Editor’s note: This is an excerpt of a post written by Tatyana Elleseff for her Smart Speech Therapy blog. Her full post can be read here.
As a speech-language pathologist who works in an outpatient psychiatric, school-based setting, I frequently review previous evaluations on incoming students. I notice several common threads in these reports. In this post, I share my thoughts regarding the lack of background information in student assessment reports.
Despite its key role in assessment, this section often gets left empty or includes only minimal details about the student’s age, grade level and reasons for referral. Occasionally, I also get notes on the student’s developmental milestones. A variety of reasons might cause the blank space: lack of parental involvement, lack of access to records or overwhelming paperwork burdens.
However, I remember multiple grad school professors telling me the vital importance this section plays in the student’s evaluation. Many years later, I still see the relevance. Unearthing the student’s family history, developmental milestones, medical/surgical history and past treatment frequently leads to a successful diagnosis. I understand legitimate barriers in getting this information, but I think if we dig deep enough, we can find the information we need.
I’ve used student background information to make important discoveries. These discoveries include traumatic brain injuries, family language and literacy disabilities, family genetic disorders or cognitive disabilities, maternal alcohol abuse during pregnancy, and more.
So what do I consider an adequate background history section of the assessment report?
- I begin with the child’s age and grade level, who referred the child and for what reason, and if the child received any form of speech-language assessment or treatment in the past. If I perform a reassessment—especially if it happens shortly after the last assessment took place—I provide a clear justification about why I feel the need for a reassessment. Here’s an actual excerpt from one of my reevaluation reports: Despite receiving average language scores on his _______speech-language testing, which resulted in the recommendation for speech therapy only, upon his admission to ______, student was referred for a language reassessment in _____, by the classroom staff who expressed significant concerns regarding validity and reliability of past speech and language testing on the ground of the student’s persistent “obvious” listening comprehension and verbal expression deficits.
- Next, document medical history, which includes prenatal, perinatal and early childhood diseases, surgical interventions and incidents. If a child has a longstanding history of documented psychiatric difficulties, you may want to separate that information within this section.
- Also list developmental history, which should include gross/fine motor development, speech-language milestones, and cognitive/socioemotional function. I typically add information regarding any early intervention services to this section.
- Then discuss the child’s academic performance. Mention if the student qualified for preschool services, any educational classification, results of previous testing and academic struggles, if applicable.
- I next cover psychiatric history. Briefly document when any emotional or behavioral problems first arose and how they’ve been treated. I also include recent psychiatric diagnoses, if available, and any medication the child takes.
- I consider this next section one of the most important: family history of genetic disorders, psychiatric impairments, special education placements, and language, learning or literacy issues. This helps me determine if language difficulties contribute to any behavioral issues and guides my recommendations with borderline assessment results.
I also briefly discuss family composition, as well as language knowledge and use. Family composition sheds insight on lack of consistent caregivers, prolonged absence of parental figures, or presence of a variety of people in the home potentially causing stress for children. Language knowledge and use relates to culturally and linguistically diverse children, understanding what languages are used at home and the child’s abilities in both languages. These factors help me decide what type of assessments might work best for this student.
So there you have it. I include all this information as background history for every one of my reports. I believe it contributes to making an appropriate and accurate diagnosis.
Tatyana Elleseff, MA, SLP, is a bilingual speech-language pathologist with Rutgers University Behavioral Healthcare and runs a private practice, Smart Speech Therapy LLC, in New Jersey. She specializes in working with multicultural, internationally and domestically adopted children, and at-risk children with complex communication disorders. She is an affiliate of ASHA Special Interest Group 16, School-Based Issues. Visit her website for more information or contact her at email@example.com.