Speech Pathology Australia’s concerns about Independent Assessments | External submission

Level 1 / 114 William St T 61 3 9642 4899 office@speechpathologyaustralia.org.au Melbourne Victoria 3000 F 61 3 9642 4922 www.speechpathologyaustralia.org.au Speech Pathology Australia

Speech Pathology Australia’s submission to the Joint Standing Committee on the National Disability Insurance Scheme Inquiry: Independent Assessments

                                 14 April 2021

(extension granted on 24 March 2021 )

                                             The Speech Pathology Association of Australia Limited

Hon Kevin Andrews MP Chair Joint Standing Committee on the National Disability Insurance Scheme PO Box 6100 Parliament House Canberra, ACT 2600

Dear Mr Andrews

Speech Pathology Australia welcomes the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into Independent Assessments. As you are aware, Speech Pathology Australia is the national peak body for speech pathologists in Australia, now representing nearly 12,000 members. Speech pathologists are university-trained allied health professionals with expertise in the assessment, diagnosis and treatment of communication and swallowing difficulties.

Overall, we acknowledge the need to streamline the access process for NDIS participants. It is hoped that this may assist many prospective participants who the Association’s members work with who have not yet been able to access the Scheme due to factors such as geographic location, socio-economic status, diverse cultural and linguistic backgrounds, and/or prohibitive waitlists for public services.

We do, however, have several concerns regarding the proposed process, primarily how it ignores an individual’s needs and goals to solely focus on function. We are also wary that a number of communication disabilities may not be accurately represented or assessed appropriately. Finally, we feel that the proposed use of the Independent Assessment toolkit as the only assessment tool to determine a prospective and existing participant’s eligibility for the NDIS, is insufficient and therefore we strongly assert that existing allied health practitioner reviews/assessments should also be considered and included.

Due to these concerns, we do not support the Independent Assessment process as it is currently proposed and therefore call for a ‘pause’ on the program’s implementation until there is comprehensive consultation and evaluation, including exploration of potential alternative models. If, however, Individual Assessments do proceed in some form, then the Association recommends specific role definition and clinical governance features are included.

We provide more detail on these below in our response to the relevant terms of reference and make recommendations that we hope the Committee will embrace. To inform our feedback we have held focus groups with our members and used their comments and examples to augment our response. We preface this with brief background information about communication disability, swallowing difficulties and the role of speech pathologists. As always, we would be very willing to appear before the Committee to provide more detail of the issues we highlight in our submission and to discuss potential solutions.

Yours sincerely

Tim Kittel

National President 2

Table of Contents

Introduction ………………………………………………………………………………………………………………………………. 4 About Speech Pathology Australia ……………………………………………………………………………………………. 4 About communication disability and swallowing disorders ……………………………………………………………. 4 The role of speech pathologists ………………………………………………………………………………………………… 5

Speech Pathology Australia’s response to relevant terms of reference: ……………………………………… 6 a. the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS …………………………………………………………………………………………………………………………………………… 6

  b. the impact of similar policies in other jurisdictions and in the provision of other government services.............. 8

  d. the independence, qualifications, training, expertise and quality assurance of assessors ................................ 8

  e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan
 funding ................................................................................................................................................................ 14

  g. the implications of independent assessments for NDIS planning, including decisions related to funding
 reasonable and necessary supports ................................................................................................................... 15

  h. the circumstances in which a person may not be required to complete an independent assessment ............ 16

  i.opportunities to review or challenge the outcomes of independent assessments ............................................. 16

      j. the appropriateness of independent assessments for particular cohorts of people with disability, including
 Aboriginal and Torres Strait Islander peoples, people from regional, rural and remote areas, and people from
  culturally and linguistically diverse backgrounds ................................................................................................. 16

  k. the appropriateness of independent assessments for people with particular disability types, including
 psychosocial disability................................................................................................................................         17

      l. any other related matters ................................................................................................................................. 18

Recommendations ………………………………………………………………………………………………………………….. 19

References ……………………………………………………………………………………………………………………………… 24

Introduction

Speech Pathology Australia welcomes the opportunity to provide feedback to the Joint Standing Committee on the National Disability Insurance Scheme’s Inquiry into Independent Assessments. We have structured our feedback in response to the terms of reference we believe are relevant to speech pathology and provide examples from our members where applicable/appropriate. We preface our comments with some background information on communication and swallowing disability and the role of speech pathologists.

About Speech Pathology Australia

Speech Pathology Australia is the national peak body for speech pathologists in Australia, representing nearly 12,000 members. Speech pathology is a self-regulated health profession through Certified Practising Speech Pathologist (CPSP) membership of Speech Pathology Australia.

The CPSP credential is recognised as a requirement for approved provider status under a range of government funding programs including the NDIS.

As the national body regulating the quality and safety of speech pathology practice in Australia, Speech Pathology Australia is also well placed to monitor and progress workforce developments and initiatives. Speech Pathology Australia accredits the 26 university entry-level training courses for speech pathologists in Australia, evaluates requests for recognition of overseas qualifications, administers the continuing professional development (CPD) program for the profession and provides mentoring and support programs to the significant cohort of new graduate/early career speech pathologists currently within the speech pathology workforce. The Association also manages the formal complaints process for the profession and can, if necessary, place sanctions on practice for any member who is demonstrated to contravene the Association’s Code of Ethics.

About communication disability and swallowing disorders

The Australian Bureau of Statistics’ 2015 Survey of Disability, Ageing and Carers (SDAC), estimated that 1.2 million Australians had some level of communication disability, ranging from those who function without difficulty in communicating every day but who use a communication aid, to those who cannot understand or be understood at all.i

Some people have problems with their speech, language and communication that are permanent and impact on their functioning in everyday life.

Difficulties in speech, language, fluency, voice, and social communication can occur in isolation or the person may have difficulties in more than one area and can negatively affect an individual’s academic participation and achievement, employment opportunities, mental health, social participation, ability to develop relationships, and overall quality of life.

Communication disabilities can arise from a range of conditions that may be present from birth (e.g. Down Syndrome or Autism), emerge during early childhood (e.g., Developmental Language Disorder, stuttering, severe speech sound disorder), develop during adult years (e.g., traumatic brain injury, stroke and head/neck cancers, neurodegenerative disorders such as Motor Neurone Disease) or be present in the elderly (e.g., dementia, Alzheimer’s disease, Parkinson’s disease). The prevalence and complexity of these disorders increase with age as both communication and swallowing functions are vulnerable to the natural ageing process; therefore, with an ageing population, prevalence and subsequent demand for supports will increase.

Some people with disability have complex communication needs (CCN), which are difficulties with understanding and/or the expression of communication, associated with additional physical, cognitive or sensory impairments. Many people with CCN benefit from the provision of alternative or additional methods 4

of communication, including aided Augmentative and Alternative Communication (AAC) such as communication books, boards, speech generating devices and accessible technology for phone and internet-based communication.

Swallowing disorders affect the ability to safely swallow food or liquids and can lead to medical complications, including aspiration pneumonia, and potentially death through choking, as well as a reduced ability to safely and enjoyably participate in social, employment and educational experiences where consumption of food and drink is needed. Swallowing problems are common in people with a complex disability such as cerebral palsy. For people with swallowing difficulties, supports may be required for the preparation and/or safe provision of meals to help to eat and drink effectively, safely, and as enjoyably as possible and ensure adequate nutrition. Too many people are still dying as a result of preventable swallowing disorders in Australia, at a young age.

The role of speech pathologists

Speech pathologists work to give people with disability a voice and connect with others in an accessible and meaningful way, assist in teaching the social communication skills required to participate in different environments across the lifespan and all life activities, and reduce the impact of swallowing or feeding difficulties experienced by individuals.

People with communication and swallowing disability span the entire age range, and the nature of their difficulties impacts on most areas of life. These people frequently require interventions and supports from multiple areas of public and private services (including health, disability and education sectors and mental health services). Speech pathologists, as experts in the assessment, diagnosis, and treatment of communication and swallowing disorders are essential members of multi-disciplinary teams providing services to people with disability.

The clinical protocols for speech pathology treatment are evidence-based and backed by strong multidisciplinary scientific evidence for efficacy. Clinical protocols for treatment (in terms of session duration, frequency of care, intensity) differ depending on the clinical presentation and diagnosis – with speech pathology care aimed at maximising function for that person. Speech pathologists use their diagnostic capacity to provide tailored and individually targeted intervention solutions to achieve functional outcomes. Some speech pathologists working in the disability sector focus their practice on the assessment and provision of communication aids for people with CCN.

The pervasive nature of certain difficulties, varied and fluctuating presentation and high incidence of co- existing conditions requires a thorough diagnostic process that examines all aspects of development and functioning.

Speech pathologists are the only profession with the knowledge and skills required to comprehensively assess the core communication, speech, language, social pragmatic and eating and drinking difficulties associated with disability. The speech pathology assessment process involves multiple assessment sessions as the speech pathologist observes and assesses the individual in a range of contexts (for example, clinic, home and/or educational setting) and with a range of communication partners (e.g. family, peers or strangers). This will often include a standardised assessment and a comprehensive report addressing all areas of communication and eating/drinking.

An important role of a speech pathologist in the diagnostic process is the differential diagnosis of other communication related conditions; for example in a childhood setting this may be specific language impairment, social (pragmatic) communication disorder, language disorder, speech sound disorder (e.g., childhood apraxia of speech), and specific learning disorder (e.g., dyslexia). In addition, the speech pathologist will assist the multidisciplinary team to decide if the person’s communication profile is more consistent with a description of intellectual disability, trauma, anxiety, or attention deficit disorder, or Autism in conjunction with one or more of these other conditions. 5

Speech pathologists also provide valuable contributions to the assessment of decision-making capacity and the facilitation of supported decision making for people with communication support needs. This includes developing communication accessible health information and decision-making procedures and protocols. In addition to identification of disease/disorder, assessment and intervention, speech pathologists can also provide counselling/support to families and caregivers, education of other professionals, case management, consultation, and advocacy. Communication partner training, including staff training, is considered an essential part of a speech pathologist’s work.

Speech pathologists have a pivotal role in the assessment and management of swallowing difficulties (dysphagia). Speech pathologists conduct assessments and diagnostic measures for dysphagia such as screening assessments, clinical and instrumental assessments (e.g. Videofluroscopic Swallow Studies, FEES), oral medication assessment, conduct oral trials to determine the most appropriate type of food or fluid for the person to consume safely, and help the participant and their support networks decide on a mealtime management plan, and consider compensatory measures or rehabilitation for their swallow.ii

Speech Pathology Australia’s response to relevant terms of reference:

a. the development, modelling, reasons and justifications for the introduction of independent assessments into the NDIS

Overall, we commend the National Disability Insurance Agency (NDIA) on its intention to streamline the access process for NDIS participants. This will be particularly useful for people with communication disability, who are not always able to advocate for themselves, and the added challenges they face in applying for services such as gathering information in written form when the application process does not have alternative accessibility formats, using a communication device to get their message across during a medical appointment, or the stress of needing to make a phone call when they are not sure what to say or find it hard to be understood.

It is hoped that this process may assist many prospective participants that the Association’s members work with who have not yet been able to access the Scheme because of their geographic location or socio- economic status, as well as other factors such as diverse cultural and linguistic backgrounds, and prohibitive waitlists for public services across the country. It could also act as a bridge to closing the gap for those people who have not had the opportunity to access assessments that demonstrate permanency or yet understand that their difficulties impact a number of areas of life, or need support to navigate the system, particularly where medical services and specialists are not easily accessible.

The Association however does not support the use of the existing Independent Assessment toolkit as the only assessment process to determine a prospective and existing participant’s eligibility for the Scheme. Existing allied health practitioner reviews/assessments should also be considered and given equal weighting as our members have the expertise and ability to provide valid and comprehensive assessments, based on the Association’s requirement to follow the Code of Ethics, professional standards, scope of practice and the regulation process in place.

We are also concerned about the notion of ‘sympathy bias’ as justification for introducing an independent assessor.iii Allied health professionals are specifically trained to use their clinical judgement, in conjunction with assessment tools, as assessment tools are not 100% reliable, even if they are standardised. Tools are also not the only aspect of the assessment process, as this also involves a clinician drawing together background history, current context and contributing factors, as well as their own knowledge and experience to form a clinical picture. This is not based in sympathy for the client, but rather a complex clinical skill, honed over time and exposure, working across different contexts with different clients. This is particularly important when working with people with disability as it takes time to understand their

capabilities and needs, particularly for those who have not had support before, or those with fluctuating or degenerative conditions. Current research in speech pathology shows that it is the strength in clinical reasoning over time that makes speech pathologists competent, rather than using standardised checklists.iv

One of our members states that:

“Overall, there is a simplistic understanding, underpinned by a medical model worldview, that assessment is objective. All assessment involves some sort of judgement process (even interpreting blood tests and x- rays) and, in the case of disability, the diagnosis tells us very little about the person’s needs and potential. So, it’s about ensuring quality judgements are being made in collaboration with the person with a disability. An effective and trust based working relationship is critical to this as many people with disability, rightly so, distrust the system and have had promises made and not kept or even experienced trauma at the hands of services and service providers – so it can take a long time to work out what someone could do if only they had the right supports. This becomes even more acute when they have a communication disability of any kind and further intensified when it is combined with cognitive or neurological disabilities.”

The Association strongly asserts the competency of its members to assess, develop goals and design treatment plans for participants, without sympathy bias, through the Association’s rigorous process of certification and supervision.

Another area of concern relates to some communication disabilities not being accurately represented or assessed in the Independent Assessment Process. These include people with Childhood Apraxia of Speech, people with Complex Communication Needs, Developmental Language Disorder, younger onset Dementia and Parkinson’s Disease.

As our members’ highlight:

“If we support the concept of independent assessors making this determination, we are doing our clients a disservice. There is no toolbox of assessments that can ever replace the need for reports from professionals. If I consider eligibility decisions in motor accident insurance schemes, the measures used (FIM, CANS) are impossibly broad but are at least administered by accredited members of the multidisciplinary team. This works relatively successfully for catastrophic injury determination but NDIS participants have much more nuanced needs”.

“I think we need to advocate that we can’t substitute clinical experience and expertise with standardized assessments. They go hand in hand. CHOOSING, APPLYING and INTERPRETING an assessment relies on the clinical expertise of the therapist. Otherwise how can we say we are applying best practice for the most vulnerable people of our communities who often cannot communicate and advocate for themselves?”

As speech pathologists have expertise in observation and social interaction, it is recommended that the participant interaction component of the assessment is extended and used to validate the skills gathered in the formal assessments. Similarly, extra time for the assessor themselves to score, interpret and summarise the findings would be far more person-centred and clinically appropriate.

As other of our members highlight:

“There is a need for so many different assessments to look at the functional impact of a person’s disability across their life and something that I feel needs to be carried out dynamically across several sessions. It also takes skill to interpret the assessment results.”

“The ones who would pass a checklist or can have a social conversation but have deeper difficulties are the ones I most worry about being disadvantaged in this.”

Due to the above issues, we do not support the Independent Assessment process as it is currently proposed and call for a ‘pause’ on the program’s implementation, until there is comprehensive consultation and evaluation, including exploration of potential alternative models. If, however, Individual Assessments do proceed in some form, we strongly recommend that the role definition and clinical governance features set out in our response to terms of reference ‘d’ are enacted. 7

b. the impact of similar policies in other jurisdictions and in the provision of other government services

In discussion with some of our members, the Transport Accident Commission (TAC) model was proposed as an alternate assessment process as it not only aligns with the values of the International Classification of Functioning, Disability and Health (ICF), but also allows the person to work with the accredited practitioner of their choice towards improved functional outcomes. Reviews are conducted by an experienced clinical panel to ensure appropriate progress and compensation as necessary.v

This would be a much more preferred method of operating for our members, who have concerns about the emotional burden on families who are already dealing with a diagnosis and other tasks, as well as the mental health impacts on people with disability having to tell their story to strangers, as opposed to being able to complete the assessment process with their trusted current providers, who could then be reviewed as needed by a panel.

Another alternative assessment process we would support as an alternative to the Independent Assessment Toolkit, is that used by the Disability Support for Older Australians (DSOA) program.vi This was designed by the Centre for Disability Studies using the I-CAN assessmentvii, based on the World Health Organisation’s ICF framework, and is more inclusive of the person with disability and their support networks.

d. the independence, qualifications, training, expertise and quality assurance of assessors

We have several concerns about the independence, qualifications, training, expertise and quality assurance of assessors, for example, the proposal that children between the age of one and six, are assessed by an Early Childhood Intervention Partner who is not required to be an allied health professional, is not supported by the Association.

As previously stated, Speech Pathology Australia does not support the Independent Assessment process as it is currently proposed and calls for a ‘pause’ on the program’s introduction until there is comprehensive consultation and evaluation including exploration of potential alternative models. If, however, Individual Assessments do proceed in some form, we strongly recommend that the following features, are enacted.

Please note that details of these recommended features are taken directly from the Allied Health Professions Australia (AHPA) report commissioned by the NDIA and submitted in October last year.viii The report made extensive recommendations to the NDIA about the independence, qualifications, training, expertise and quality assurance of assessors and Speech Pathology Australia was one of six peak bodies in the working group that contributed to its development.

The following recommendations apply across the lifespan:

It is recommended that Independent Assessors have a minimum of twelve months full-time clinical experience working as a clinician.

For newly graduated clinicians, Speech Pathology Australia recommends that new graduates with less than 2 years full-time clinical experience receive a minimum of an hour of clinical supervision weekly from a speech pathologist with at least three years of clinical experience. In addition, speech pathologists with two or more years’ experience who are entering into a new field of practice may benefit from this same level of supervision for a period of time.ix

In the context of Independent Assessments, Speech Pathology Australia recommends that the clinical supervisor is someone with a minimum of three years of experience working in the area of disability, and the supervisor is provided as external support through NDIA, if a speech pathologist with the appropriate qualifications and experience is not available through the organisation employing the Assessor.

In addition, for each profession involved in the Assessment process, it is recommended that there are additional modules provided in the training package to ensure consistent and appropriate services for a range of backgrounds and disabilities. These modules should include how to best interact with people with:

Vision impairment
Hearing impairment
Wheelchair users and people with limited mobility
People with multiple disabilities and/or medical conditions
Cognitive disability (e.g. developmental disability, acquired brain injury)
People with language and comprehension difficulties
Augmentative and Alternative Communication (AAC) devices
Neurological diversity (e.g. Autism, ADHD)
Psychosocial conditions
Culturally and Linguistically Diverse (CALD) backgrounds
Aboriginal and Torres Strait Islander peoples.

Lastly, it is recommended that, given the diversity of allied health professions and the limited number of professions eligible to become Independent Assessors, the training packages should also provide guidance about the scope and roles of other professions and their roles in supporting different participant cohorts.

Competency Assessment

Again, we refer the Committee to the competency assessment framework developed by Allied Health Professions Australia (AHPA)x and strongly support the following recommendations it proposes:

That competency assessment occurs after the successful completion of the online training component and prior to any individual conducting assessments independently. Competency assessment within this context is intended to refer to the process of an experienced Independent Assessor evaluating a trainee assessor. The framework for this evaluation and the criteria needing to be met to progress to conducting assessments independently needs to be established.

The competency assessment framework would need to consider at a minimum:

The competencies required for successful completion of an Independent Assessment both generally and with each identified participant cohort.

That a competency framework for working with each and every participant cohort is developed in conjunction with professionals, consumers and other relevant stakeholders in each community and assessment occurs within each cohort.
This is recommended to address the need identified in item 4.35 of the Tune reviewxi which reads “one of the biggest risks in implementing the new functional capacity assessment process will be disengagement, that is, people with disability refusing to interact with any of the NDIA approved providers. As with the NDIA, as a system more generally, this is a particular risk for Aboriginal and Torres Strait Islanders, those from CALD backgrounds and those with psychosocial disability.”
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That prior experience working with a particular cohort is desirable and should be facilitated where possible, but is not considered essential if adequate training, competency assessment and supervision and support is provided. Experience does not equal competence and experience is not a substitute for a competency assessment.
Given the different education requirements related to different professional backgrounds, it is likely that some professionals will be immediately able to demonstrate competency with some cohorts without additional training. For workforce expediency, individuals confident of competence with particular cohorts could be afforded the opportunity to be assessed in these areas prior to training module development if required
It is noted that Assessors do not need to be competent with every cohort prior to conducting Independent Assessments but they must have been deemed competent with the cohort of any potential participant referred to them for assessment.

Which methods are used to assess competence e.g. online competency program, face-to-face training, observational assessment, simulated and/or real-world scenarios?

The AHPA report recommended consideration of a model such as:

Once deemed competent in a simulated training environment, Independent Assessors are required to attend a ‘live’ Independent Assessment where they first observe another Independent Assessor (Ideally 2 different assessors where possible, at least one time each)
The Independent Assessors must then be supervised when conducting their initial Independent Assessments until a supervisor deems that they are suitable to conduct Assessments alone
Then an individual can complete an Independent Assessment alone utilising the supervision structure for support until they become more experienced.

The level of competence to be achieved and how this will be evaluated consistently among different supervisors.

Allied health professional associations should be involved in the competency framework development process as they have detailed expertise in this area and are well placed to assist as many aspects of professional registration/regulation criteria employ such frameworks.

Supervision Framework

Access to an ongoing mentor/supervisor as well as the ability to engage with colleagues for further learning must be facilitated once a professional is deemed competent to conduct assessments independently.

Supervision support must be provided when an initial individual first begins conducting assessments independently. When independent assessments first occur, the supervisor should be available to the assessor for discussion when finalizing their report and should review the report before submission. This process is intended to help assessors build confidence, to support consistency among assessors, and to facilitate immediate feedback. Again, the supervisor should determine when the individual assessor no longer requires this oversight. However, the assessor should always be expected and able to seek peer review and support if needing to discuss assessment findings before submitting a report.

The development of a formal supervision framework which facilitates a relationship between a more experienced assessor and practitioner and a less experienced one is recommended. This framework should encourage supervisors and Independent Assessors from different professional backgrounds to

enable multi-disciplinary collaboration, more easily facilitate face-to-face rather than remote supervision and facilitate different areas of inherent strengths within professions to be shared.

To facilitate this, the AHPA report recommended that panellists are required to have at least one fully trained and competent Independent Assessor from each of the six professional backgrounds available at any one time
This requirement will also assist with the depth of the workforce required to meet the differing needs of potential participants.

Criteria which determines who can act as a supervisor and what is required of this role needs to be developed. It is acknowledged that an optimal solution here will take time to develop, given the infancy of The Independent Assessor role. We therefore offer the following for consideration in the development of this framework:

A community of practice which incorporates a ‘buddy system’ for Independent Assessors should also be facilitated to enable collaboration and support between practitioners across a variety of professions and locations.

It is noted that without competency assessment, ongoing supervision and engagement and review of the Participant Interaction and Information sections, two significant risks with this model are present:

The participant does not receive a true assessment of their abilities because the assessor is not able to engage with them in an appropriate manner;
The safety of the professional is at risk if they interact with the potential participant in a manner which facilitates increased risk, e.g. if the potential participant becomes violent.

The NDIA is in a unique position to compare data about current access decisions with the results of the implementation of the independent assessment process to ensure improvement is occurring. Effective evaluation will highlight areas that remain problematic post implementation and/or identify anything valuable in the current system that is unintentionally lost.

The AHPA report recommended that to achieve effective system evaluation, independence and transparency of both the process and results must be integral to the evaluation method. There are different methods by which this can be achieved, however it is necessary to ensure that the method employed enables a governance structure that provides relevant stakeholder representation from across the disability sector and sharing of results publicly.

The independent and transparent evaluation should at a minimum:

− Consider whether the Independent Assessor model is achieving the goals it was implemented to achieve;

− Review whether the assessment toolkit is fit for purpose for all participant cohorts; and

− Consider complaints, the number of requests for reviews of eligibility decisions internally and externally, as well as benchmarking results from different panellists against one another.

Audits of NDIA decision making regarding access based on Independent Assessor reports should occur regularly, i.e. have more than one person make a decision based on the same assessment report at the same time and over time to determine if consistent decision making is occurring among NDIA decision makers:

− All feedback data and information must be shared by Panellists as they have a vested interest in ensuring positive feedback.

− NDIA must ensure they collect consistent data from each Panellist so this can be analysed to determine whether weaknesses are systemic and need to be addressed at an NDIA level or whether they are Panellist specific. 11

− Panellists must be encouraged to share positively evaluated processes with one another to allow collaborative improvement across the system to occur.

Evaluation of Panellists

The NDIA will need to determine before they finish the process of contracting with Panellists which Key Performance Indicators (KPI) will apply and to outline which actions will be taken if those KPIs are not being met. Remedial actions should include timeframes for corrective actions. We support the KPIs relating to assessment delivery times outlined in the tender documentation:

The tender document also outlines the following two aspects:

Service Level 4: At least 90% of Participants or Prospective Participants who were referred to the Supplier and who return a survey conducted by the NDIA (including through their representatives), report being either “satisfied” or “very satisfied” with the Assessor’s engagement and skills. This Service Level 4 only applies if the NDIA decides to conduct a survey about Participants or Prospective Participants’ satisfaction with Suppliers. Any questions in such a survey about satisfaction with the results or outcomes of an Assessment will not be used by the NDIA to calculate a Supplier’s level of compliance with this Service Level.

Service Level 5: Less than 2% of Participants or Prospective Participants who are the subject of a Referral Form issued to the Supplier make a complaint (including through their representatives) to the Supplier and/or to NDIA about their interactions with the Supplier or the Supplier’s provision of the Services. For clarity, complaints about Assessment results or outcomes are not to be included in measuring this Service Level 5.”

In relation to Service Level 4: the AHPA report strongly recommended that the NDIA ensure high levels of potential participant feedback are sought. However, feedback should be related to experience during an independent assessment and not related to satisfaction measures.

Literature is unanimous in recommending experience as opposed to satisfaction is measured to understand whether the process is occurring as intended.
Satisfaction is based on prior expectation levels and in no way demonstrates achievement of the desired level of experience that NDIA would hope for their participants or that which participants may ideally hope for themselves.
Measuring experience of the assessment process would enable a deeper understanding of the level to which assessors are performing in various areas from the potential participants’ perspective and highlight areas for improvement if poor experiences are occurring; overall an experience may be satisfactory but it doesn’t mean there is not room for improvement and achievement of a more positive experience.
That person-centred experience levels are measured, the relevant questions would need to be developed from consideration of the literature, the goals of the program and through engagement with participants.
Such a method would also eliminate the risk that satisfaction responses are impacted by the access decision made.
The feedback mechanism should also enable contribution to the evaluation and improvement process for the model as a whole.
This feedback mechanism could be included within a broader option related to the application process if appropriate.

In relation to Service Level 5: Concerns were raised that the KPI related to complaints discourages Panellists from supporting complaint making. This appears inconsistent with NDIA Quality and Safeguards

Commission (NDIA Commission) requirements, which indicates that complaints should be encouraged to enable quality improvement. Measures related to complaints must relate to how comfortable the potential participant feels to make a complaint, were they aware of how to make a complaint if they wanted to, was the process accessible for them to do so, and how quickly and how well were any complaints resolved. We recommend adjusting these in line with the NDIA Commission.

Measures relating to all requirements for training must be implemented and Panellists able to demonstrate that all requirements are being adhered to. It was noted that Page 12 of the tender document states that “suppliers may be required to provide proof to the NDIA that Assessors have completed the required training” - this is not a suitable level of requirement. All Assessors must have completed all required training and completed the assessment to the required level prior to conducting assessments with potential participants.
There must be evidence that this training has been satisfactorily completed and this evidence must be able to be produced at any point in time.

It was noted that the NDIA has requested an exemption for this workforce from the NDIA Commission registration processes. However, the AHPA report recommended that each Panellist must complete the NDIA Commission registration process for the following reasons:

− Panellists should meet the NDIA Commission practice standards and the NDIA Quality and Safeguarding Framework is the most appropriate framework for this workforce.

− By not applying the NDIA Commission’s registration requirements means there is the potential for the assessor role to become akin to an unregulated profession.

− In the absence of the requirement to register with the NDIA Commission, how will aspects such as complaints mechanisms be addressed? What will be the requirements related to aspects such as this and who will evaluate whether these are being suitably met?

− Whilst it was acknowledged that a number of aspects related to workplace suitability and Health and Safety requirements have been addressed in the tender, e.g. signed deed of confidentiality, current Working with Vulnerable People registration at all times, Working with Children Checks, Police Check, culturally responsive and sensitive; further consideration needs to be given to additional aspects required, what regularity of reporting is required and to what level standards are required and how these will be assessed, if the NDIA allows Panellists to remain outside the remit of the NDIS Commission.

− The skill tags document encompasses a number of workplace suitability and Health and Safety requirements. It was recommended therefore, that aspects related to legal requirements and broader workplace requirements are separated from the competency framework which should remain focused on skills required for interacting with different participant cohorts.

Evaluation of Independent Assessors

Independent Assessors must be audited to determine the level of consistency across assessors; that is, a process which evaluates inter-rater reliability - whether assessors would provide the same summary for an individual to the NDIA for eligibility assessment.

Given the diversity of locations this process would need to be conducted over, it appears a method whereby an assessment is recorded, and each assessor produces a report based on review of the same recording is likely suitable for this auditing method
The implementation detail of this method will determine its suitability and it is likely the Participant Information and Interaction sections will require a different evaluation method of assessor accuracy to the standardised tools. 13

Participant Interaction and Information sections - the literature related to simulated assessment and evaluation consistency would need to be reviewed and a model implemented in line with best practice in the area. For example, a checklist of what must be identified within these assessment tasks would likely need to be developed to determine whether assessors are identifying all relevant aspects which impact NDIA decision making and a scoring system developed so that one assessment result can be objectively compared to another.

Standardised tools - Pearson Australia or the relevant assessment publisher should be utilised to assess tool use and set the standard at which tool assessments should be occurring; standards of required achievement should be set at what is reported within the literature for inter-rater reliability.

A clear target for the level of inter-rater reliability between assessors needs to be established prior to conducting the evaluation.
Evaluation results should be made publicly available.
The inter-rater reliability results should inform if/how the training for all or certain aspects needs to be adjusted over time.

The system must empower Independent Assessors to provide feedback and recommendations for change that elicit actual change and continuous improvement.

− This may be facilitated via surveys throughout the training when considering training aspects.

− Methods for feedback on the system generally must be provided to Independent Assessors at
         all times to identify challenges and solutions found in the field to enable the desired continuous
   improvement to occur to the system and training information.

The NDIA must ensure the system of training delivery can collect relevant data across assessors to inform training evaluation, such as the length of time on site, frequency utilised, average quiz scores, survey results.

Despite these potential safeguards being in place, members are still concerned about how it is possible to accurately capture the needs of a participant in a single session, without observing or interacting with them in a number of environments over time. Therefore, it is recommended that in the situation where the Assessor has not deemed eligibility in the first session, a second session in a different environment is undertaken. This may occur in a school, workplace or community setting.

As a Speech Pathology Australia member writes:

“I have dedicated the last 18 years of my career to understanding multimodal communication - how non- speaking people communicate using gesture, facial cues, sounds and formal systems depending on the situation in order to complete a valid communication assessment, and have only just achieved it. How can a well-meaning allied health professional be asked to do that in three hours, as a recent graduate in a different profession? That’s a lot to ask and shouldn’t really be asked. I’m told that they will try their best to match speech pathologists with communication device users etc. But will this happen in every single situation, and in every state?”

e. the appropriateness of the assessment tools selected for use in independent assessments to determine plan funding

We would recommend that at least one additional assessment is added to the toolkit immediately to cover the complex domain of communication. A number of suggestions have been put forward by our members and academics, and these can be provided on request. However, after considering the Independent Assessment of Selection Tools, it may be most appropriate to initially include Children’s Communication Checklist (CCC-2)xii for ages 4-16; and the Communication Checklist-Adult (CC-2),xiii for ages 17-79, for

speaking/signing participants or those with a communication system. For non-speaking participants, the Triple C Checklist of Communication Competenciesxiv is recommended, or by adding the Communication Function Classification System (CFCS) to the Participant Interaction Checklist as demonstrated in Appendix A.

This may also address some of the concerns our members have about the self-reporting aspects of the tools chosen. As one of our members reports:

“Experience with similar intake systems in state services has shown that because of the self-reporting aspect of many tools they disproportionately disadvantage vulnerable populations, particularly young adults with communication impairments who may not accurately report on their needs”.

In addition, our members have concerns about the focus of the assessments in the Toolkit on verbal language and written competencies. For example, in the Vineland-3 assessment, all the language assessment items require a person to respond verbally, use written responses or follow complex instructions. For someone who is non-speaking, without a communication device, with cognitive disability or not literate, this will mean their score is nil or very low, asking them about a skill they may never have the chance or ability to learn, and it doesn’t give the person an opportunity to express their strengths or abilities. This also raises concerns about the potential mental health impact and grief triggers for participants and their support networks of having to go through an assessment that is not reflective of their skills.

g. the implications of independent assessments for NDIS planning, including decisions related to funding reasonable and necessary supports

When examining the Toolkit for ages seven and over, the selected tools are looking for functional impairment where they compare the participant’s functional ability against that of a person of a similar age without disability. For adults with complex communication needs, or multiple disabilities, who don’t have an existing AAC system, this is likely to underestimate their capacity, as these participants have often lacked opportunity, access to equipment and clinical support prior to the NDIS. This is regardless of need or potential as most participants will score at similar levels as they are all being compared against activities that none of them have had experience, expectation or support to do.

Types of individuals that would all score similarly on the Toolkit include:

A woman identified as having a significant cognitive disability and difficulties interacting with family members and other support networks. This person relies on people who know her well to understand her idiosyncratic individual communication. Goals would include supporting her support network to understand and respond to her communication, documenting her communication to allow for consistency of support and supporting communication partners to increase interaction. Her needs are unlikely to change over the years and after initial outlay costs would reduce.
A woman with a diagnosis of Rett Syndrome. The woman does not have a comprehensive AAC system due to her age and the fact that the technology was expensive and not sophisticated at the time of her education (she can use yes/no with eye gaze). Evidence based practice is to use eye-gaze to access AAC. Her intellectual ability is masked by her significant motor impairment. Her needs are likely to be ongoing over many years as:

She requires access to a high-tech Speech Generating Device.
Due to her intellectual capacity she has the ability to learn to use an AAC system effectively.
She requires access to a low-tech back-up system when the technology is down.

She will need to learn the motor patterns to use an eye-gaze system. While eye gaze is less affected in Rett Syndrome it is still affected at times.

She has mealtime and swallowing issues, which will change over time due to complications with her Rett Syndrome.

A man with a diagnosis of Microcephaly who left school with a PODD book able to point to single symbols of interest. Due to clinical support he now can generate 5-word symbol sentences such as

spoken. This member therefore has huge concerns about the independent assessment model being used in the future.

Furthermore, during COVID, telehealth was trialled with these children in their communities, but the internet access was inadequate. Therefore, the Association has concerns about the appropriateness of Independent Assessments for Aboriginal and Torres Strait Islander peoples, as the process may unfairly disadvantage them for numerous reasons.

k. the appropriateness of independent assessments for people with particular disability types, including psychosocial disability

The Association wishes to strongly highlight the potential impact of independent assessments on people with a primary diagnosis of Developmental Language Disorder (DLD), whose disability affects other developmental domains. DLD is the recognised diagnostic term for children who have difficulties in the ability to learn and use language which is life-long, interferes with daily life and cannot be explained by associated biomedical conditions. The use of the term ‘Developmental’ in this context refers to the fact that the disorder emerges during development, rather than being acquired.

DLD during childhood negatively impacts communication development and social participation. Without adequate, timely and ongoing intervention, there is a significant risk of academic failure. Effective early intervention for children with DLD is shown to have significant lifelong benefit for the individual and the community. It may be difficult to provide a definitive diagnosis of DLD for children below the age of four. A period of intervention may be needed to determine if the language difficulties are persistent and significantly impact a child’s functioning and participation. Longitudinal studies demonstrate lifelong negative impacts of DLD on educational outcomes, employment and mental health.xv Children, adolescents and adults with a diagnosis of DLD, should be recognised as meeting the criteria for access to the NDIS and a plan, either under the Early Childhood Early Intervention or the Disability access criteria.

Despite this clear synopsis, our members spend a great deal of time advocating for prospective participants to access the Scheme and demonstrate permanence of their disability. This comes at a huge emotional and financial cost to families, as well as the young person. As this diagnosis will still be required before an independent assessment is undertaken, adding another assessment with someone new again highlighting the young person’s difficulties, seems unnecessary.

As one of our members describes:

“The general population sees these children as being very capable because they can verbally communicate. I’m really concerned about these kids being assessed by somebody without our expertise. It’s not possible to see the functional impact of DLD in a short period of time by someone not experienced in the diagnosis of it, and in comparison to the other people they might see with more obvious disability is in their mind ‘fine’, but because of their ”fineness”, is at more risk of suicide or mental health conditions. It’s called a hidden condition for a reason. These kids are really good at masking until it’s not ok anymore. Maybe it would be more obvious for some people who don’t use verbal communication that there is a disability, but for verbal children, it is more tempting to say they are just a little behind. The damage that someone can do by making these judgements to a person, or their family, even subconsciously, are catastrophic. I don’t understand how their time is more valuable than me spending 6 hours observing that child at home and school and getting to know how their disability impacts them.”

Our members are also concerned about the format, purpose and structure of the Participant Interaction Checklist, which has been described as a way to validate the quantitative data from the checklist component of the Toolkit, by asking the participant to do a task such as make a cup of tea, which may have no bearing on their actual disability.

Our members report:

“A child is going to pick a task that they are good at. A teenager will not choose a task that shows their difficulties as they spend all day at school hiding their disability, they will just keep hiding it”

“I can make a cup of tea, but I’m still disabled”

l. any other related matters

There is currently a lack of speech pathologists available to fill positions across a number of sectors in Australia, and many of our members are worried about how the introduction of independent assessments will impact the market.

As one member notes:

“Workforce is the largest concern. Where will they find workforce? We know about the issues in rural and remote Australia, but I can’t find speechies in metro areas. In the middle of Sydney we can’t fill positions. People offering well over award wages and amazing incentives and receiving no applications.

We are at a critical point when it comes to the Allied Health workforce and I can’t see this helping.”

For those speech pathologists who are provisional speech pathologists, and wanting to transition to certified practising speech pathologist (CPSP) status, they must work for a minimum of 200 hours in speech pathology practice within three years of graduating from their university course. CPSP status is required to be maintained in order to qualify to provide services under Medicare and private health funds, as well as to work as, or for. a registered provider under the NDIS Quality and Safeguarding Commission. While currently under review by SPA, conducting independent assessments (that are not speech pathology specific) will not qualify towards the practising hours for speech pathology certification, and therefore the implications for newly trained speech pathologists, or those needing to maintain their CPSP status, are vast. This will disincentivise speech pathologists from taking up, or holding a position as an Independent Assessor for long periods of time, as they may not be able to maintain their CPSP status.

There have also been reports about NDIS planners making recommendations about therapy and a child’s future progress from the outcomes of an independent assessment in the pilot phase. If this is not regulated, this will continue to cause distress and anxiety for families who are already experiencing difficulties accessing services. One of our members reports:

“The family I work with was told that my services were no longer justified because their child hadn’t made enough gains in communication over the 12 months and the family should focus on other areas for capacity building. This was based solely on the scores of the assessment, and not on the detailed report I had written about how the child could now make sounds, point to pictures and stay with a task for more than two minutes, all fantastic and measurable gains that the family were so proud of.”

Recommendations In summary, Speech Pathology Australia recommends the following:

The proposed Independent Assessment rollout is paused until adequate evaluation, consultation and planning has been undertaken with participants, providers and peak bodies.
Trialling the independent assessment process with prospective participants first over a 12-month period, and reviewing the outcomes with the assessors, participants and each of the allied health peak bodies involved in the assessment process, before commencing independent assessment with existing participants.
If independent assessments are used to determine eligibility, they should be just one part of an assessment toolkit, and equal weighting should be given to any existing assessment reports completed by relevant allied health professionals, or indeed used as a way to consolidate report findings by a third party.
The assessment process must be more person-centred and clinically appropriate and allow adequate time for the assessor to score, interpret and summarise the findings and present a verbal summary to the person on the day of assessment (in addition to the written copy prepared after the assessment).
Independent assessments are considered as an alternate entry pathway for families who may not have the means to access and demonstrate permanence of disability in the first instance.
In the situation where the Assessor has not deemed eligibility in the first session, a second session in a different environment is undertaken. This may occur in a school, workplace or community setting.
Ensure all participants are aware that the independent assessment decision can be reviewed and that the review process is clear and accessible (including communication accessible).
If a person with demonstrated communication or swallowing needs is deemed not eligible after completing an independent assessment, the NDIA contracts a second opinion from a Certified Practising Speech Pathologist.
If independent assessments for children under the age of six are adopted, they are conducted by experienced allied health professionals such as speech pathologists, psychologists and occupational therapists.
All independent assessors who are speech pathologists, are required to become certified members of Speech Pathology Australia, for auditing and regulation purposes.
Planners and LACs are bound by a code of ethics, code of conduct and scope of practice.
The participant interaction component of the assessment is extended and used to validate the skills gathered in the formal assessments (as proposed in Appendix A).
At least one additional assessment is added to the toolkit immediately to cover the complex domain of communication (as proposed in response to e. within the TOR).
People who are non-speaking, those with cognitive disability, Aboriginal and Torres Strait islander peoples, those who are not literate, and those with a demonstrated primary disability in the communication domain have the choice to opt out of the independent assessment process and continue with the existing process and use their current team of health professionals.
For non-speaking people with augmentative and alternative (AAC) devices, they are given a choice about taking part in the assessment and allowed extra time for the assessment. If they do choose to have an independent assessment then the assessor will liaise with the person and their support network, and the person’s supporting health professional where appropriate, to see what vocabulary
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might be needed to be programmed onto the person’s device for the appointment, or what responses can be prepared in advance.

The Participant Interaction Checklist must include a Mealtime/Swallowing section (see Appendix A), which triggers an immediate referral to a speech pathologist if there are any self-reported or observed signs of swallowing difficulties.
Introduce minimum requirements for training, supervision, and competency assessments for Assessors.
In the context of independent assessments, the clinical supervisor is someone with a minimum of three years of experience working in the area of disability, including that the supervisor is provided as external support through NDIA if a speech pathologist with the appropriate qualifications and experience is not available through the organisation employing the Assessor.
For each profession involved in the Assessment process, there are a number of additional modules provided in the training package to ensure consistent and appropriate services for a range of backgrounds and disabilities.
The NDIA provides details of the current training package, job description, access to supervision and conflict of interest arrangements, to the relevant allied health peak bodies.
That the NDIA advises all allied health professionals considering becoming assessors that they should seek clarity on potential implications to their practice hours. For example, in the case of a speech pathologist, the Association cannot guarantee that a generic role such as an independent assessor will count as eligible speech pathology hours for recency of practice requirements.

Thank you for the opportunity to provide feedback.

Appendix A: Speech Pathology Australia example adjustments to Participant Interaction formxvi

Communication

Comment on the participant’s expressive communication and understanding. Include brief comment on response to people and activity around them.

Expression (please provide examples)

Please note: Words in this context will represent verbal words, signs or symbols accessed on a communication system or device (Augmentative and Alternative Communication (AAC) user). Please note communication system here: verbal/sign user/AAC user

Uses mainly gesture, body language, and facial expressions to communicate
Uses single sounds or single words, such as “ma” for “more”, or “yum” for food.
Uses 2-3-word sentences such as “I need help” “My turn now”
Uses 4-5-word sentences such as “My car go there” or “Time for bed now dog”
Uses 6+ word sentences such as “Can I go to the shops?”
Uses language for a variety of purposes and is able to get their point across to unfamiliar

listener.

Comprehension (please provide examples)

Responds to sound, voices and movement
Comprehends single words such as “stop!”
Comprehends sentences of 1-2 words such as “more bread?”
Comprehends sentences of 3-4 words such as “where is the ball?”
Comprehends sentences of 5 or more words such as “Can I have the small, yellow cup please?”
Comprehends language about the past, present and future.

Voice and Speech Quality (if applicable) (please provide examples)

Able to understand all of what person says
Difficult to understand some of the time
Difficult to understand most of the time
Difficult to understand all of the time
Not applicable
Reason: (please check all that apply).

Too fast - Too slow - Too quiet - Speech sounds not clear
Another reason

After interacting with or observing the person with their communication partner, please mark the Communication Function Classification System (CFCS) level below that you think best matched the person’s ability:

☐ CFCS Level I - A person independently and effectively alternates between being a sender (gives) and receiver of information with most people in most environments. ☐ CFCS Level II - A person independently alternates between being a sender (gives) and receiver with most people in most environments but the conversation may be slower. ☐ CFCS Level III - A person usually communicates effectively with familiar communication partners, but not unfamiliar partners, in most environments. ☐ CFCS Level IV - The person is not always consistent at communicating with familiar communication partners. ☐ CFCS Level V - A person is seldom able to communicate effectively even with familiar people.

Social Interaction

Comment on how the participant interacts and engages with others. Note if the participant initiates contact and asks/answers questions.

For example, the participant:

paid attention to others around them and copied actions e.g. laughed and vocalised
responded appropriately when addressed – said ‘hello’ and made eye contact
watched others from 3m away – engaged only when called over to join
lined up blocks independently and quietly – turned away when carer tried to join in
engaged in conversation without difficulty
had trouble finishing conversations – turned away abruptly
talked at length on a preferred topic.

Self-Care

Describe briefly any observations related to tasks such as dressing, continence, eating, grooming. For example, the participant:

put on a jacket unprompted when they felt cold
requested assistance to open a packet of chips - brought packet to carer
required frequent prompts and direction to get ready for school
put shoes on when carer said ‘we need to do one more thing before we go outside’

Mealtimes / swallowing

Please note: if any of the checklist items or interview questions have indicated that the person has difficulty with eating and drinking, you will need to ask if they have seen a speech pathologist for a swallowing assessment. If not, please ask the person or their family / staff about:

☐ recurring aspiration pneumonia or chest infections (more than 2 in the last 12 months)

☐ any choking events (food getting stuck in the throat that was cleared with a cough or

requiring assistance to clear)

☐ coughing during or right after eating or drinking
☐ wet or gurgly sounding breathing or voice during or after eating or drinking
☐ complaints of /feeling like food is

References

i Australian Bureau of Statistics (2017) Australians living with communication disability, http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4430.0Main%20Features872015?opendocument&tabname=Summary&prodno=4430.0&issue=2015&num=&view

ii Guidance – swallowing difficulties.UK Government https://www.gov.uk/government/publications/reasonable- adjustments-for-people-with-learning-disabilities/swallowing-difficulties-dysphagia

iii National Disability Insurance Scheme (2020). Independent Assessment Framework. Retrieved 30 March, 2021, from https://www.ndis.gov.au/participants/independent-assessments/independent-assessment-framework

iv See:

McAllister, S., Kruger, S., Doeltgen, S. & Tyler-Boltrek, E. (2016). Implications of variability in clinical bedside swallowing assessment practices by speech language pathologists. Dysphagia, 31, 650–662. https://doi.org/10.1007/s00455-016-9724-8.

McAllister, S., Tedesco, H., Kruger, S., Ward, E., Marsh, C., Doeltgen, S. (2020). Clinical reasoning and hypothesis generation in expert clinical swallowing examinations. International Journal of Language and Communication Disorders, 55(4), 480-492.

v Transport Accident Commission (2021). Medical Assessments and Examinations. Retrieved 29 March, 2021 from https://www.tac.vic.gov.au/providers/resources/medical-assessments-and-examinations.

Transport Accident Commission, Worksafe Victoria and State Government Victoria (2012). Clinical Framework For the Delivery of Health Services. Retrieved March 30, 2021, from https://www.tac.vic.gov.au/__data/assets/pdf_file/0010/27595/clinical-framework-single.pdf

vi Australian Government (2020). Disability Support for Older Australians Program. Retrieved March 29, 2021 fromhttps://www.health.gov.au/sites/default/files/documents/2021/01/disability-support-for-older-australians-program- dsoa.pdf

vii Centre for Disability Studies. (2021) I CAN Facilitator Training. Retrieved 29 March 2021 from https://cds.org.au/education-training/i-can-v5-facilitator-training/

viii Allied Health Professions Australia (2020) NDIA Scheme Access: Independent Assessment Project, Credentialing, Training and Quality Assurance - FINAL REPORT

ix Speech Pathology Australia’s Position Statement (2014) The Role and Value of Professional Support. https://www.speechpathologyaustralia.org.au/SPAweb/Members/Position_Statements/SPAweb/Members/Position_Statements/Position_Statements.aspx?hkey=b1a46941-246c-4609-bacc-1c1b5c52d19d

x Allied Health Professions Australia (2020) NDIA Scheme Access: Independent Assessment Project, Credentialing, Training and Quality Assurance - FINAL REPORT

xi Tune, David (AO PSM). Review of the National Disability Insurance Scheme ACT 2013: Removing red tape and implementing the NDIA participant service guarantee. Canberra: Australian Government: Department of Social Services, 2019. 224 p.

xii Bishop, D. V. M. (2006), CCC-2; Children’s Communication Checklist-2, United States Edition, Manual.San Antonio, TX: Pearson

xiii Whitehouse, A. J. O., & Bishop, D. V. M. (2009). Communication Checklist - Adult. London, UK: Pearson.

xiv K. Bloomberg, D. West, H. Johnson, & T. Iacono, (2009) The Triple C: Checklist of Communicative Competencies (Revised) https://www.scopeaust.org.au/wp-content/uploads/2015/05/5.Triple-C.pdf

xv Conti-Ramsden G, Durkin K, Toseeb U, Botting N, Pickles A. Education and employment outcomes of young adults with a history of developmental language disorder. Int J Lang Commun Disord. 2018;53(2):237–255. doi:10.1111/1460-6984.12338

xvi Hidecker, M.J.C., Paneth, N., Rosenbaum, P.L., Kent, R.D., Lillie, J., Eulenberg, J.B., Chester, K., Johnson, B., Michalsen, L., Evatt, M., & Taylor, K. (2011). Developing and validating the Communication Function Classification System (CFCS) for individuals with cerebral palsy, Developmental Medicine and Child Neurology. 53(8), 704-710. doi: 10.1111/j.1469-8749.2011.03996.x, PMC3130799.