Principles of Assessment

What is assessment (ax)?

• “process of collecting and interpreting relevant data for clinical decision making.”

• Is both a problem solving and descriptive process

• Diagnostic, evaluation and assessment can be used interchangeably

3 approaches to assessment

1. Medical Model

2. Descriptive-developmental

3. Systems model

Medical model approach

• Aims to determine the cause of the problem or etiology

• Impairment based

• Appraisal

  • Collection of quantitative and qualitative information about the client

• Diagnosis

  • Interpretation of data to determine if a problem exists or differentiating it from another problem (differential diagnosis)

e.g. Qiana’s video - diagnosis aspect of speech impairment, figuring out cause of hypernasality

Descriptive-developmental model

• Less distinction between appraisal and diagnosis

• Emphasis on the present problem rather than causative factors

• asking lots of questions to get to bottom of what’s wrong

• collecting data on barriers to goals

• E.g. presenting characteristics of aphasia (already had lot of therapy for acutes stages of disorder)

• e.g. Leah simucase - therapist was gathering info about how she communicates and the barriers she has with communicating to others, learning to use AAC device

Systems/social model

• Stresses importance of whānau/family and cultural context that the client functions in as part of the assessment

• Social model

• e.g. Leah - Focusing on how she can use AAC to overcome barriers that she has in her life – communicating with her family, teachers at preschool etc

How to choose an ax model?

Slection of model of ax can depend on these factors:

• Type of communication needs or disorder demonstrated by client

• Setting e.g. hospital v community

• Team approach – whānau/family members are critical member of the team

• Philosophical orientation of client/organization

ICF and assessment models

ICF not an assessment or ax framework, but each ax model fedds into different parts of the ICF

Medical model

• body function and structure (impairment)

Descriptive developmental

• activities, environment and personal factors

Systems/social model

• participation

What can/does and SLT assess when working with a client/whānau?

• Language

  • Expressive (formulation/production)

  • Receptive (comprehension/understanding)

  • Pragmatic language/ social skills

  • Literacy

• Speech

  • Intelligibility

  • Delay/ disordered

  • Weakness/coordination

  • Dysarthria or apraxia of speech

• Voice

• Fluency

• Swallowing/ dysphagia

  • Muscles used for swallowing and speech (oromotor/cranial nerve ax)

• Multi-model communication (AAC)

• Hearing – screening only

7 purposes of assessment in SLT

1. Screening

2. Determining eligibility for services

3. Tracking and documenting progress

4. Establishing a baseline

5. Determining intervention targets - goals

6. Determining diagnosis/differential diagnosis

7. Prognosis

Screening

• Involves the collection of data to determine likelihood of a problem

• Usually pass/ fail – or has a “cut-off score”

• Number of specific screening instruments

• Can also utilise standardised assessments

• May screen a number of areas and not just presenting problem

• Example:

  • Adult: Bedside Evaluation Screening test – (BEST)

  • Child: Clinical evaluation of language fundamentals 5th edition screen (CELF-5)

Determining eligibility for services

• Services which are provided by public funding (such as Ministry of Education, Ministry of health) or third party (such as health insurance) will have eligibility requirements

• May also apply for eligibility for support services

  • Child disability allowance

  • Community services card

• Important to utilise many types of assessment - to cover all bases for a client

Tracking and Documenting Progress

• Measure progress towards goals

• Evaluate the effectiveness of therapy

• Provides information for discharge from therapy

• Can take the form of formal re-evaluation and also ongoing assessment during therapy - Qiana simucase

Establishing a baseline

• Document the clients current functioning or perception of their problem

• Profile of strengths and weaknesses, perceptions e.g. quality of life scales

• Gather baseline information in variety of settings and contexts – to ensure accurate profile of client’s abilities

• Research assessment to show current ability

• e.g. Leah simucase

Determining Intervention targets - goal setting

Intervention targets may be determined in a number of ways including:

• The client and family priorities (systems) – Quality of Life scales

• What is developmentally appropriate (medial/developmental/descriptive)

• What will have the greatest impact on the client’s communication (developmental/descriptive)

Informal ax to assist with goal setting:

• Stimulability testing to determine communication behaviours that may be easily modified or elicited

• Dynamic assessment– trial /testing to determine client responsiveness to different supports, complexities

e.g. Leah simucase - what form of AAC will be most useful for the client, what is most developmentally appropriate, what will have the greatest impact on the client’s communication

Determining Diagnosis or Differential Diagnosis

• Answers: what is the specific disorder?

• Useful to determine specific course of action and determine appropriate therapy plan

• Diagnosis might be for within a disorder category such as flaccid vs spastic dysarthria

• Differential diagnosis will be across disorder types such as aphasia vs apraxia vs dysarthria

Prognosis

• Understanding the diagnosis - knowing what is likely to occur

• Reviewing evidence of diagnosis

• thorough investigation, not making incorrect assumptions and missing things

• Strengths and weaknesses of assessment

  • Can result in ability to determine prognosis for some areas of our work

  • E.g. Stuttering – later onset can predict ongoing stutter.

  • E.g. developmental delay (phonological process error) versus lateral /s/ (articulation error)

  • E.g. Voice – find a cyst on instrumental ax, know surgery is needed not voice therapy

Methods/Types of Assessment

1. Interview

2. Norm referenced

3. Criterion referenced

4. Behavioural Observation

5. Instrumental

6. Ecological (also called ‘family centred practice’)

Interview

Informal

• Aka case history

• Perception of problem, history

• Open/closed question types

Formal - a specific tool

• If client too young/unable to contribute

• E.g. Aphasia needs assessment

• E.g. Language use inventory (child)

Norm-referenced Tests

• Standardized instruments “formal assessment” that can be used to compare individual’s performance to the performance of others with similar demographic characteristics

• Useful for determining existence of problem and establishing eligibility for services

• Statistical properties that allow for meaningful comparisons

  • Validity, reliability, bell curve, percentile ranks, standard scores

• Procedures for norm-referenced assessment are detailed and must be followed exactly to allow for interpretation and comparison to norms

• Common examples:

  • Boston Diagnostic Aphasia Examination (BDAE)

  • Language sampling (SALT)

Criterion Referenced Procedures

• Measures skill in terms of mastery not in comparison to others

• Does not provide information whether this individual’s performance varies from the norm

• Useful for establishing baseline functioning, developing intervention targets and documenting progress.

• Administration procedures can be individualised (such as across settings)

• Scores are pass/ fail, percentage correct, simple rating scales etc.

• Common examples:

  • Developmental Scales – for example - age of first words

  • Apraxia Battery for Adults

• use if standardised assessment doesn’t fit

Behavioural Observation

• Describes behaviour in a systematic fashion without reference to any predetermined standard

• Most common to use quantitative systematic observation

• Useful for measuring presence/ absence of behaviour, frequency, rate, magnitude, duration

• Observations are made in real time

  • e.g. conversational analysis to describe competency of conversation of person with aphasia

• Also used to assess attitudes and impairment

  • E.g. Check lists for social skills/pragmatic language turn taking, asking questions

Instrumental Assessment

Includes:

• Range of instrumentation for hearing assessment

• Acoustic analysis of speech

  • Praat

• Voice

  • Endoscopy - e.g. Qiana simucase

• Swallowing

  • Flexible endoscopic evaluation of swallowing (FEES)

  • Videofluroscopy (VFSS)

Ecological Assessment

• Tamariki/ children only

• Used frequently in Ministry of Education

• Ideally child will be in inclusive classroom

• Supports a consultation/coaching approach to intervention

• How child manages in different environments and settings

  • What environments could they be?

• Purposes:

  • Generate information about social, education, functional activities and routines in natural environments/settings where the child with additional needs wants/needs to be a successful and active participant.

  • Determine what resources, supports child needs to participate in/receive maximum benefits from activities and routines

  • Plan for provision of required resources/supports

Steps in ecological assessment

1. Person centred planning - Getting to know tamaiti/child

2. List routines/activities in typical day

3. Prioritize activities/routines – develop broad goal statements

4. Observe, interview re: expectations

5. Observe/record tamaiti in action

6. Compare – behaviour with expectations

7. Highlight language/communication skills – tamaiti needs ako/ to learn

8. Ascertain why lang/com not being demonstrated

9. State lang/com objectives for each activity

10. Develop individualised plan (including ax data) for each objective

Assessment isn’t a one off

• will complete as much assessment as is needed with client/whānau to gain an understanding of the problem/their concerns.

• Each session you gain data as evidence for progress.

• You will re-assess if/when their goals change

Other considerations of assessment

• High rate of co-occurrence of problems

  • Such as articulation problems and language problems

• Comorbidity with other developmental problems

  • Such as hearing impairment with language delay in Downs syndrome

• Collateral areas of assessment

  • Cognitive status

  • Literacy

  • Social/ emotional/ behavioural

  • Motor functioning

To complete ax picture

Need holistic/comprehensive ax including:

• Cognitive status

• Co-morbidities/ co-occurring conditions and their impact

• Social / emotional/ behavioural

  • E.g. Quality of life scales

• Motor skills - fine/gross

• Home/school/work

• Aswell as the SLT specific assessment information

• Depending in what type of team you are working in you and/or another team member may gather and assess this information

• are all components of ICF addressed - of so = well rounded ax

Planning for ax/questions you can ask yourself before undertaking ax

• What is the presenting problem/concern?

• Who knows the most about this client?

• What is the kaupapa/purpose of the assessment?

• What do you already know?

  • No need to assess what you already know!

• What do you want to find out during the assessment?

• What setting/environment will you need to complete assessment in?

• How will you find out what you want to know?

General steps in ax process

1. Referral

2. Data Gathering

   • (Records, case history, interview, client goals/concerns)

3. Diagnostic/Aromatawai (Ax)

   • (Observation, ax/tests, collateral areas, dynamic, stimulability)

4. Results

   • (Score, analyze, severity and prognosis)

5. Recommendations

6. Complete report

   Discussing and working alongside client/whānau /educator at all steps

Administration considerations

Assessment setting

• Across contexts

• Background noise

• Familiarity – tester and setting

• In person or telepractice?

Room set up

• where to sit

• how to record

• where to sit caregiver

Formal ax

• follow instructions in manual

Client behaviour

• fatigue

• medical stability

• ‘compliance’

Feedback

• neutral

• within testing guidelines

Scoring/Interpretation

• scoring in the moment, audio-recording

• use the manual

• complete in pen not pencil

Testing Considerations

Barriers:

• Assessment only represents the client’s performance in a limited number of situations during a limited time period, and under limited circumstances

• You only get to see what the client does not necessarily all they are capable of doing (Ecological and dynamic ax aims to overcome these areas)

• Time spent during assessment forms the beginning of effective intervention and good intervention is characterised by regular, ongoing, assessment of its effectiveness