Unbabbled: CAPs

Dynamic Testing for Social Communication Disorders Using the CAPs with Dr. Adriana Lavi

Have you ever sent a text asking someone how they’re doing and received the reply “great.” You may have interpreted it as your friend is having a wonderful day. However, they might have actually been having a horrible day and meant “great” sarcastically. Understanding a person’s meaning behind their words (otherwise known as pragmatic language ability) often requires knowing a lot of contextual clues, including tone of voice, body language and facial expressions. “Great” with an eye roll is vastly different from “great” with a smile. These subtle clues can be difficult to detect in many pragmatic language assessments, yet they are a large factor in determining if a person has a social communication disorder and pragmatic language difficulties. 

In this episode, we speak with Dr. Adriana Lavi about her new video-based pragmatic language assessment, the Clinical Assessment of Pragmatics (CAPs). She discusses her clinical background, what led her to develop the assessment tool, and why this assessment can be more accurate in detecting pragmatic language disorders. This interview can help parents and educators understand why their child may have scored well on other language assessments, yet they struggle with reading these ever-important social cues in real situations.

About Dr. Lavi

Adriana Lavi, PhD, CCC-SLP, is a practicing licensed school-based speech-language pathologist with more than 15 years of experience working with children and young adults who present with a variety of communication disorders. She currently supervises speech-language pathologists in three school districts in Southern California. Dr. Lavi developed the Clinical Assessment of Pragmatics (CAPs) and founded the Lavi Institute for Research and Professional Development, where she completes research and develops a variety of treatment programs. She has also served as an assistant professor at the Department of Communicative Disorders at Loma Linda University. Her primary research interests focus on pragmatics, and the assessment and treatment of culturally and linguistically diverse students with communication disorders. Dr. Lavi is also a mother of four young, highly energetic little boys, ages 6, 5, 4 and 18 months. 

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Stephanie (00:05):

Hello, and welcome to Unbabbled, a podcast that navigates the world of special education, communication delays, and learning differences. We are your hosts, Stephanie Landis and Meredith Krimmel, and we're certified speech language pathologist who spend our days at The Parish School in Houston, helping children find their voices and connect with the world around them.

Stephanie (00:23):

Part of pragmatic language is the ability to understand a person's meaning behind their words. This often requires knowing a lot of contextual clues, including tone of voice, body language, and facial expressions stating that your morning has been "great" with an eye roll is vastly different from "great!" with a smile. These set of clues can be difficult to detect in many pragmatic language assessments. Yet they are a large factor in determining if a person has pragmatic language difficulties. In this episode, we speak with Dr. Adriana Lavi about her video-based pragmatic language assessment, the clinical assessment of pragmatics. Dr. Lavi is a practicing licensed speech language pathologist with more than 15 years of experience working with children and young adults who present with a variety of communication disorders. She currently supervises SLPs in three school districts in Southern California. She also recently founded the Lavi Institute for Research and Professional Development where she completes research and develops a variety treatment programs. During the episode, Dr. Lavi discusses her clinical background, what led her to develop the assessment tool and what makes this assessment accurate in detecting pragmatic language disorders. This interview may also help parents and educators understand why their child may have scored well on other language assessments yet struggled socially in real life interactions.

Meredith (01:47):

Welcome. We are so excited. We are live here at TSHA on the convention floor, and we're here speaking with Dr. Lavi. Welcome, Dr. Lavi!

Dr. Lavi (01:56):

Wow. Thank you so very much. I'm so excited and so grateful for this opportunity, everyone.

Meredith (02:02):

Dr. Lavi developed the clinical assessment of pragmatics. Can you just give us a brief overview of what that assessment is?

Dr. Lavi (02:09):

Yes, of course. This is the very first video-based assessment of pragmatic language and social communication. Um, it is a comprehensive test. It looks at six separate domains, six areas, and what's different about it is that it looks at nonverbal language, not just overall, um, how children use a nonverbal language. We separated into judgment and performance. So we look at the ability to decode facial expressions, the decoding, and understanding vocal inflections, tone of voice. And we also look at, um, children's ability to use facial expressions. How well they, um, are able to express their messages using their faces like eyebrow movement and vocal inflections and all of that.

Meredith (03:02):

Great! What led you to develop the test?

Dr. Lavi (03:05):

I, my background is, um, being a school-based speech pathologist. So a while ago, as a high school SLP, middle and high school SLP, I've been frustrated with the area of pragmatics. To me, this is the most subjective and vague area. So difficult to organize it and to make sense out of it. So the difficulties that I've encountered were mostly with the fact that my kiddos would pass with flying colors on all of those tests on pragmatic language. And the difficulty that I was seeing was, um, them being able to read pictures really well. Pictures are static, and they would read facial expressions off of those pictures really well. So I thought that that was one of the weaknesses and decided to use videos. Why not videos? They're just real life social situations that help, would help us elicit more authentic responses from our kiddos.

Stephanie (04:09):

Yeah, I'm really looking forward to diving into this assessment and using it in my practice because I've come across the same thing is that if you present it in a very static way of looking at a picture or reading a scenario question to the children they kind of know what to say and they can give a very canned response, but when you really then watch them either in the classroom or in the clinic or at the park or interacting with their family, they're presenting very differently. And we're at such a big gap of these standardized tests not really capturing where their true struggles were.

Dr. Lavi (04:43):

Exactly.

Meredith (04:43):

When you were designing this protocol what kind of clients did you think would benefit from, from this type of testing?

Dr. Lavi (04:51):

So, mostly I had in mind, our higher functioning students with autism, but also kiddos with pragmatic language impairment. And these are the students who mostly pass or do really well on standardized assessments. And, you know, as an SLP with so many kiddos on your caseload, in a school-based setting, I, I know it's just so difficult to do informal observations, which are crucial and so important. But honestly, personally, me personally, as a clinician, I've struggled with being able to elicit, um, responses such as ability to express empathy or ability to read sarcasm. It's really difficult to try and catch that on campus with students. You really need to have your situation set up in a way that you would be able to, um, listen in or hear that it's actually almost impossible.

Meredith (05:47):

Yeah. You can't follow them around all day and see them in different situations and settings.

Dr. Lavi (05:52):

Yeah. So for me, it was really important to figure out a way for us to look into their pragmatic skills, but in an effective, but also authentic way. So that's why the idea of videos came up, um, that we would be able to show them real life, real people, real situations. And how would they judge a situation, social situation, for example, or what would their response would be? I mean, obviously it's not perfect, but it is as close as you could probably get.

Meredith (06:26):

So you mentioned when you do this assessment, there's different areas and domains that you're assessing. So after the assessment is completed, does it help a speech language pathologist really narrow down what areas they need to address where they need to start with their therapeutic plan?

Dr. Lavi (06:41):

Yes. So the way the test is designed, we separate pragmatics into two big areas of judgment and performance. So we're basically looking at pragmatics in terms of receptive way. How much they're able to read, how much social context and social cues can they understand, how well they process situations and then also we look at performance. So that has to do with how well they actually act out and how they perform in real life. And then also we look at intent, communicative intent. What is the point? What is the intent of your conversation, or what message do you want to send and also ability to read that intent? So the test is separated into these big areas. So at the end, the results will give you insights into their comprehension versus ability to perform. And also we'll separate pragmatics into basic instrumental. How well they perform in everyday situations versus higher level affective intent that has to deal with emotions. How well you communicate your emotional state, or how well can you read other people's emotions? And we know that that's a huge difficulty that our kiddos with autism have. And finally, the last piece is parent linguistics and that's nonverbal language. So you would be able to get information on how well they read faces, vocal inflections, overall nonverbal language, and how well they use that.

Stephanie (08:18):

Yeah, just the other day I was working with a child and we were trying to read a video and the character smirked in it. And it was interesting that something that subtle, they were not picking up on that cue, but it totally changed the intent of what the character was doing and they missed that cue. But if we hadn't used video, it would be really hard to, to get that out of just a like static situational test.

Dr. Lavi (08:43):

And, you know, it's interesting is that research shows that children with autism focus their attention on lower part of the face. So basically your mouth, but if you think about it, most of our communication happens everywhere, nose and up. So it's all in your eyes, eyebrows and the root of your nose. And this is where we mostly communicate our emotions. And if you're just not focusing on that part, you're missing out on a whole big, huge area.

Stephanie (09:12):

Yeah, so much information is missed.

Meredith (09:16):

Yeah. I love how you guys focus on intent and intention because, um, that's so hard to assess in static pictures and you really need context and videos allow you to bring in context to a situation that helps really understand a person's intention.

Meredith (09:32):

Who did you have do your videos?

Dr. Lavi (09:33):

Oh, that's, that's really interesting. So I can tell you the story of how the test was developed. I was actually a school-based SLP and a PhD student. So I was working in a high school and one day walking my dog in a park, I saw a bunch of teenagers talking to each other from a distance. And I was able to pick up a little bit on their conversation just off of their facial expressions and body language. And then I thought to myself, wow, I wish I could capture that on camera and I wish I could ask my students how much information they are able to pick off of that. So then I came home and I asked my sister and my cousin. She made a video of various social scenes. So these were initially really self-made silly videos of my sister and I acting out different situations where something goes wrong or just regular appropriate situations. Then I started using that with my kiddos in the high school, and I was shocked. I was shocked at how much information they're missing out on. And then it hit me. This has to be my dissertation. This has to be my area. So I developed a series of self-made videos and just, you know, played trial and error, asking different questions. And it's interesting, even simple questions won't get you to elicit the responses that you want. You can ask a question what went wrong, or you can ask, why did this person do this or that? And you're not actually able to get that processing, that thought processing. So with trial and error, different pilots studies, we figured out that the questions that need to be asked should be yes, no, first. So did anything go wrong in this video? And then the student would tell you yes or no. And then you follow up with the question: What went well? What went wrong? And this really leads you to get those responses and get the rationale of how they're processing these situations and the same thing for the expressive part. Show me, how would you say and what would you say and how.

Dr. Lavi (11:54):

So, I developed a bunch of videos and did a little bit of a pilot study. And then I thought to myself, you know, let's try and make professional videos out of it with actors. And, um, we hired a local filming company in, out of LA because I'm from California and we hired a bunch of students, actors, and we went ahead and we filmed the scenes. So this was my dissertation. Then we use this videos and we tested close to 200 students to validate the tasks, to see if this type of assessment, these type of tasks are valid and reliable and a good way to look at pragmatics.

Meredith (12:42):

To make sure there's reliability, that you're really actually testing what you hope that you're testing for. So you mentioned you were working with highschoolers when you develop this, what age range can this test be given to?

Dr. Lavi (12:53):

So originally, and for my dissertation, the test was given to students ages 13 to 18. But eventually when I graduated, I got my degree, my dissertation was done, my husband said, "you know what? You need to actually make it into a real test to help all the SLPs out there."

Meredith (13:13):

Thank you to your husband.

Stephanie (13:14):

Yes, thank you.

Dr. Lavi (13:15):

So we, we just started testing a bunch of kids starting age five, as young as five. And five to seven, we got a lot of variability in our data. So the data wasn't stable and only at age seven is where we're able to get really consistent responses from our typically developing students. So the age range for the test as of right now is seven to 18.

Stephanie (13:42):

Okay. Yeah. And that makes sense, children, five to seven and younger, still typically developing some of those subtle skills.

Meredith (13:49):

So you said that this was part of your dissertation. How did you make that leap and that jump from dissertation to a published available to the public test?

Dr. Lavi (13:59):

Oh my gosh. So one interesting story is that my husband is actually a statistician. My husband works for Quest Diagnostics. This is a company that develops tests, blood tests to detect various diseases. So this is life and death, right situation. And he really understands the process of standardizing tests to at the gold standard, the highest level. So he was able to help me analyze the data, set up the test, design the standardization process in a way that we would be able to develop an accurate test. So once we've done that, and once we've made the videos available on a flash drive and we printed all of our books and protocols. Okay, time to go and let the world know about it. So what did we do? The first thing we did, we decided to exhibit and showcase the test at the California Speech and Language Association. Well, let me tell you, at that time I had three boys. My oldest was almost five, and then I had a four year old and an almost three year old.

Meredith (15:07):

Wow.

Dr. Lavi (15:07):

So, I couldn't leave them at home. So what did we do? Went off to CSHA. We had a whole booth set up and my husband was supposed to watch the kiddos in the hotel room, right? Well, wrong. What happened? There I was at my booth exhibiting and telling the world about this video-based test. I get a phone call from my husband saying, I can't handle these three boys in this room. So he brings them to the booth. And if you're one of those people who attended CSHA, you probably remember me holding a three year old in my arms and a four year old next to me and a five-year-old running all around the booth and the whole exhibit area. So this is how we launched the test with the whole family, my kids and my husband right there.

Meredith (15:55):

I love that. You're talking to two moms of young children. We have been there and we understand. So how did you get in touch with your publisher then?

Dr. Lavi (16:03):

Um, at the very same CSHA exhibit, I was walking around with my kids, getting a break from the booth and I just, I walked by the WPS booth and I saw the CASL test. So I just stopped by to tell them how much I liked the test, because at that time I've been using it a lot and just wanted to chat a bit. And there I met Laura Stevenson from WPS. And somehow I mentioned to her that I was exhibiting and I happened to have a pragmatics test. And there it was, Laura said, "Oh, really? Well, let me check it out." And that was a match made in heaven. That day we met each other, she learned about my test and, um, we decided that the WPS would actually be a good, um, a good match and a good company to make this test available to all the other SLPs. Because let me tell you, trying to market and sell or let the other people know about a test, just being a mom now with four kids is just impossible. It's so much work. It's so hard. We thought that WPS would be a really better option for us at that time.

Stephanie (17:14):

That's fantastic. Are there any other professionals that can give this test?

Dr. Lavi (17:18):

Yes. It could be administered by, um, school psychologists. Uh, obviously speech pathologists.

Stephanie (17:26):

Yeah. What about have any neuropsychs or anyone doing like developmental pediatricians?

Dr. Lavi (17:31):

Yes. Yes, absolutely. Yes.

Meredith (17:33):

Great.

Stephanie (17:33):

So if a parent is listening and saying, this sounds like my kid, they keep falling through the cracks, they might be able to reach out to whomever they are getting a diagnostic through and ask for it.

Dr. Lavi (17:43):

Absolutely.

Meredith (17:43):

Where can they find the test? Is it through the publisher?

Dr. Lavi (17:45):

Yes. Through the publisher, WPSpublish.com.

Stephanie (17:50):

Yes.

Meredith (17:50):

Great, we're going to put you on the spot real quick. We have a question that we ask every one of our guests at the end of the podcast. And it can be related to this area, or it can just be life in general, but if you had one piece of advice to give our listeners, what would it be?

Dr. Lavi (18:04):

Oh my goodness. So now talking as a mom, uh, I have four boys. My oldest is six. My youngest is 13 months. So as a speech language pathologist, just the first thing that comes to my mind, to all the parents out there, communication is so important. So it's so important to really spend a little bit more time teaching your children strategies or ways to communicate and express their needs, their wants. Because, especially younger ones, they're two and now three year olds, unable to communicate their feelings leads to a whole lot of different problems like tantrums and behavior difficulties. So always like to tell my parents it's important to get to the same level with your, with your kiddos, literally like kneel down. Whenever you talk to your kiddos, face to face is so important to communicate with them and telling them, um, I know you're hurting right now, or I know you're not happy with something, but that face to face, eye to eye connection is so important. We as adults, we kind of forget about that. Facial expressions are important. So getting at that face to face level really helps not just learn, but help figure out difficult situations, those tantrums or behavior. So not for, don't, don't forget about that. Also using simple language with our little ones, just simple words, and try and slow down. Especially those moments of difficult behaviors. Just slow down, nice and calm. I know it's so easy to get angry and both parent and the adult get overstimulated and we are the adults. And it's important to always remember that whatever our state of mind is, it's what they pick up on. And whenever we're angry, it's not going to help them. And I know it's hard as moms we, we've been there. We've done it. We know, but just try and keep that in mind.

Stephanie (20:14):

That's fantastic advice. I love the getting on their level and keeping it simple. Well, we've really enjoyed speaking with you today. Thank you so much. It was such a pleasure.

Meredith (20:23):

Thank you.

Dr. Lavi (20:24):

Thank you. Thank you so very much. This was fun. This was lots of fun.

Meredith (20:31):

Thank you for listening to the Unbabbled podcast. For more information on today's episode, please see our episode description. For more information on The Parish School, visit parishschool.org. If you're not already, don't forget to subscribe to the Unbabbled podcast on your app of choice. And if you like what you're hearing, be sure to leave a rating and review. A special thank you to Stig Daniels, Amanda Arnold and Stella Limuel for all their hard work behind the scenes. Thanks again for listening.