Exploring the need for dynamic assessment in the diagnosis of children with suspected language disorders

Introduction

In the past decades, considerable attention has been given to the role of children's language development in education for children in general as well as children from low socio-economic (SES) and culturally and linguistically diverse populations (CALD) (Finders et al., 2023; Hoff, 2013). Language difficulties, either due to environmental factors such as insufficient language exposure or opportunity to learn, or neurodevelopmental disorders such as language disorder, are risk factors for academic difficulties and exclusion, with associated societal costs (Cronin et al., 2020). Developmental language disorder (DLD) is one of the most common developmental disorders, with a prevalence of 7–10% (Norbury et al., 2016), and the associated difficulty acquiring and using one's native language(s) compared to peers affects both learning in general, reading and writing ability and social life (Bishop et al., 2016). This means that early identification of language difficulties, timely intervention to address children's language and language learning abilities, and efforts to reduce the impact of these difficulties are urgent.

National school curricula in many countries, including Sweden, set detailed goals across various subjects, all requiring strong language abilities for students to fully engage with and meet the curriculum standards while promoting multilingualism to varying degrees. (Paulsrud et al., 2020). This is also reflected in recent OECD frameworks for language learning, which many countries have adopted (Marconi et al., 2020). Understanding and appraisal of a wide range of spoken and written discourse types, verbal reasoning, articulating and presenting knowledge, and communicating with teachers and peers in both spoken and written language are some of the explicit central requirements. In addition, national curriculum tests, as well as classroom assessment and evaluation of learning (both summative and formative), are often delivered and conducted through spoken or written language. Although there has been an increased focus and debate on the need for differentiating ways of presenting and expressing knowledge in learning, academic success relies heavily on spoken and written language proficiency.

In recent decades, the need for developing early identification and intervention services for children with language disorders has also been highlighted (Skarżyński and Piotrowska, 2012). Assessment of suspected language disorders among children from culturally and linguistically diverse populations constitutes a challenge in many countries (Scharff Rethfeldt et al., 2022). In Sweden, children in second language studies comprise about 14% of all students (Skolverket, 2023). Due to segregation, it is not uncommon that children born in Sweden to parents who do not speak Swedish at home do not get enough high-quality exposure to Swedish until school age or later (Andersson et al., 2019). Differentiating language difficulties due to lack of experience and insufficient opportunities for language learning from compromised language learning ability due to a language disorder constitutes an enormous challenge for professionals both within and outside the school system, such as SLPs, special education teachers, and psychologists. To broaden the scope to a global perspective, migration in recent years has increased the number of children from CALD backgrounds (Mwanri et al., 2022). This constitutes a challenge for clinical professionals in healthcare and within school systems worldwide.

The challenge regarding accurate identification and diagnosis of language disorders is not restricted to the assessment of second language learners. Research has also highlighted several general challenges with standardized assessment tests, for example, norm comparisons, problems with sensitivity and specificity for different populations, and problems with reliability and validity, in addition to the more apparent cultural and linguistic biases (see, e.g., Andersson et al., 2019).

The challenges regarding assessment and intervention for children with language and reading disorders and children from CALD populations are also evident in the Scandinavian context (Hallin and Partanen, 2022). While the need for supporting children with language disorders in education has been highlighted in recent years by state authorities like the National Agency for Education (Skolverket) and The National Agency for Special Needs Education and Schools (SPSM) in Sweden, SLPs in both schools and clinics lack instruments for assessment of language abilities that have been standardized and norm-referenced on a Swedish population, especially for the older school-age population. This can be partly explained by fewer speakers compared to English (Swedish ≈10 million, Norwegian ≈5 million, Danish ≈6 million), but most of all, a lack of SLPs working directly with school-age children and thus a smaller market for such tests, although this is changing rapidly. The number of norm-referenced tests for reading and writing skills is greater than for assessment of language abilities, most likely because professionals in schools also use them.

The critique of standardized norm-referenced testing has a long history, originating in cognitive and educational psychology. From the 1970s onward, this led to the development of Dynamic Assessment (DA) procedures for assessing cognitive functioning, which later included language learning abilities (Feuerstein et al., 1979; Haywood and Lidz, 2006; Poehner and Lantolf, 2005).

A central tenet in DA is Vygotsky's concept of the Zone of Proximal Development (ZPD) and the need to assess not only the current level of functioning (cognitive, language, etc.) but also the plasticity and emergent and potential level of functioning. In the literature, DA is often operationalized as a test-intervention-test paradigm, revealing additional information about the child's responsiveness to intervention and the modifiability of the child's development (Haywood and Lidz, 2006). Central to the development of DA have been the works of Reuven Feuerstein and his theory of Structural Cognitive Modifiability, stating that cognitive abilities are not fixed traits but that they can develop over time through the enrichment of appropriate forms of instruction within the framework of Mediated Learning Experiences (Tzuriel, 2013). Of particular interest has been the role of DA in the assessment and intervention of children from CALD, low SES backgrounds and children with special needs (Tzuriel, 2021).

While DA was originally developed in the field of cognitive assessment and intervention, the last decades have seen a broadening of research on DA related to language development and abilities (Peña et al., 2001; Peña and Iglesias, 1992; Poehner and Lantolf, 2013) and diagnosis and intervention of language disorders, particularly among second-language learners (Bedore and Pena, 2008; Gorman, 2015; Hasson and Joffe, 2007; Kapantzoglou et al., 2012; Lu and Hu, 2019; Peña et al., 2014; Petersen et al., 2017). In addition, studies on the implementation of DA within the language classroom and teaching context (Poehner et al., 2017; Poehner and Lantolf, 2005; Vergara et al., 2019) and DA in understanding reading development (Dixon et al., 2023a) have also been published. Several research reviews and meta-analyses have suggested that DA has clear advantages in the assessment of learners with a range of difficulties in that it taps additional information about the plasticity of cognitive and language functions, but it has also been suggested that it contributes to higher classification accuracy of language and reading disorders (Caffrey et al., 2008; Dixon et al., 2023b; Orellana et al., 2019).

In the field of SLP practice, there has been recent and critical debate regarding the need for consensus on the criteria used for identifying and classifying language disorders in children, as well as the need for developing assessment instruments and procedures. A multidisciplinary panel including international experts (the CATALISE consortium) have presented several consensus statements related to language difficulties and language disorders (Bishop et al., 2016; 2017). Regarding assessment, the panel agreed that assessment approaches that explore how children learn language provide a promising approach. The authors conclude that DA embodies this kind of approach and that a test-intervention-retest approach can help indicate a child's language modifiability, differentiate differences in language development from language disorder, and identify possible intervention goals and intervention procedures. In addition, the Multilingual-Multicultural Affairs Committee of the International Association of Communication Sciences and Disorders (IALP) also recommend using DA to assess multilingual clients (Scharff Rethfeldt et al., 2022).

It can be noted that several frameworks and models for assessment and intervention have been developed that can be classified as interactionist approaches, similar to DA. One example is the framework Response-to-Intervention (RTI), which is a model for the identification and remediation of reading difficulties in school-age children where all children are ensured good quality teaching and exposure, struggling students are identified and given increased intensity and individualization of intervention in several tiers before concluding that a difficulty is due to a learning disorder (Grigorenko, 2009; Lidz and Peña, 2009). RTI has also been discussed in the context of language development and support (Ebbels et al., 2019). Another approach resembling DA is formative assessment, which focuses on teachers’ assessment of domain-specific skills or curricular knowledge, for example, in school subjects like math (Antón and García, 2021; Black and Wiliam, 2009). In this study, we choose to focus on DA with the purpose of aiding diagnostic decisions, specifically in the field of speech and language pathology, given the recommendations given by the above-mentioned CATALISE consortium and the IALP.

In summary, DA procedures have been recommended as an assessment tool by leading language experts. There is evidence that adding DA methods to an assessment battery yields a higher sensitivity and specificity in the challenging L2 population than relying on standardized norm-referenced tools only, and the lack of norm-referenced instruments for Scandinavian countries highlights the need for more alternative tools. To our knowledge, both knowledge and use of DA procedures for assessing suspected language disorders are underdeveloped in the Scandinavian context. A previous research project examining the assessment practices of medical, psychological and educational professionals in several European countries, including Sweden and Norway, showed that standardized assessment of intellectual, behavioural and language functioning was mainly used. At the same time, only a small portion of the professionals also used dynamic, formative and/or contextual observations in the assessment of children with special educational needs and children with developmental difficulties (Lebeer et al., 2012). To complement this research, a recent study has shown that DA is used significantly more by Swedish SLPs working in areas with low or mainly low SES than in areas with mostly high/high SES (Hallin and Partanen, 2022). Also, Hallin and Partanen (2022) identified one published dynamic assessment tool used in the Swedish context named DYMTA, a Swedish version adapted from Dynamic Evaluation of Motor Speech Skills (DEMSS; Strand et al., 2013).

Despite DA being recommended as vital in SLP practices, there are few studies about the knowledge and use of DA, including what might promote or hinder such use among SLP practitioners in different countries.

This study examined the current knowledge and use of dynamic assessment (DA) approaches, specifically in identifying children with language disorders among Speech and Language Pathologists (SLPs) in Sweden. We investigated whether there are variations in SLP practices based on workplace, multilingual, and socioeconomic settings in DA knowledge and use, considering CALD and SES factors. We particularly wanted to know

to what degree do SLPs acknowledge DA as a concept, i.e., how well-known is it?

Participants and methods

Participants (n = 565) were drawn from a large national web-based survey study on SLP assessment practices in Sweden. The survey was conducted using Qualtrics XM software (Version 09/2019, Qualtrics, Provo, UT) with a specific section dedicated to questions focusing on DA (see appendix A). Participants were recruited via local and national networks for SLPs, advertising in social media dedicated to SLPs, and e-mail lists from the Swedish Association of Speech and Language Pathologists. A total of 815 respondents answered the survey. After cleaning for incomplete responses (i.e., not completing the survey or not filling in the informed consent), 565 participants who completed the section with questions related to DA remained (see Hallin and Partanen, 2022 for a detailed account of the original survey). Demographic data, including workplace, multilingual assessment setting and SES setting, was reported by respondents (see Table 1).

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Table 1.

Demographics of respondents (n = 565).

	Work setting %			Multilingual assessments %			SES %
	Clinicaln = 318	Habilitationn = 98	Municipaln = 148	Lown = 127	Mediumn = 221	Highn = 217	Lown = 115	Mixedn = 396	Highn = 54
%	56.4	17.4	26.2	22.5	39.1	38.4	20.4	70.1	9.6

Note: Work setting: Clinical includes hospitals and private practices. Habilitation includes habilitation centres and disability services; municipal includes preschools and schools. Multilingual setting: Low was defined as lower than the proportion of multilingual children in Sweden (up to 20%), mixed around population estimations up to half of all assessments (21–50%) and high defined as the majority of assessments (50%+). SES setting was defined as parental level of education, income, and socio-geographic housing structure.

We deployed a convergent mixed methods design, simultaneously collecting quantitative and qualitative data via the survey (Creswell and Plano, 2017). Descriptive and inferential statistics were used to analyse the quantitative data. Chi-square tests of homogeneity (2xC) were used to determine if there existed a difference between the binomial proportions of three independent groups (three groups with varying work settings, multilingual assessment setting and SES setting, respectively) regarding how frequently (low vs high) DA was used as a tool among those who were familiar with DA. In order to meet the assumptions for chi-square tests of homogeneity (2xC), the frequency of DA use was thus collapsed into a dichotomous variable (low-high). Low indicated answers from respondents stating “never” and “rarely” on the survey question “How often do you practice DA?” while high indicated that respondents used DA “often” or “always” in their practice. Post hoc analysis involved pairwise comparisons using the z-test of two proportions with a Bonferroni correction.

Data from the free text questions were analysed using qualitative content analysis (Creswell et al., 2011), following the Graneheim and Lundman approach (Graneheim et al., 2017). This involved the authors reading the free text entries and coding them into preliminary categories related to the questions. The categories were then collapsed into descriptive themes and finally interpreted and summarized in relation to the study's aims. Finally, they were presented in narrative form.

Results

The results from the survey showed that out of 565 SLPs, 407 respondents (72%) were familiar with the concept of DA. Among these 407 respondents, 143 (35.1%) reported never using DA in their practice. Out of those SLPs that reported that they used DA, 174 respondents (42.8%) used DA seldom, 78 respondents (19.2%) used DA often, and 12 respondents (2.9%) used DA always. Thus, 264 out of all 565 respondents (47%) used DA to a varying degree.

The results from the chi-square tests showed that three independent binomial proportions were not statistically significant for differences in frequency of DA use between the three work setting groups (Clinical, Habilitation and Municipal), only including the subset of SLPs who were familiar with the concept of DA (n = 407). However, the chi-square test concerning differences in use of DA was statistically significant when comparing low, mixed and high SES health catchment areas (p = .009) and the three multilingual assessment settings (Low, Medium, High) (p = .048).

As shown in Table 2, SLPs working in health catchment areas with low SES present the highest proportion of frequent use of DA in their practices (32.3%), similar to SLPs with the highest proportion of multilingual assessments (28.1%). Post hoc analysis with pairwise comparisons showed that low SES differed significantly from high SES in DA use but not when comparing mixed with high or low SES settings. Post hoc analysis concerning multilingual assessment settings could, however, not establish statistically where the differences between the three groups occurred.

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Table 2.

Low versus high frequency of use of DA in daily practice among SLPs who are familiar with DA, divided by work setting, proportion of multilingual assessments and SES in catchment area.

	Work setting %			Multilingual assessments %			SES %
Frequency of DA use in practice (%)n = 407	Clinicaln = 222	Habilitationn = 63	Municipaln = 122	Lown = 84	Mediumn = 163	Highn = 160	Lown = 93	Mixedn = 281	Highn = 33
Low (77.9)	81.5	74.6	73.0	84 . 5	80.4	71.9	67.7a	79.7 a,b	90.9 b
High (22.1)	18.5	25.4	27.0	15.5	19.6	28.1	32.3a	20.3a,b	9.1b

Note: Bolded numbers indicate significant chi-square tests. Each subscript letter (a,b) denotes a subset of SES categories whose column proportions do not differ significantly from each other at the .05 level.

Among those 407 SLPs who were familiar with DA and/or practised DA, 188 SLPs (46%) rated that the need for DA was very big (5 out of 5 on a Likert scale), and 185 (45%) rated the quite large need for DA (4 out of 5). The 34 remaining SLPs (8%) rated neutral (3 out of 5), and no SLPs rated little or very little need for DA.

Among all 565 SLPs, 53 (9%) reported that they received DA training as part of their graduate training at the university. However, 105 (19%) could not remember if DA was introduced. 34 SLPs (6%) had received postgraduate training in DA.

An analysis of respondents’ attitudes towards DA and recurring themes in the free-text responses showed that a majority of the respondents who do not use DA (n = 283) reported a positive view. Frequent comments were about a lack of knowledge about how to conduct DA and a lack of time and resources for conducting DA. Notably, several respondents reported that they use assessment techniques similar to DA in a more informal way but did not define this as DA. Only a few respondents in the non-user group expressed hesitation regarding the value of DA in assessment, stating mainly the lack of validated instruments and questions about the evidence for DA.

Among respondents using DA who also commented (n = 109), all respondents were positive about the value of using DA. Frequent themes were the necessity of using DA for children with diverse backgrounds (CALD) and the increase in ecological validity of results from DA, particularly when used to plan treatment/intervention. Similarly to non-users, some users reported that the DA techniques they used were informal and stated the lack of validated measures and procedures as reasons.

Discussion

The current study explored how well-known DA is among SLPs in Sweden, the prevalence of DA procedures and tools, whether there were differences in the frequency of DA use depending on work settings, the proportion of multilingual assessments, and socioeconomic status in the health catchment areas of the SLPs. We also wanted to know the degree and type of formal training in DA and the perceived need for and motivations for using DA among SLPs.

Given the recommendation for DA in SLP assessment practices by the CATALISE consortium and others (e.g., Scharff Rethfeldt et al., 2022) and the evolving evidence that DA procedures increase the diagnostic validity of children with language disorders, the results are concerning. Even though many SLPs recognize DA as a concept and identify suitable target groups for DA, particularly for children with diverse backgrounds (CALD), it is alarming that almost a third of the SLPs are not familiar with the concept of DA, and that only about a fifth of the practising SLPs actually use DA frequently, and only 15% has received training in DA during their graduate or postgraduate studies. These results reveal a substantial gap between recommendations and practice. In our investigation of the perceived need for and motivations for DA, some preliminary conclusions can be drawn.

Regarding the difference in the use of DA in different workplace, multilingual and SES settings, our results are in line with research finding that among children from low SES, standardized norm-referenced assessments might fall short of differentiating between language difference and language disorder (Andersson et al., 2019). This could explain the significant increase in the propensity to use DA among SLPs working with children from low SES settings, which aligns with previous research in DA, focusing specifically on children from CALD, low SES and children with special needs (Tzuriel, 2021). Among SLPs conducting a high proportion of multilingual assessments, this tendency for increased use of DA was also significant, although the statistical analysis could not establish where these differences occurred. The reason for this could be that the Bonferroni post hoc analysis is conservative. Still, it can be noted that the highest percentage of DA use was in the high multilingual assessment setting, almost double the frequency compared to low multilingual assessment settings. It can also be expected that there is a significant overlap between SES health catchment areas and the proportion of multilingual assessments, with many children from diverse CALD backgrounds growing up in areas with lower SES.

The awareness of the necessity for DA among those who know and/or use DA is overwhelming, with over 90% of these respondents rating quite or very large need of DA in the clinical practice of SLPs in Sweden. However, it is clear that the level of formal training in DA is low among SLPs in Sweden, both during graduate and postgraduate education. This is an urgent call for universities to increase their training in DA, given both the CATALISE and IALP recommendations and the body of research supporting DA, particularly for children with second language and low SES backgrounds. It is also urgent for workplaces to address the need for more knowledge and improved resources for training and use of DA. Although outside the scope of this study, an explanation for the lack of DA could be that use of DA as a diagnostic tool requires more extensive training and is more time-consuming than standardized norm-referenced tests. Combined with limited resources for training at many workplaces in Sweden and the scarcity of researchers and practitioners in the field of DA in Sweden, this serves as a bottleneck for the development of DA in the country. At the same time, it is a vicious circle: with the lack of validated tools for DA, training and practice are affected negatively, and with the lack of systematized knowledge following research and practice in DA, the incitements for validating tools and developing training are low. Also, standardized assessment tests are well established and have their own eco-system with a long tradition both in research and practice, publishing companies, and are more easily operationalized and administered than DA. Still, the research regarding DA reminds us of the need for increased efforts among researchers and practitioners.

A limitation of our study is that a survey with ratings and free text entries does not allow us to examine the qualitative understanding of DA more in-depth, and the more intricate interplay between promoting and hindering factors for using DA. However, the relatively large number of respondents allows us to draw some robust conclusions, even though the understanding and working definitions of DA might vary among respondents. In this context, it is also important to note that DA is not a single method but an umbrella term for several methods that share some characteristics. Also, our study was conducted with SLPs in Sweden, and of course, might have limitations in generalizability to other countries. However, our previous study of the assessment practices of SLPs in Sweden (Hallin and Partanen, 2022) showed that several challenges and themes have been seen internationally, which tentatively supports that our study of DA practices might have broader relevance.

Furthermore, studies on the frequency, use and experiences of DA among practitioners in different countries are scarce (Hallin and Partanen, 2022), and our study serves as an example of the importance of assessing the situation in a specific context in order to address the need of developing assessment practices. The recommendations from CATALISE and IALP for using DA as a part of diagnostic assessments constitute an essential starting point for many countries. The expanding evidence regarding the need for DA, particularly among CALD children, requires action from universities, researchers, graduate and postgraduate teachers, and trainers. It also calls for hospitals, clinics, municipalities, and relevant policymakers to address this need. Notably, our study shows that lack of knowledge, validated tools and procedures, and time and resources work as barriers to developing evidence-based DA assessment practices among SLPs. Many SLPs have resorted to using non-validated assessment tools to capture the dynamic and responsive aspects of children's language development and its potential plasticity. In these matters, we can do better.

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