test should be of more benefit given differences in DLI and
cognitive communication difficulties after TBI. Evidence currently available would
suggest that SLPs are using the CELF-4 the same way it would be used for a
school-aged child with a DLI. This has possible implications for such a child with a
TBI in terms of access to therapy, resources, and ongoing support if access to these
services or resources are reliant on an assessment result that consists of CL, RL,
and EL index scores that have been shown not to identify impairment. Further
research should be considered utilising other subtests from the CELF-4 besides
those comprising CL, RL, and EL.
As demonstrated in the Rolandic epilepsy study by Overvliet et al. (2013), the
additional new CELF-4 subtests of semantic processing; that identified areas of
weakness in that population could possibly highlight that the tabulation of the LC
index might be appropriate to be utilised in clinical research and highlight their
clinical utility with the paediatric TBI population. Similarly, the ORS and PP
supplementary tests should be utilised in clinical research as they assist with
providing clinical assessment recommendations that reflect evidence-based practice.
The LC index score is designed to measure semantic development and
interpretation of factual and inferential information (Semel et al., 2003), areas of
language and cognitive communication that have been highlighted as areas of
weakness (Ewing-Cobbs & Barnes, 2002; Hallet, 1997; Sullivan & Riccio, 2010).
Nonetheless, considering the CELF-4 is routinely used in clinical practice, the results
suggest that some SLPs are not examining these areas of weakness.
Finally, even though the SLP has a role in assessing phonemic awareness
surveyed infrequently used the PA supplementary test. This may highlight that the
use of the PA measure is not favoured in preference for other aspects of the CELF-4
in clinical practice.