1. CATALISE Criteria and Terminology Applied to Language Impairments: Synthesising the Evidence Dorothy Bishop, Maggie Snowling, Paul Thompson & Trisha Greenhalgh

2. 2 Why we need to get criteria and terminology sorted out Sense that some children who would benefit are denied services Lack of recognition of children’s language difficulties – the ‘taxi-driver’ test The language we use affects the services that children get Can’t do research without common definitions specific language impairment developmental dysphasia SLCN language delay

3. 3 Maggie Natalie (Team Spirit) GinaCourtenay Becky Beth (Team Spirit) Raising Awareness of Language Learning Impairments: the start

4. 4 https://www.youtube.com/RALLIcampaign Goals of RALLI campaign Raise awareness of language impairments through YouTube Sort out the terminological mess

5. 5 Labels used for unexplained language problems Prefix Descriptor Noun Google Scholar: 1994-2013. Of 168 possible combinations, 130 found at least once. 33 distinct terms were used 600 times or more during that period

6. 6 Progress to date Special issue of International Journal of Language and Communication Disorders Internet forum/Twitter debate Delphi: CATALISE a) On criteria (completed Nov 2015) b) On terminology (ongoing) Sheena Reilly Susan Ebbels Trisha Greenhalgh

7. 7 Aim of the exercise: CATALISE 1 Seek consensus on how to identify children in need of extra, specialist help with language beyond what is usually available in the classroom.

8. International Expert Panel English-speaking countries Authors of the commentaries in the IJLCD special issue Additional panel members recruited from under-represented categories Discipline Country TOTAL AusCanadaIreNZUKUS SLT313415632 SLT/Psychology2300207 Psychology1300318 Spec. teacher0000202 Audiology0001001 Paediatrics0000303 Psychiatry0100102 Charity0000404 TOTAL683530759

9. Delphi for CATALISE 1: criteria

10. 10 Round 1 Round 2 CATALISE 1: Criteria for identification

11. Refer for evaluation Assessment of speech, language and communication Identification of additional factors Concern about speech, language or communication OR Behavioural or psychiatric difficulties ‘Late talker’ under 2 yr old Need information from multiple sources: caregiver report, observation, standardized tests, language learning context Language is complex: need to consider content, form and use; receptive as well as expressive Pragmatics and phonology as well as grammar/vocabulary Verbal learning and memory as well as static performance Reassess later Co-occurring problems in motor skills, attention, reading, social interaction, nonverbal skills and behaviour problems. Check for associated known conditions – genetic syndromes, ASD, acquired brain injury, hearing loss CATALISE 1: Criteria for identification - summary

12. Hypothetical 8-yr-old: George 12 Late to start to talk Didn’t speak in sentences until 4 years old Otherwise developed normally Weak vocabulary for his age Struggles with reading: has extra support Doesn’t always remember what his teacher says Teased for not understanding jokes Loves art and constructing things Parental concern; he is now reluctant to go to school Hates being singled out and made to feel different from others.

13. Educational psychology assessment 13 Nonverbal IQ of 103 Vocabulary and comprehension levels are lower, with scaled score equivalents of 85 Poor scores on tests of verbal memory Reading ability is at a 7-year- old level

14. What should be done about George? 14 Nothing Extra classroom support Referral to speech and language therapist Something else?

15. Would George benefit from any kind of label? 15 Speech, Language and Communication Needs (SLCN) Specific Language Impairment (SLI) Social Communication Disorder Developmental dyslexia Something else None of the above

16. Would your answer to previous questions be any different if George had... 16 Autistic features A moderate sensorineural hearing loss Language problems after traumatic brain injury Polish-speaking parents with poor English A chaotic and impoverished home background A score of 80 on a nonverbal IQ test Attentional problems

17. Would your answer to previous questions be any different if George had... 17 Autistic features A moderate sensorineural hearing loss Language problems after traumatic brain injury Polish-speaking parents with poor English A chaotic and impoverished home background A score of 80 on a nonverbal IQ test Attentional problems CATALISE 1: agreement that these may indicate different intervention pathway

18. 18 Round 1 CATALISE 2: Items focused on terminology Round 1

19. 19 Terminology needs to be flexible in order to be suitable for different needs in terms of policy, education, clinical practice and research More specific terms may be useful for specialist SALTS/SLPs or for researchers, to indicate specific types of problem. This terminology is likely to change as knowledge advances. 78% agreement 85% agreement 15% disagreement 8% disagreement General vs specific terminology

20. 20 For policymakers, it can be useful to have a broad category that encompasses the full range of communication problems, including cases where problems have a clear physical basis (e.g. dysarthria), affect speech fluency, voice or auditory perception, or involve other aspects of communication (e.g. use of augmentative or assistive technologies). The term Speech, Language and Communication Needs (SLCN), already in use in educational services in the UK, is recommended for this purpose. An overarching term? 72% agreement 17% disagreement

21. Vocabulary knowledge Phonology Verbal learning and memory Language use: Pragmatics Grammar Subset of SLCN: Language problems The generic term Language Impairment is recommended for situations where it is useful to adopt a broad category, where there is difficulty differentiating types of language difficulty, or where difficulties affect many domains of language 76% agreement* 13% disagreement Would exclude cases where problem involves dysarthria, stuttering, voice disorder, but otherwise broadly inclusive Areas of impairment * NB diagram revised since Delphi

22. 22 Children may do poorly on a language assessment but have adequate language learning capacity, esp if: a)Tested in English when home language is different b)Child has hearing loss so poor comprehension because cannot hear Such children have needs to be addressed, but may demonstrate normal language skills if (a) assessed in home language or (b) assessed in another modality (written or signed) Language impairment: problems with this category

23. 23 Where the main problems are in the language learning domain (as evidence by tests of memory and learning and/or lack of response to intervention) we propose the term Language Learning Impairment Language learning impairment 62% agreement* 19% disagreement Vocabulary knowledge Phonology Verbal learning and memory Language use: Pragmatics Grammar Would exclude cases where e.g. vocabulary limitations due to lack of exposure to ambient language, poor hearing, etc. Evidence from literature suggests LLI would include many of those with grammatical problems * NB diagram revised since Delphi

24. 24 For children whose main problems are with pragmatics/social communication and who do not meet diagnostic criteria for Autism Spectrum Disorder, we propose the term Social Communication Disorder. 67% agreement* 16% disagreement Vocabulary knowledge Phonology Verbal learning and memory Language use: Pragmatics Grammar CATALISE item was ‘social communication impairment’, but preference was to use SCD for consistency with DSM5 Social communication disorder * NB diagram revised since Delphi

25. 25 For children whose main problems are with phonology, we propose the term Phonological Impairment. 67% agreement* 13% disagreement Vocabulary knowledge Phonology Verbal learning and memory Language use: Pragmatics Grammar This is restricted to those where the speech problem is linguistic rather than articulatory (structural or motor). Phonological impairment * NB diagram revised since Delphi

26. 26 SLC SLCN Language Impairment LLI Phono- logical impairmt SCD Russian dolls view: Terms as subsets of broader terms

27. What about exclusionary criteria? 27

28. Exclusionary criteria misused in three ways 1.Presence of risk factor taken to mean it is whole explanation for poor language 2.Presence of risk factors used to deny services to children 28 87% agreement that allocation of services should not depend on whether language impairment primary or secondary to other cause 98% agreement that presence of a risk factor does not mean it necessarily explains child’s difficulties

29. 29 93% agreement that these should be noted but not used as exclusionary criteria Reading difficulties Behaviour problems Motor impairment Social impairment Limited adaptive behaviour/ self-help skills (low IQ) Attentional/ executive problems Panel member queried if overlap accurately depicted here – it’s not! 3. Criteria extended from factors that reliably affect language learning to include others with more tenuous link 88% agreement that there is no distinctive language profile associated with social disadvantage

30. 30 Where a risk factor, X, is present, the impairment can be described as Secondary to X, provided that the language difficulties are consistent with what is known about the impact of X Secondary language impairment 62% agreement 30% disagreement Relatively poor agreement may be soluble, as it depends greatly on what ‘risk factors’ are included. In CATALISE 1, there was good agreement that we should distinguish children who had language problems that were: consistent with hearing loss associated with Autism Spectrum Disorder consequence of acquired brain injury But we should NOT differentiate on the basis of socio-economic background

31. Need to move from exclusionary factors to: a) Differentiating factors – i.e. those that would indicate a different intervention pathway,.e.g. ASD hearing loss brain injury b) Associated factors: commonly co-occur, but cause-effect relation to language problems unclear social disadvantage motor impairment attentional problems 31 91% agreement that there are contexts when we might want to restrict consideration to those without risk factors* N.B. ‘Language impairment’ does not do this * NB: in CATALISE 2 we did not make distinction between differentiating and associated factors – we hope this might resolve some disagreements!

32. Terminology preferences: Language impairment of unknown origin Primary Specific Developmental 2 13 15 1 1 6 ‘Primary’: concern re ambiguity – what about other needs? ‘Specific’: confusing; “no longer a valid entity or useful label’ ‘Developmental’: problem for adults; in US concern that this means low IQ? Other suggestions: Idiopathic Of unknown origin Disorder rather than impairment

33. Progress so far Clarification of what criteria are relevant Agreement to adopt a ‘Russian doll’ approach to terminology Phonological impairment and social communication disorder under broad umbrella of language impairment More from focus on ‘exclusionary criteria’ to differentiating and associated factors Agreement about need to abandon some conventional views, esp re: –IQ referencing –Treating low socioeconomic status as a cause 33

34. Remaining questions Is the construct of LLI, with a focus on learning/memory and dynamic assessment useful? Can we agree of list of things that should be considered differentiating or associated factors? Can we agree terminology for cases where there are no differentiating factors? 34

35. Dorothy Bishop Oxford Study of Children’s Communication Impairments, Department of Experimental Psychology, South Parks Road, Oxford, OX1 3UD, England. dorothy.bishop@psy.ox.ac.uk

36. 36 Additional slides

37. 37 Research funding and frequency of neurodevelopmental disorders Bishop, D. V. M. (2010). Which neurodevelopmental disorders get researched and why? PLOS One, 5(11), e15112. doi: 10.1371/journal.pone.0015112 *Frequency – best estimate from epidemiological studies

38. Terms have different connotations Needs Difficulties Problems Delay Impairment Disability Disorder 38 Serious Biological Etiological Medical Mild Situational Descriptive Educational “Specific learning disability” introduced in US to ensure legal right to services

39. 39 Google Scholar search results for various terms Often applied to acquired disorders or those with known cause Mostly used for language problems in children of no known cause Excluded “communication delay”/”communication problems” – used for electronic systems !

40. 40 Specific language impairment (SLI) Advantages Most common term in academic settings, though less widely used in clinical and educational practice in UK. Disadvantages Too exclusive: ‘Specific’ often taken to mean that child (a) has a substantial discrepancy between language and nonverbal ability and (b) has no other difficulties – this excludes many children from services Research on genetics and intervention does NOT support distinguishing children with and without verbal- nonverbal discrepancy

41. Primary language impairment Not widely used: 362 hits on Google scholar search Used by Boyle et al (2007) to refer to language difficulties that are not secondary to another condition, without requiring a discrepancy with nonverbal ability PROBLEMS People may think ‘primary’ refers to school-aged People may interpret to mean language is the child’s primary problem – subtly different meaning from ‘not secondary to other condition’ Not always easy to judge if a language problem is secondary to another problem Potential for confusion with ‘pragmatic language impairment 41

42. 42 Developmental language disorder Advantages –Descriptive, without implying anything about causes –This term will be used in ICD-11 (and also fairly compatible with DSM5 ‘language disorder’) Disadvantages –Objections to ‘disorder’; too medical, disease focused; implies qualitative rather than quantitative differences between children –Affected children grow up: ‘developmental’ may be seen as inappropriate for teenagers/adults

43. Language Learning Impairment Adopted for RALLI Advantages Avoids ‘specific’, ‘primary’ and ‘developmental’, but more narrow than ‘language impairment’ Focus on learning Could be applied to any child where language learning impaired, regardless of other factors Would imply dynamic assessment of learning potential should be used Disadvantages Not widely used; break with the past, though some overlap with SLI 43