Determining the Existence of a Communication Disorder.

Determining the Existence of a Communication Disorder

A thoughtful A thoughtful problem solverproblem solver who brings who brings current understanding of communication current understanding of communication disorders to bear on the problems of the disorders to bear on the problems of the client.client.

The diagnostician

The most important tool is the The most important tool is the diagnostician.diagnostician.

Characteristics of a diagnostician (Emerick & Haynes, 1986)

• Flexibility – must be able to gain from new experiences, within the Flexibility – must be able to gain from new experiences, within the testing situation to shift from a predetermined plantesting situation to shift from a predetermined plan

• Personal attributes – empathy, congruency an unconditional positive Personal attributes – empathy, congruency an unconditional positive regard regard

• Sensitivity – detect subtle physical, psychological or interactional Sensitivity – detect subtle physical, psychological or interactional changes in client’s behaviorchanges in client’s behavior

• Insight into the meaning of behaviorsInsight into the meaning of behaviors• Evaluative attitude – critical, questioning attitudeEvaluative attitude – critical, questioning attitude• Persistent curiosity - inquisitiveness and determined to search for Persistent curiosity - inquisitiveness and determined to search for

explanationsexplanations• Objectivity Objectivity • Rapport – establishment of a working relationship based on mutual Rapport – establishment of a working relationship based on mutual

respect, trust and confidence that encourages optimum performance of respect, trust and confidence that encourages optimum performance of bothboth

Guiding Principles of Diagnosis (Darley, 1964)1.1. Beware of priori conceptions (avoid biases and Beware of priori conceptions (avoid biases and

preconceptions)preconceptions)2.2. Stick to first-order facts (describe rather than speculate)Stick to first-order facts (describe rather than speculate)3.3. Choose the simplest explanation consistent with the Choose the simplest explanation consistent with the

facts (be careful with cause and effect)facts (be careful with cause and effect)4.4. Keep your conclusions tentative rather than absolute Keep your conclusions tentative rather than absolute

(don’t be afraid to change your mind) – you are not (don’t be afraid to change your mind) – you are not ethically bound to be correct – but to seek the best for ethically bound to be correct – but to seek the best for your clientyour client

5.5. Respect the relevance of normsRespect the relevance of norms6.6. Seek the counsel of other professionalsSeek the counsel of other professionals

Clinical Standards

The collection of knowledge, beliefs, and The collection of knowledge, beliefs, and attitudes that will determine your clinical attitudes that will determine your clinical interpretations of the information you have interpretations of the information you have obtained.obtained.

The process of making clinical judgments

Steps to clinical Steps to clinical problem solvingproblem solving

1.1. Establish the clinical questionEstablish the clinical question

2.2. Determine the information needed to answer the Determine the information needed to answer the questionquestion

3.3. Determine how to obtain this informationDetermine how to obtain this information

4.4. Gather the informationGather the information

5.5. Interpret the information using clinical standardsInterpret the information using clinical standards

6.6. Answer the questionAnswer the question

Diagnosis

The clinical process concerned with The clinical process concerned with understanding the clients communication understanding the clients communication disorder.disorder.

This is an on-going process.This is an on-going process.

Paradigm of diagnosis (Emerick and Haynes, 1986)

Parent InformationAnd counseling

Clinical ManagementSuggestions

Case History

Prior Reports,

Tests

ClientObservation

InterviewInformalTesting

FormalTesting

Diagnosis Synthesis of Findings

ReferralPrognosis

Addition to Clinician’sFund of Knowledge

Clinician’s Knowledge and Skill Base

The need to be descriptive

• The first law of diagnostics:The first law of diagnostics:

Describe the Describe the behaviorbehavior

• If you cannot describe it, you do not If you cannot describe it, you do not understand it; or understand it; or

• You cannot expect to understand the You cannot expect to understand the behavior if you cannot describe it.behavior if you cannot describe it.

Description does not guarantee understanding, Description does not guarantee understanding, but description makes understanding but description makes understanding possible.possible.

Behavior (Muma, 1978)

““Behavior is relative, conditional, complex, and Behavior is relative, conditional, complex, and dynamic. Accordingly, clinical assessment must dynamic. Accordingly, clinical assessment must be relative, contextual, process oriented and be relative, contextual, process oriented and dynamic. Contrary to some views, it should not dynamic. Contrary to some views, it should not be categorical, quantitative, or normative. These be categorical, quantitative, or normative. These three traditional notions need to be challenged. three traditional notions need to be challenged. Clinical assessment should be about an individual Clinical assessment should be about an individual as he functions in natural contexts or deals with as he functions in natural contexts or deals with systems and processes directly relevant to natural systems and processes directly relevant to natural behavior.”behavior.”

The clinician’s role

• Siegel (1975)Siegel (1975)

““The best The best instrumentinstrument available is a clinician who available is a clinician who has some knowledge of research and theory in has some knowledge of research and theory in language, some experience in describing and language, some experience in describing and dealing with important communication dealing with important communication behaviors, and some reservoir of confidence in behaviors, and some reservoir of confidence in his or her own abilities to observe behavior, his or her own abilities to observe behavior, develop hypotheses, and change ideas and develop hypotheses, and change ideas and approaches when necessary.”approaches when necessary.”

• In other words we need observations.In other words we need observations.

Determination of the Complaint

Address the concerns of the client and othersAddress the concerns of the client and others

• Why has the person come to us?Why has the person come to us?• Determine who is concerned about the Determine who is concerned about the

communication performance and whycommunication performance and why

Determination of the Existence of a Communication Disorder• Does the person have a communication Does the person have a communication

disorder, and if so, what aspects of disorder, and if so, what aspects of communication are affected?communication are affected?

What is a communication disorder??

• Write in a piece of paper your definition.Write in a piece of paper your definition.

• Consider that the communication disorder is Consider that the communication disorder is not only the behavior, but also the not only the behavior, but also the relationship between the client and the relationship between the client and the person’s current and future audiences…person’s current and future audiences…including the client as an audienceincluding the client as an audience

• Consider the social systemConsider the social system

Terminology Used

• Impairment – the disruptions in the basic Impairment – the disruptions in the basic biological and psychological systems that biological and psychological systems that are necessary for communication.are necessary for communication.

• Disability – the functions disrupted by the Disability – the functions disrupted by the impairmentimpairment

• Handicap – limitations in the fulfillment of Handicap – limitations in the fulfillment of social and cultural functions that result from social and cultural functions that result from impairments and disabilities.impairments and disabilities.

• Social values very importantSocial values very important• When we say a person has a communication When we say a person has a communication

disorder we are making a statement about a disorder we are making a statement about a relationship the person’s communication behavior relationship the person’s communication behavior and the problems they may face in their life and the problems they may face in their life because of their communication skills.because of their communication skills.

• Judgment involves considering likely Judgment involves considering likely consequences of interactions with social context—consequences of interactions with social context—social penaltiessocial penalties

Reactions and Attitudes

Determine Client and Family Feelings toward Determine Client and Family Feelings toward the disorderthe disorder

Identifying Associated Problems

Communication Problems may occur in Communication Problems may occur in context of other problems.context of other problems.

Determining Factors Causing or Exacerbating the Problem• The etiology of the problem – reasons for presenting the The etiology of the problem – reasons for presenting the

behaviorbehavior• Terms (Emerick and Haynes, 1986)Terms (Emerick and Haynes, 1986)

• Predisposing – Agents that incline or dispose an Predisposing – Agents that incline or dispose an individual toward communication impairmentindividual toward communication impairment

• Precipitating factors – factors that actually bring about Precipitating factors – factors that actually bring about the onset of the problem, are generally no longer the onset of the problem, are generally no longer operating and may not be identifiableoperating and may not be identifiable

• Perpetuating – variables responsible for the persistence Perpetuating – variables responsible for the persistence of the abnormality, currently at workof the abnormality, currently at work

Determining Factors Causing or Exacerbating the Problem• Some may be readily identified and some Some may be readily identified and some

may notmay not• Some may be treated and some may notSome may be treated and some may not• Some may be directly within the client Some may be directly within the client

some notsome not• Some may be in the past and some in the Some may be in the past and some in the

presentpresent

Prognosis – Course of the Problem (change)• Depends onDepends on

• Client’s ageClient’s age• Severity of the problemSeverity of the problem• Cause(s) of the problemCause(s) of the problem• Characteristics of the speech and language Characteristics of the speech and language

performanceperformance• Client and family reactions to the problemClient and family reactions to the problem

Determining Treatment Alternatives

• Therapy – Efforts to modify the communication Therapy – Efforts to modify the communication problem problem

• Very much related to diagnosisVery much related to diagnosis• Basic issue concerning treatment – whether or not Basic issue concerning treatment – whether or not

initiating treatment or continuing treatment is initiating treatment or continuing treatment is warranted.warranted.

• QuestionsQuestions• What is the prognosis?What is the prognosis?• Will outcome be improved if treatment is Will outcome be improved if treatment is

provided?provided?

Models of Diagnosis

Different orientations that guide the decision Different orientations that guide the decision making processmaking process

Diagnosis – Science and Art

The Medical Model

• Orientation emphasizes the classification of symptoms into Orientation emphasizes the classification of symptoms into a disease category that often has a particular cause. a disease category that often has a particular cause.

• Objective is on classification and explanation.Objective is on classification and explanation.• Once the diagnosis is done, focus is on knowledge about Once the diagnosis is done, focus is on knowledge about

the disease to make decisions about its course and the disease to make decisions about its course and treatment outcomes.treatment outcomes.

• AssumptionsAssumptions• Problems tied to a disease categoryProblems tied to a disease category• Disease is internal to patientDisease is internal to patient• Nature and cause can be predetermined through Nature and cause can be predetermined through

examinationexamination• Treatment is on causeTreatment is on cause

Behavioral Model

• Primary interest is in characterizing the client’s Primary interest is in characterizing the client’s performance in tasks that are viewed as important to performance in tasks that are viewed as important to school and social setting.school and social setting.

• Focus is on describing the child’s performance on relevant Focus is on describing the child’s performance on relevant tasks rather than behaviors suggesting a diseasetasks rather than behaviors suggesting a disease

• Focus is on conditions that ma lead to improved Focus is on conditions that ma lead to improved communication performance even if these factors were not communication performance even if these factors were not involved in the cause of the problem.involved in the cause of the problem.

• Interested in ways of changing the behavior often using Interested in ways of changing the behavior often using educational or behavioral models to encourage change.educational or behavioral models to encourage change.

Systems Model

• Requires looking at the family and cultural context Requires looking at the family and cultural context of clientof client

• Observe client in natural settingsObserve client in natural settings• Assessment performed at school/home rather than Assessment performed at school/home rather than

officeoffice• Learn from contexts and interactionsLearn from contexts and interactions• Communication Problem is seen as a mismatch Communication Problem is seen as a mismatch

between client and environmentbetween client and environment• Focuses on describing behaviorsFocuses on describing behaviors