You’re a new grad! Congratulations! All your hard work has paid off and you’re now ready to enter the work force! You’ve landed a great job evaluating minimally verbal preschoolers and children with autism. You soon find those lengthy evaluations you learned to do in grad school are perhaps not as practical as they once seemed. What is now valued is time – and you find you have very little of it now. What do you do?
How can you quickly, efficiently, and accurately complete assessments for preschoolers and children with autism who speak very few words, particularly when behavior and compliance are a factor in presenting standardized measures?
Here are 5 tips that I have learned over nearly 15 years of working with this population. I currently do mostly evaluations – sometimes up to 10 or 11 in a day - across my 2 job settings and am on a daily time crunch to finish both evaluations and reports quickly. These are tried and true techniques from personal experience, but may not work on every child. Your own clinical judgement, best available research, and needs of the client should be considered to make the best decision on a case by case basis.
Get the information you need early
For every evaluation you will need to know some basic information. Some information may be provided to you by your work location already (e.g., age, date of birth, presenting complaint). I will usually have most of the history information I need collected before the initial evaluation. This can be done either by phone, by emailing intake forms for the parent to bring filled out already, or by having the parent fill out an intake/questionnaire while waiting in the lobby.
You will want to briefly review this information again just before beginning the evaluation. You may need information such as: parent concerns (this will shape what measures you will give – unless you are required to give certain measures by your work location), medical/birth history, medical problems, feeding/swallowing/motor concerns, history of ear infections, developmental history (age first walked, crawled, age first babbled, spoke, combined 2 word utterances), etc.
By getting this information early you will avoid 20+ minutes of parent interview during the evaluation. For this population time is of the essence. If your evaluation is too long you risk fatigue from the child and tantrums.
Invest in bubbles and use them for transitioning!
When I go out to get the child from the waiting area, I will call the child’s name then blow bubbles. This helps reduce the fear of the unknown. Many children think they are going for a doctor’s visit where they will be poked and prodded. When they see the bubbles this helps them forget their fears and run towards you.
You can squat down and catch a bubble on the wand then offer it to the child to pop. This helps you establish early rapport as a safe and fun person. You can blow more bubbles, and while the child pops the bubbles, you can introduce yourself to the family (see number three). You can create a trail of bubbles for the child to follow all the way to the evaluation room.
Note: bubbles are also useful at the end of the session when the child may not want to leave.
I will usually indicate to parents that I will direct the child out of the room. I like to create a game where they follow the bubble trail out of the evaluation room. I’ll have the parent turn off the light of the therapy room on the way out because most children won’t run back into a dark room. For children who understand rewards, I’ll offer a sticker, a lollipop, or a small toy as a reward, but most of my preschoolers need the bubbles to leave the room peacefully.
This will save you from loud tantrums and parents having to pick up screaming children while other coworkers look on and wonder what you did to the poor child.
Introduce yourself to the child as well as to the parents
I have had children as young as two or three years old, point to their arms miming a needle stick with fear in their eyes as they stare at me. It is sometimes helpful to tell the child exactly what to expect, even if you are not sure that they can understand you.
For example, “Hi Johnny, My name is ____. Today we’re going to look at some pictures and play with some toys, then you’ll get a prize and be all done!” I usually repeat this three or four times in between blowing bubbles. Sometimes I’ll just say, “let’s go play!!”
To the parents you can say something like, “Hi ______, my name is _____ and I’m a speech pathologist. The evaluation for Johnny will take about 30 minutes of your time today.” I like to include a time so that this helps all of us stay on track. Of course we sometimes will take longer based on the needs of the child.
Set up your testing environment to elicit spontaneous communication and minimize tantrums
I will usually place a high interest toy on the treatment table and put all other toys in visible places that cannot be reached (also known as communication temptations). For example, I’ll put a large train set on the top shelf, Mr. Potato Head in a tightly closed clear bin, and a fun cause/effect musical toy on the table. This allows the child to eagerly approach the testing table in order to play with the toy.
I will generally tell the child something such as “you have to push the yellow, smiley face button to make it work!” in a cheerful voice. If the child pushes the correct button, it is clear that on some level he/she understands directions. If they don’t do anything, I’ll push the button and observe. Many children are able to imitate actions in play which is a good sign.
As we know from the literature, play is a precursor to speech and language development
If the child is not able to imitate after seeing me or the parent push the button once and stares at the toy in confusion, I’ll do it again. I make note of how many times it takes for the child to imitate. Children who don’t imitate at all will likely be more delayed than those who do imitate.
Of course, if the child just tries to eat the toys and doesn’t play properly at all this is another indicator of a delay depending on the child’s age.
Use appropriate tests
There are many options available for tests, but if you’ve worked with a population with difficulty complying with instructions (i.e., individuals with autism) you know that certain tests that require frequent pointing to pictures or following standardized directions with multiple manipulatives may not give you reliable results. Measures such as the Receptive-Expressive Emergent Language Test-Third Edition (REEL-3), Rossetti-Toddler Language Scale or Developmental Assessment of Young Children, Second Edition (DAYC-2) are able to provide information swiftly from parent report and clinical observation.
The final decision to use a particular test may be based on multiple factors including facility preference/requirements, type of scores needed, needs of the child, personal preference, etc. Using an appropriate test will ensure your evaluation is completed quickly and efficiently.
Completing the evaluation
So you’ve done it! You’ve completed an evaluation at your new job in 30 minutes or less. You had all the information you needed prior to seeing the child, your child was happy to see you and come with you, your child and family understood who you were and how long you would be with them, you set up your testing environment so that you could observe the child’s method of communication spontaneously, and you used an appropriate test!
What do you do now? Your next steps (report writing, referrals, etc.) depend on your facility’s regulations and policies. I often will review the findings briefly and then take a few minutes to train the parents on how to create a language rich environment in their homes that will facilitate communication development (another topic of discussion), then let them know the next steps in terms of receiving their report and services if warranted. The art of writing a 10-15 minute report is another topic for another day.
All the best in your speech pathology journey! May it be all that you hoped for upon entering graduate school.