1. Changing terminology and diagnostic criteria: evidence based decisions and practice
Dr Susan Ebbels
Prof Courtenay Norbury
#DevLangDis #workshop

2. Overview of session Impetus for change
Summary of CATALISE process and key changes to terminology and diagnostic criteria
Summary of evidence supporting these changes
Food for thought

3. the taxi driver test…. Language disorder Language delay
Speech language and communication need
Language
learning impairment
Language processing difficulties
Specific language impairment
Primary language impairment
High-level language difficulty

4. Labels matter!!
relative to prevalence and severity, ‘specific’ language impairments:
attract less research interest (as measured by publications)
attract less research funding
attract less media attention
are not recognised by the public
lack of consistency in terminology contributing factor
people don’t recognise we’re talking about the same thing
people don’t realise its an important problem if it doesn’t have a name
parents need and value labels
Bishop, D.V.M. (2010) PLoS One

5. Included multidisciplinary input from English speaking countries
SLTs, psychologists, charities, parents, teachers, etc

6. Key changes to terminology and criteria

7. Unfamiliar with local language? Competent in another language? [4] Yes
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]

8. Fail to combine words at 24m Comprehension problems
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Under 3:
Prediction from late language emergence to subsequent language disorder at school age is surprisingly weak.
Indicators are:
Fail to combine words at 24m
Comprehension problems
Don’t communicate via gesture
Don’t imitate body movements
Poor social responsiveness and joint attention
Family history of language or literacy problems
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]

9. START
Child presents with difficulty producing or understanding language that affects everyday functioning
3-4 years:
Prediction improves as children grow older. In 4 year olds, greater number of areas impaired, higher the likelihood that problems will persist.
Sentence repetition is a relatively good marker for predicting outcomes
(those with problems only with expressive phonology have generally good prognosis)
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]

10. Prognosis particularly poor when: Receptive language is impaired
START
Child presents with difficulty producing or understanding language that affects everyday functioning
5 years and over:
Language problems that are still evidence by 5 years are likely to persist
Prognosis particularly poor when:
Receptive language is impaired
Non-verbal ability is relatively low
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]

11. Associated biomedical conditions (examples) brain injury,
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Unfamiliar with local language?
Competent in another language? [4]
Yes
Associated biomedical conditions (examples)
brain injury,
acquired epileptic aphasia in childhood,
certain neurodegenerative conditions,
genetic conditions such as Down syndrome,
cerebral palsy
sensori-neural hearing loss.
autism spectrum disorder (ASD)
intellectual disability No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]
Associated biomedical condition, X?
Yes
Language disorder associated with X [6] No
Developmental
Language
Disorder [7]

12. Developmental Language Disorder No differentiating conditions
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Developmental Language Disorder
No differentiating conditions
“developmental” means “emerges in the course of development”
Does not mean child might ‘grow out of’ problem
Does not mean child unable to develop language
Could drop “developmental” term for adults
Large discrepancy between verbal and non-verbal ability not required
Children with low non-verbal IQ (who do not meet criteria for intellectual disability) can be included as cases of DLD
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]
Associated biomedical condition, X?
Yes
Language disorder associated with X [6] No
Developmental
Language
Disorder [7]

13. Additional Information
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Co-occurring disorders
Attention (e.g., ADHD)
Motor (e.g., dyspraxia, dysarthria)
Literacy
Speech
Adaptive behaviour
Behaviour/emotional problems
Auditory processing (e.g., APD)
Language disorder [2]
Associated biomedical condition, X?
Yes
Language disorder associated with X [6] No
Developmental
Language
Disorder [7]
Additional Information
Co-occurring disorders [9]
Risk factors [10]
Areas of language impairment [11]

14. Additional Information
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]
Associated risk factors
Family history
Male
Younger sibling in large family
poverty
Fewer years of parental education
Associated biomedical condition, X?
Yes
Language disorder associated with X [6] No
Developmental
Language
Disorder [7]
Additional Information
Co-occurring disorders [9]
Risk factors [10]
Areas of language impairment [11]

15. Additional Information
START
Child presents with difficulty producing or understanding language that affects everyday functioning
Unfamiliar with local language?
Competent in another language? [4]
Yes No No
Yes
Features suggestive of poor prognosis? [3] No
Yes
Language disorder [2]
Areas of language impairment
Phonology (may get dual diagnosis of DLD with SSD)
Morphology
Syntax
Word finding and semantics
Pragmatics/language use
Discourse
Verbal learning and memory
Associated biomedical condition, X?
Yes
Language disorder associated with X [6] No
Developmental
Language
Disorder [7]
Additional Information
Co-occurring disorders [9]
Risk factors [10]
Areas of language impairment [11]

17. Summary of terminology (as used by SLTs)
Children with a previous diagnosis of SLI would all meet new criteria for DLD
Children with previous diagnosis of SLI are a subset of those who meet new criteria for DLD
DLD is broader than SLI as non-verbal criteria relaxed (although those with intellectual disability would not be included)
Children with DLD are a subset of those with Language Disorder (those who do not have differentiating conditions)
Children with LD are a subset of those with SLCN

18. Advantages of new terminology
Agreed by consensus
If all SLTs use same criteria, should reduce disputes between SLTs (e.g. between independent vs NHS practitioners)
Can use different levels of labels depending on purpose:
SLCN for discussing with policy makers (all children who may require SLT support)
Language Disorder for discussing with commissioners/teachers (all children likely to need SLT support including a focus on language)
DLD for highlighting particular needs of and support required by this group which may differ from others (e.g., ASD)
Full description of areas of language impairment and co-occurring/associated disorders – for planning intervention and educational provision for an individual child
Used in DSM-V
Likely to be used in ICD-11

19. Terminology vs Intervention
In an ideal world, intervention and educational provision should be based on a detailed understanding of the child’s full profile of strengths and needs
In this case, changes in terminology / criteria should have no effect on intervention/educational provision, as the children’s needs have not changed

20. Terminology versus Intervention
However, in some places,
intervention/educational provision has been determined by diagnosis (using exclusionary criteria)
some children have been excluded from services despite having needs which could benefit,
changes in criteria and labels could mean more children are now eligible for services, creating greater pressures
But the need always was and is still there…

21. Problems with new terminology
We have a big problem when talking with education services
Education uses terminology in a different way – especially SLCN

22. Terminology as used by education

23. Problems with new terminology
We have a big problem when talking with education services
Education uses terminology in a different way – especially SLCN
Primary SLCN most similar to DLD
Secondary SLCN most similar to “Language Disorder associated with X”
But SLTs use SLCN to mean all children who we may need to be involved with for any reason

24. Evidence based decisions

25. why ‘specific’ language impairment?
previously “developmental dys/aphasia”
term ‘SLI’ took hold in era of universal grammar
Language is modular / innate
Can be selectively impaired
non-verbal cognitive abilities limit language development
Language impairment ‘in line’ with mental age is different to LI when discrepancy
Children with low non-verbal ability don’t learn as fast or respond to therapy

26. view that language is ‘selectively’ impaired is under pressure…
Behavioural
moderate correlations between language and non-verbal ability
children with intellectual disabilities (i.e. Down syndrome) benefit from language intervention (Burgoyne et al. 2015)
‘selective’ impairments derived from arbitrary cut-offs on continuous data

27. could improving language drive other kinds of learning?
Reilly et al. (2014) IJLCD

28. what is the causal relationship of language and non-verbal ability?
language is a fantastic problem solving tool!!

29. view that language is ‘selectively’ impaired is under pressure…
Neurobiological
genetic evidence is that ‘specific’ and ‘non-specific’ language impairment arise from same genetic mechanisms
developing brain is not as rigidly modular as adult brain – language processing is distributed (Krishnan, Watkins, Bishop, 2016, for recent review)
neural circuits implicated in language disorder involve general, complex rule-governed LEARNING
‘specific’ deficits highly unlikely in a developing system

30. Impact of changing criteria on prevalence and clinical presentation

31. If child has language difficulties at school entry, what co-morbidities are present from the start?
How do co-morbidities affect language change over time?

32. Prevalence Year 1
% of population
Developmental Language Disorder (cause unknown)
7.58%
higher NVIQ
4.80%
lower NVIQ
2.78%
Language Disorder (known cause and/or intellectual impairment)
2.34%
Total Language Disorder
9.92%

33. children with lower non-verbal cognitive ability (70 – 85) do NOT have a different clinical profile
Low NVIQ
(>-2SD & <-1SD)
Normal NVIQ
(>= -1SD)
T-test N
156
256
IDACI rank ns
Age (months)
69.91
72.81
Communication checklist
19.61
18.06
Social, emotional, behavioural problems
7.00
7.81
Academic attainment
27.20
28.32
Weighted group comparisons using linearised SEs

34. children with lower non-verbal cognitive ability (70 – 85) do NOT have a different profile of language deficit

35. SLT COULD BE CRUCIAL TO QUALITY OF LIFE FOR THESE CHILDREN!
NOTE: children with Language Disorder and associated conditions (ASD, Down syndrome, etc):
more severe language deficits
more severe social, emotional, behavioural problems
greater academic challenges
more likely to be in specialist education provisions
SLT COULD BE CRUCIAL TO QUALITY OF LIFE FOR THESE CHILDREN!

36. why developmental language “disorder”?
‘disorder’ indicates a problem that should be taken seriously.
puts language disorder on a par with other neurodevelopmental disorders
autism spectrum disorder
developmental co-ordination disorder
attention deficit hyperactivity disorder
is compatible with the two main diagnostic systems, DSM-5 and ICD11
term ‘specific’ language impairment has connotations that are misleading and confusing

37. DLD is a lifelong disorder

38. language is incredibly stable
Better than Year 1
Total Language Year 3 (z-score)
Worse than Year 1
Total Language Year 1 (z-score)
ICC = .93

39. stable, but considerable language ‘growth’ over time
Not only is this group improving, growth RATE is similar to TD peers

40. to “narrow the gap”…
LD groups must learn language at a faster rate than the TD group
Is this possible?
Is there a critical period?
Is current provision sufficient to do it?

41. food for thought… More inclusive criteria: Interface with education:
How to manage the need…
Interface with education:
Joint working paramount
Lifelong disorder:
Changing need and limited adult services at present
Consider the goal of intervention
What is a ‘good’ outcome?

42. Key papers to read
Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T., & Catalise-consortium. (2017). Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology. Journal of Child Psychology and Psychiatry.
Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T., & The CATALISE Consortium. (2016). CATALISE: a multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLOS One, 11(7),
Ebbels SH, McCartney E, Slonims V, Dockrell JE, Norbury C. (2017) Evidence based pathways to intervention for children with language disorders. PeerJ Preprints 5:e2951v1,
Norbury, C. F., Gooch, D., Wray, C., Baird, G., Charman, T., Simonoff, E., Pickles, A. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study. Journal of Child Psychology and Psychiatry,