How is specific language impairment identified? Dorothy V M Bishop

Specific language impairment (SLI) Identified in children when language development falls well behind that of other children of the same age Problems interfere with everyday life and school achievement Not due to hearing loss, physical abnormality, acquired brain damage, lack of language experience Not part of a general developmental delay

The first step Child comes to attention because a parent, caregiver or teacher recognises a problem, such as: Doesn’t talk much Language seems immature for age Struggles to find words Doesn’t seem to understand what is said In older children, may fail to understand written language

N.B. Be aware that… Language problems are not always obvious. Language difficulties may underlie problem behaviour such as: Anxiety in social situations Bad behaviour in class Inattention Failure to obey instructions Problems with peer group Academic problems (esp. poor reading/writing) Cohen, N. J. (1996). Unsuspected language impairments in psychiatrically disturbed children: developmental issues and associated conditions. In J. H. Beitchman, N. J. Cohen, M. M. Konstantareas & R. Tannock (Eds.), Language, Learning, and Behavior Disorders (pp. 105-127). Cambridge: Cambridge University Press.

Three strands to assessment Information from parents/caregivers/teachers Direct observation of the child in a natural setting Formal assessment using standardized tests

Information from parents and others who know the child May be seen initially by paediatrician, speech and language therapist, or educational psychologist, who will take a case history Useful if parent or teacher can give specific examples of how the child communicates and can describe occasions when child’s language problems have been an issue Need to know what motivates the child to communicate and how communication is achieved – e.g. does the child use gesture/pointing Can he/she follow simple verbal instructions out of context? Can he/she understand a story, or talk about something in the past in a coherent sequence? Bishop, D., & Norbury, C. F. (2008). Speech and language disorders. In M. Rutter, D. Bishop, D. Pine, S. Scott, J. Stevenson, E. Taylor & A. Thapar (Eds.), Rutter's Child and Adolescent Psychiatry (pp. 782-801). Oxford: Blackwell.

Standardized approaches to parental report Parental report may be obtained by a standardized interview such as the Vineland Adaptive Behaviour Scales (which also assesses other domains) The Children’s Communication Checklist-2 is useful for screening for language problems and identifying particular types of difficulty Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales: Second Edition (Vineland II), Survey Interview Form/Caregiver Rating Form. Livonia, MN: Pearson Assessments. Bishop, D. V. M. (2003). The Children's Communication Checklist, version 2 (CCC-2). London: Pearson.

Direct observation of the child Clinician may observe how the child communicates with a parent For those at school, it can be informative to observe the child interacting with other children in the classroom The focus will be on the language used by the child, the extent to which the child appears to understand what others say, and whether the child uses nonverbal means of communication, such as gesture and facial expression

Standardized assessments A standardized assessment is one that has been given to a large group of children of different ages, to establish the normal range of performance. Test scores are often reported as percentiles, which indicate the percentage of people obtaining a score at a given level or below. A score at the 50th percentile is average for age – half the population would be expected to get a score lower than that A score at the 10th percentile would mean one in 10 children would get a score as low Common cutoffs for disorder: either 16th percentile or 10th percentile

Test scores and language impairment Scores are not set in stone: a child’s performance may vary depending on how they feel on the day In general, language impairment would not be identified on the basis of a single language test It’s more usual to give a collection of assessments that look at different aspects of language, and then to consider the overall profile

EpiSLI criteria EXPRESSIVE RECEPTIVE Vocabulary Grammar Narrative Vocabulary composite Grammar composite Narrative composite Expressive composite Receptive composite Total of 6 tests, giving 5 composites Language impairment: 10th percentile or lower on 2+ language composites Tomblin, J. B., Records, N. L., Buckwalter, P., Zhang, X., Smith, E., & O'Brien, M. (1997). Prevalence of specific language impairment in kindergarten children. Journal of Speech and Hearing Research, 40(6), 1245-1260.

Limitations of test scores Test scores have advantage of being reasonably objective; standardized tests have strict instructions on administration and scoring But some aspects of communication not easy to capture on tests Also, should we worry about a child who gets low test score if neither teachers or parents are concerned? In Tomblin et al study, only 29% of children meeting EpiSLI criteria enrolled in intervention

Combining test scores and parental report Parental checklist, CCC-2, identifies different subset of children than standardized tests Children identified by parental checklist do have academic problems, so seems parental report is important May be best to combine both sources of information: standardized tests and parental report Bishop, D. V. M., & McDonald, D. (2009). Identifying language impairment in children: combining language test scores with parental report. International Journal of Language and Communication Disorders, 44, 600-615.

Assessing nonverbal abilities Children with SLI often have additional problems, especially with attentional skills and motor skills However, they are usually distinguished from children who have a generalised cognitive impairment by the fact that they have normal range nonverbal ability Assessment of nonverbal ability is done using a standardized test that looks at ability to reason using shapes and pictures.

Debate over nonverbal ability Some formal definitions of specific language impairment, such as the one in the International Classification of Diseases – 10, require that a child has a substantial gap (1 SD or more) between their nonverbal ability and language ability This has been criticised on several counts: Very few children meet that criterion A child’s response to treatment doesn’t depend on whether they have a big or small gap between language and nonverbal ability Twin studies do not support the idea of a language-nonverbal gap as defining a coherent group with a common genetic basis Bishop, D. V. M. (2004). Specific language impairment: diagnostic dilemmas. In L. Verhoeven & H. Van Balkom (Eds.), Classification of Developmental Language Disorders (pp. 309-326). Mahwah, NJ.: Erlbaum.

EpiSLI criteria (Tomblin et al) SLI definition requires normal range nonverbal ability, but does not require large gap with language. Also studied children with Nonspecific LI, with low language/nonverbal scores Specific language impairment (SLI): score at/below 10th percentile or lower on two or more language composites 19th percentile or above on nonverbal IQ Non-specific language impairment (NLI): below 19th percentile on nonverbal IQ These two groups vary in severity, and the SLI group has better outcome. But overall, differences are a matter of degree; few qualitative differences

Terminology Speech, language and communication needs SLI = Developmental dysphasia = Specific developmental language disorder = Primary language impairment