Communication disorder

WESTERN WASHINGTON UNIVERSITY- AN INTERACTIVE INTRODUCTION TO COMMUNICATION SCIENCES & DISORDERS
Evans, Kelli
CHAPTER 4: DEVELOPMENTAL LANGUAGE DISORDERS
Chapter Author: Brenda L. Beverly, Ph.D. CCC-SLP
READING GUIDE
Reading strategies are methods of reading that learners use to increase comprehension of text. Research shows that students who use reading strategies have better reading comprehension than students who don’t (Bimmel & Schooten, 2004; Chamot, 2004; Pani, 200; Pressley, 2002). Reading strategies can help you learn and support your preparation for exams. The following are ve suggested strategies for reading this chapter.
STRATEGY 1: BEFORE YOU START READING, PREVIEW THE CHAPTER.
Skim over the chapter title, the headings, the illustrations, and the chapter
overview. Answer the following questions:
What is this chapter about?
Can I predict anything about this chapter that will be harder to understand?
Activate what you already know by agreeing/disagreeing with the following statements. After you read the chapter, come back and revise your answers.
POLL 1.
A developmental language disorder is not caused by an acquired brain injury.
Agree Disagree
2.
Children with developmental language disorders will grow out of their language challenges.
3.
Specic language impairment is diagnosed by an SLP.
Agree Disagree
Agree Disagree
4.
Form, content, and use are three language domains.
Agree Disagree
5.
Using Baby Sign® will limit language development in typically developing children.
STRATEGY 2: BEFORE YOU START READING, REVIEW THE STUDY GUIDE.
Be familiar with the vocabulary and questions on the study guide, so you can take notes as you read and focus your reading effort. You can ll in the study guide at the end of the chapter, but here is a preview:
STUDY GUIDE: OVERVIEW OF THE PROFESSIONS
Agree Disagree
Dene the following terms:
phoneme
language delay
mean length utterance (MLU)
milieu teaching pragmatics
Study Guide Questions:
developmental language disorder
norm-referenced
sentence combining
morphology
language difference
criterion- referenced
syntax phonology
language sample
Fragile X syndrome
semantics morpheme
specic language impairment (SLI)
language
child directed speech
secondary developmental language disorder
primary language disorder
receptive
expressive
1. Compare and contrast communication, speech, and language. How are these concepts related and how are they different?
2. Explain how Baby Signs® impacts language development.
3. Describe form, content, and use and how they relate to semantics, pragmatics, phonology, morphology, and syntax. Can you think of a way to represent this in a diagram or chart?
STUDY GUIDE: OVERVIEW OF THE PROFESSIONS
4. What is the key question posed during assessment of developmental language disorders?
5. This chapter contains a table describing criteria for language development at specic age ranges. How would you summarize this table?
6. How is standardized testing different from language sampling?
8. List some characteristics of SLI.
9. List populations who exhibit secondary language disorders.
7. How would you know if a client had a primary developmental language disorder or a secondary developmental language disorder?
10. This chapter describes several guiding principles to support effective treatment (individualized treatment, contextualized services, interprofessional practice, and evidence-based practices). List a brief description for each.
11. Several treatment goals are listed in the “treatment goal” section of the chapter. What underlying language function is targeted by each goal (i.e., expressive language, social communication, reading comprehension, receptive language, reading uency, etc.)?
12. Provide one example of clinician-directed approaches, child- centered approaches, and hybrid approaches.
13. What are two treatment techniques used in Milieu Teaching?
15. Compare and contrast phoneme vs. morpheme.
16. Why is cultural competence important for an SLP or audiologist?
STRATEGY 3: THINK ALOUD AS YOU READ THE CHAPTER.
Read each section, then stop and ask yourself the following:
Did I understand that? If not, write a reminder to ask for clarication.
14. Does the use of child-directed speech aid language development? Explain your answer.
Did this content answer one of the study guide questions? If so, enter the answer in the study guide.
Does this content relate to what I already know in my personal life or what I am learning in other courses?
STRATEGY 4: SUMMARIZE WHAT YOU LEARNED.
Review your study guide answers.
Create ashcards for the vocabulary words.
Summarize the main points of the chapter on one page of paper. Fold the paper in half and condense your knowledge to t on half the page.
Develop a chart or table that organizes the information you learned.
STRATEGY 5: TEST YOURSELF.
Go back and revise your answers to the agree/disagree statements at the start of this guide.
Take the end-of-chapter quiz. Pay attention to the items you get wrong and learn the correct answer.
STUDENT LEARNING OBJECTIVES Objectives
After interacting with the material presented in this chapter, students will be prepared to:
1. Compare and contrast the characteristics of a developmental language disorder with other communication disorders, such as acquired disorders, disorders of speech or communication, and language difference.
2. Outline the language domains to assess when identifying and describing a developmental language disorder.
3. List developmental disorders (e.g., autism spectrum disorders, intellectual disabilities) that frequently co-occur with or need to be differentiated from a primary developmental language disorder.
4. Identify key principles supporting effective intervention for children with developmental language disorders.
ASHA ROLES AND RESPONSIBILITIES
The American Speech Language Hearing Association (ASHA) supports ethical practice of certied and licensed audiologists and speech-language pathologists by periodically updating and publishing guidelines. In February 2016, ASHA approved and publicized an updated document on the scope of practice for SLPs. This scope is summarized in other portions of this introductory textbook. Developmental language disorders represent only a portion of the SLP scope of practice, but it’s a diverse and broad area within the whole.
To begin your understanding of this area, access ASHA’s Practice Portal for the topic area of Spo ken Language Disorders.
For school-age children, spoken language disorders are closely associated with written language disorders (e.g., dyslexia, learning disabilities). For this reason, ASHA developed a Literacy Gatew ay to highlight the role of SLPs.
If you are interested in some of the additional populations associated with developmental language disorders, you can access the following topics.
Late Language Emergence
Autism Spectrum Disorders
Hearing Impairment
Social Communication Disorders
VOICE OF EXPERIENCE
RALLI is a campaign initiated by Dr. Dorothy Bishop and her colleagues in the United Kingdom (Bishop, Clark, Conti-Ramsden, Frazier Norbury, & Snowling, 2012). It is housed entirely on a YouTube channel with many different videos highlighting various aspects of language impairment.
RALLI Campaign
The letters, RALLI, stand for Raising Awareness of Language Learning Impairments. This need for awareness is driven in large part by the limited exposure for children with specic language impairment, a language disorder that is not associated with other developmental disorders. Specic language impairment can be invisible, because children with specic language impairment do not have other observable mental or physical disabilities (i.e., Down syndrome or paralysis). They may not even have any articulation or speech differences.
First, go to the RALLI video to meet Suzanne, the mother of a boy named Sebastian, nicknamed Seb, who has specic language impairment. In this rst video, Suzanne gives many examples of Seb’s language disorder including when she rst noticed it and the characteristics as Seb grew and developed.
A Parent’s Perspective of SLI: Meet Suzanne
Next, view the RALLI video to meet Seb.
Meet Seb
In this video Seb is 16 years old talking about his own knowledge of having language impairment and how he felt.
CHAPTER OVERVIEW
In Chapter 1, the terms developmental and acquired were introduced as one important consideration in dening various communication disorders. This chapter is focused
on developmental language disorders. To be considered a developmental language disorder, the characteristics of the disorder needed to be observed when the person was still in childhood, under age 18 years but typically much earlier as you heard described by the mother of a boy with specic language impairment.
The assumption underlying a developmental disorder is that the causal factors were present before, during, or shortly after birth, such that the language impairment is emerging as the child develops and characteristics unfold in the context of changing age expectations. Acquired impairments, in contrast, are associated with specic, denable events. Although traumatic brain injury can occur in childhood, acquired disorders are not usually associated with birth events or early development prior to when at least some language skills have developed.
This chapter will support you in understanding the variety of skills and decits associated with a developmental language disorder in children with and without other developmental delays. Children with developmental language disorder are served by both SLPs and audiologists in various settings. Audiologists assist to identify, and sometimes treat, children who have developmental language disorders co-occurring with conductive or sensorineural hearing loss or auditory processing disorders.
SLPs have primary responsibility for assessing and treating children who are at risk for or who are known to display developmental language disorders in multiple settings—neonatal intensive care nursery and follow-up clinics, early intervention services for children from birth to age 3 years, school settings from ages 3 to 21 years, as well as clinic, hospital, and other agencies and practices that serve children of all ages. In this chapter, you will learn the key components of developmental language disorders, focusing on assessment and intervention for children with developmental language disorders and related developmental disabilities.
CHAPTER 4: WHAT IS A DEVELOPMENTAL LANGUAGE DISORDER?
The Focus Is on Language
In Chapter 1, you learned that SLPs and audiologists serve persons with communication disorders—a broad category that encompasses many specic types of impairments. Here, let’s address the distinctions and overlap of communication, speech, and language. Of these three terms, communication is the umbrella covering speech and language.
Communication is a broad term that encompasses sending and receiving messages through written and spoken words, with different tones of voice or punctuation, via sign language, or with body postures, facial expressions, and gestures. These communicative messages can
be intentional, such as
the purposeful text message sent to your lab partner in a science class. They can also
be unintentional, such as the cries of newborn infants that signal hunger or sleepiness to the parents or a yawn suggesting your boredom to your classroom teacher.
Communication is the core skill associated with successful social interaction, starting at age two to three years through adulthood. Communication also develops ahead of speech and language in the rst year of life. Prelinguistic communication behaviors lay a foundation for successful development of language. Parents and children use their eyes to communicate in the rst year of life—looking at one another, following each other’s eye gaze to see what the other is attending to and then talking about that object or activity.
For example, Dad notices the infant attending to the dog and says, “You see the doggy. He likes you. He’s wagging his tail.” And before the infant can say words, he or she gestures with an open hand to indicate “want” or points to pictures to get a parent to name the items in the book. Some children display a social communication disorder, usually in conjunction with another impairment (e.g., developmental language disorder, traumatic brain injury, and autism spectrum disorder).
Social Communication Disorder
Social communication disorder as dened by ASHA includes decits in social interaction, social cognition, and pragmatics. Some examples of these are the inability to vary conversational style to t the context (e.g., politeness), poor understanding of the emotions of others, inability to maintain conversations, and poor use of appropriate body language. Social communication decits can co-occur with other language disorders and developmental disabilities (e.g., autism spectrum disorder), but social communication disorder was recently recognized as a standalone clinical diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. (DSM-5; American Psychiatric Association, 2013).
Baby Signs®
Speech
SLPs and audiologists understand speech as a subset of the ways in which humans can communicate. For most individuals, speech and language develop together. Babies begin to make sounds, “oooh,” “aaah,” and “goo,” in the rst year of life, and these early babbling sounds, “bahbahbahbah” and “duhduhduhduh,” start to sound like the words they hear, “baby” and “doggie,” and the words they start to say, “mama” and “dada.” Thus, speech is the modality by which most people communicate. However, speech is only one modality.
Nonverbal communication, such as waving hello or the loud voice used by a parent scolding a child, is a communication modality that is not speech. A sign language used by individuals who are deaf is a complex language system that is not speech. Some people, such as Stephen Hawking, the famous scientist living with amyotrophic lateral sclerosis or ALS, use computer systems to communicate. ALS is an example of a motor-based speech disorder occurring in adults that affects the ability to articulate sounds and produce voicing. Children also exhibit speech disorders, sometimes secondary to a known structural problem like cleft palate or a known motor-based disorder such as cerebral palsy. Many children treated by SLPs exhibit speech sound disorders with an unknown etiology and this can co-occur with developmental language disorder.
Language
Language is considered a uniquely human skill under the umbrella of communication. Unlike what we believe about communication systems of animals (see below popup box with links), human societies across the ages and around the world have developed complex symbol systems, or languages, for the purposes of interacting, sending, and receiving sophisticated messages. The nature of these human symbol systems and their development remains a mystery in many ways. Human languages consist of tens of thousands of words referring to objects and events that can be arranged in grammatical forms to communicate an innite number of messages for a variety of purposes. And most children develop language seemingly effortlessly. It’s a human super power.
When a person is the message sender, he or she is displaying expressive language. The recipient applies his or her receptive language to decode the message. We can transmit receptive
and expressive language via speech, the spoken modality for listening and talking, or receptive and expressive language can be conveyed in written forms commonly understood as reading and writing.
KNOWLEDGE CHECK: LANGUAGE MODALITIES FOR ADL’S
For each of the following activities of daily living listed below, indicate whether the activity relies on “Receptive” or “Expressive” language and either “Spoken” or “Written” ability by typing the correct response in each column.
Activity Receptive or Spoken or Written? Expressive?
You enter your answers to the crossword puzzle
Communication Systems of Animals
You see that a post popped up on social media from your friend.
You shout across the house to tell your roommate that you’re leaving.
You study the objectives at the beginning of this chapter to prepare for an exam.
You turn on the news video to hear the breaking report on a world event.
You blurt out the answer to the teacher’s question.
You work on your psychology summary paper due at midterm.
You give directions to a building across campus.
You think about whether you’ve met the person your friend is describing.
As described above,
language most often
develops with speech,
and language serves
the purpose of
communication. In this
sense, it’s very difcult
to separate speech,
language, and
communication. This
distinction, although it
may not explain how
real people learn to
talk and communicate,
is an important
understanding for SLPs
and audiologists,
because often we
examine a person’s skills in each of these areas separately to determine if the communication impairment is manifested as a speech disorder or a language disorder or both.
Domains of Language
When a child presents with a developmental language disorder, he or she can exhibit receptive language decits, expressive language decits, or a mixed receptive–expressive
language disorder. Also as noted above, the child’s problems may be exhibited in spoken or written language. SLPs further divide receptive and expressive language abilities into form, content, and use domains. We associate form with phonology, morphology, and syntax; content with semantics; and use with pragmatics. Students in communication sciences and disorders need to carefully consider this terminology as dened and described below, because these terms underlie all aspects of assessment and treatment of language disorders for children as well as for disorders of language affecting adults.
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In 1978, Lois Bloom and Margaret Lahey published a textbook, Language Development and Language Disorders. It was in that text that they proposed the integration of form, content, and use as the core domains of language using a now classic Venn diagram of three interlocking circles. Although this integrated perspective is standard for language professionals today, it was revolutionary during a time when the grammar of language was most often the center of attention. In that same text, Bloom and Lahey offered a comprehensive denition of language, poetic in its capturing of the core elements of human language: Language is a code whereby ideas about the world are expressed through a conventional system of arbitrary signals for communication (1978, p. 4). As you study the domains below, consider how form, content, and use are each represented in that denition of language.
Pragmatics
Social language use or pragmatics extends our receptive and expressive language skills into effective social communication. An important pragmatic skill is using utterances for a variety of communicative functions. Note that the same utterance, “mama,” can be produced for different purposes. It could be a request for help when a child calls, “mama.” It could be the response to a question, if your brother asks, “Who gave you permission to go outside?.” It could be a statement or description if a child points at a woman and says, “mama.”
Other pragmatic skills include knowing how to change the language you use depending on your conversational partners or the social context. In the military, you may be expected to call persons in authority, “ma’am” or “sir,” but that wouldn’t be an appropriate form of address for your signicant other.
Because pragmatic skills build on social communication, these skills begin to develop in
the prelinguistic stage as described above. Infants take turns vocalizing with caregivers before they can say words, and one-year-olds are adept at using pointing behaviors to communicate for both requesting and commenting. Four-year-old children demonstrate changes in their language to indicate politeness and they often speak to babies using a different speaking style than they use with peers or adults. Although many pragmatic skills develop early, children and adults continue to expand their repertoire of pragmatic behaviors to meet varying activities of daily living. Decits in these skills may be termed pragmatic language impairment, but social communication disorder is the more recent label recognized by the DSM-5.
Semantics
Semantics is the aspect of language that embodies the content or meaning. Semantics is our word knowledge or vocabulary understanding and production. Words and the meanings they convey in relationship to one another are central to successful communication, and they are the critical building blocks in our language symbol systems. Words are not tied to the objects and events to which they refer; after all, the word “chair” in English is very different from “yizi” in Chinese or “sessel” in German. Children rst build their vocabulary receptively, learning word meanings in their environment before their rst birthdays or their rst spoken words. Then around age one year, children begin producing words expressively to name and talk about common people, objects, and events in their environment (e.g., mama, daddy, nose, owie).
Research (Hart & Risley, 1995) has revealed a large word and language advantage for three- year-old children whose parents talk to them frequently using language characterized by a rich vocabulary of different types of words (i.e., nouns, verbs, modiers, function words) compared to three year olds whose parents talk little or who use less varied vocabulary. These ndings were correlated with socioeconomic status. Hart and Risley estimated that children from low income backgrounds were exposed to 30 million fewer words by the age of 3 years. Vocabulary development, even when a child is typically developing, is dependent on the quantity and quality of the words he or she hears. For children with developmental language disorders, an initial lag in word learning is an early symptom of the disorder, and vocabulary weaknesses often persist through the school years impacting academic performance.
Phonology
The form of language is traditionally described as those systems that appear heavily patterned or built upon implicit sets of rules. Phonology, morphology, and syntax are all aspects of language form. Phonology is the system comprising sounds in a language and the patterns in which those
Child-directed Speech
sounds can be combined to form words. The sounds in a language that change word meanings (e.g., “p” in “pat” means something different from “b” for “bat”) are called phonemes.
The rules or the allowable combinations of sounds are phonotactics. In English, we can combine consonant sounds to form clusters at the start of syllables, such as “br” in “broom,” but we don’t combine “ts” at the start of words. Other languages consist of different phonemes and have unique phonotactic rules. For example, there is a “t” sound in the Hindi language that is made with the tongue between the teeth instead of behind the teeth, and the word for a y in Africa has the “ts” combination, “tsetse.”
Children who can hear begin to acquire knowledge of the sounds and sound patterns of their language early in the rst year. Infants can discriminate differences among speech sounds and track the patterns of those sounds at very young ages. For some children with a developmental language disorder, their phonology is impaired. These children may produce speech errors or have difculty discriminating sounds, a risk factor for future reading and spelling disabilities.
Morphology
Morphology is the system of free and bound morphemes and the language-based rules for combining them to convey properties of tense and agreement. Linguists describe free morphemes as those small units that can convey meaning as standalone words (e.g., “broom” or “the”) and bound morphemes as units that are combined with a free morpheme to change or add meaning (e.g., “s” added to “plane” to form “planes” or “ed” added to “plant” to form “planted”). When assessing morphology, SLPs working with English-speaking clients are most interested in the bound or inectional morphemes, particularly those associated with verb tense (e.g., the third person singular present tense “s” added to the verb “run” to form “runs” in the sentence, “He runs down the street”) because children with specic language impairment exhibit signicant decits for these morphemes.
Morphological skills emerge typically by the time a child turns two years old. We observe two- year-old children producing plural forms such as “cats” or verbs with “ing,” as in “going bye-bye.” Some comprehension studies have shown that children younger than two years have knowledge of these morphological combinations, even before they can produce them expressively (e.g., Fernald & Hurtado, 2006; Mintz, Newport, & Bever, 2002). Children with specic language impairment, however, often omit or make errors producing inectional morphemes in English well beyond the preschool and early school years when these skills are typically mastered.
Syntax
From words and phrases comprising the sounds and morphemes of our language, we create increasingly expanded utterances using language-based rules or syntax. Syntax overlaps with the better known term grammar, although grammar as we learned it in grade school incorporates both syntax and morphology. Syntax in a language encompasses the ways in which phrases and words are ordered in grammatically correct sentences.
A typical sentence structure, especially for young children, is noun–verb–noun or more specically, noun phrase + verb phrase + noun phrase (i.e., “the boy hit the ball”). An example of syntactic word order that can vary for languages is the relationship of modiers to nouns. In English we put the adjective in front of a noun to say “hot potato” but in other languages such as French and Spanish the modier follows the noun, “patate chaude” and “patata caliente,” respectively.
Like morphology, children appear to have knowledge of the syntax of their language around age two years. Children learning English show this knowledge by producing two-word utterances in the same word order as the utterances spoken by their caregivers, “my shoe” and “pretty baby.” During the preschool years, children demonstrate the ability to ask questions producing correct grammatical phrasing, “Is that one mine?” As with morphology, children with specic language
impairment often show greater decits for syntax than for other domains such as pragmatics or phonology.
KNOWLEDGE CHECK: LANGUAGE DOMAINS For the situation and utterance below, an SLP made ve observations. For each of the SLP’s
observations, select which language domain the SLP was addressing.
When answering her mother, the seven-year-old girl said, “We need to buy me new shoes, because these soccer cleats don’t t anymore.”
This utterance is a complex sentence with dependent and independent clauses conjoined by “because,” and there is a complex verb phrase (“need to buy”) and complex noun phrase (“these soccer cleats”).
Syntax Phonology Semantics Pragmatics Morphology
This seven-year-old showed correct articulation of several speech sounds: “cl” in “cleats,” “er” in “soccer,” and “th” in “these.” These sounds and patterns were produced consistently in this sentence and the rest of her utterances.
Syntax Pragmatics Phonology Semantics Morphology
The girl showed good knowledge and use of a specic word, “cleats,” to describe the footwear associated with soccer.
Morphology Pragmatics Phonology Syntax Semantics
The function of the utterance was to respond to a request. Phonology
Syntax Pragmatics Morphology Semantics
Note the correct use of grammatical markers including the plural “s” on the end of the word “shoes,” and the negative contraction, “don’t.”
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Phonology Semantics Pragmatics Syntax
Up to this point, you have learned that language is a complex system built on many domains with skills that are demonstrated receptively and expressively in both spoken and written forms. The average child is a super hero, attaining many adult-like skills by three to ve years of age and then honing those skills into increasingly sophisticated forms throughout the school years. We have not, however, dened the word disorder. Simply stated, a disorder is impaired functioning of a bodily or mental system. The focus of the next sections is identication of a language disorder.
When Is It a Delay or Difference, Not a Disorder?
For children with developmental disorders, early identication is viewed as a vital step in preventing the manifestation and severity of characteristics as well as optimizing outcomes for activities of daily living. There is known variation, however, in language performance at young ages, before age two years, and for spoken language associated with language dialects or speakers from bilingual and multilingual language backgrounds. This language variation can complicate the diagnosis of developmental language disorders.
Language Delay
Often, families of
young children seek
services from
audiologists and SLPs
when they or their
pediatrician notice that
a one- or two-year-old
child is not starting to
talk. Late talking or a
delay in starting to
produce rst words
around or shortly after
turning age one year is
termed late language
emergence. Some
children who exhibit late language emergence or a language delay do not have a delay in other aspects of development (i.e., social interaction, play, motor skills) or language comprehension. These late bloomers often catch up to their peers by ages three to ve years with few or no consequences due to that early lag (e.g., Dale, Price, Bishop, & Plomin, 2003).
A key difference between a language delay and a language disorder is the prognosis, because many children demonstrate late talking as the rst sign of a developmental language disorder or other primary developmental disorder such as autism spectrum disorder or intellectual disability. For these children, the late language emergence is not a language delay that will be easily resolved before the child enters school. Instead, the nature of a developmental language disorder or a primary developmental disability often leads to differences in language and learning problems through the school years and into adulthood (e.g., Johnson et al., 1999; Lewis et al., 2015).
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Language Dierence
Cultural competence involves a sincere respect for differences among people due to varying backgrounds and experiences including race, ethnicity, gender, language background, religious afliation, gender identity, and sexual orientation. SLPs and audiologists are expected to be knowledgeable about their own cultural background and assumptions as well as seeking information about other cultures. This self-awareness and knowledge of others then forms the basis for creating assessment and treatment services tailored to meet the needs of individuals from varying cultural backgrounds. More specically, SLPs and audiologists are expected to anticipate the impact of cultural variation on service provision and to maintain a respectful, learning posture with regard to understanding patient perspectives.
Furthermore, speakers of various American English dialects or English language learners can present language characteristics that overlap with symptoms of a developmental language disorder. Some American English dialects differ with respect to the form domain. That is, there can be signicant differences in the production of the phonology that could be mistaken for a speech sound disorder (e.g., pronunciation of a “d” sound for words like “the” or “these” as often observed by speakers of African-American English).
Omissions or substitutions in morphology, a common characteristic of children with specic language impairment, are typical of people who are English language learners. Pronoun substitutions, “he” for “she,” or omissions of articles “a” and “the” often occur for English language learners. SLPs and audiologists are expected to demonstrate cultural competence (see sidebar below), a set of skills that can support their successful knowledge of language differences. Cultural competence is a core competency for SLPs and audiologists.
ASSESSMENT OF DEVELOPMENTAL LANGUAGE DISORDERS
Assessment of developmental language disorders can be challenging. SLPs are tasked with considering whether there is impairment in any of the language domains (i.e., content, form, and use) receptively or expressively and for spoken or written skills, and all of these skills are changing as children grow and develop. This can be a particularly daunting task for school-age children because academic tasks are language loaded and expectations to succeed are high. No less serious is the task of determining those toddlers for whom late language emergence is a short-term delay that will have a limited impact for later performance versus those children who will experience signicant ongoing language decits or other developmental disabilities.
The key question posed during assessment is: Does this child exhibit decits in language performance?
That question is answered by comparing the child’s performance to groups of children who are the same chronological age. In this manner, developmental language disorders are dened by the expectations for language skills at specic ages and points in development. This idea of a gap between the child’s age and his or her language functioning is an age discrepancy.
Tools for Assessment
The central task for assessment of a developmental language disorder is measurement of the child’s language performance. There are many tools available for assessing language performance, and professionals are expected to understand the nature of these assessment tools to apply them in informed ways. SLPs and audiologists administer standardized assessments, tests that have been carefully constructed to allow for consistent administration. The highest quality standardized assessments demonstrate validity and reliability.
Most standardized tests are norm-referenced tests. That is, the test construction included administering the test items to large groups of children, the normative sample, in order to measure how children in different age ranges perform. When an SLP gives a child with suspected language impairment a norm-referenced assessment, he or she is seeking to determine if there is an age discrepancy by comparing the child’s test score to the scores of children who are the same age. If that standardized assessment is considered valid and reliable, then the SLP can have some condence that a true decit area has been identied.
SLPs also use assessment tools that are criterion referenced. Similar to norm-referenced tests, criterion-referenced assessments help the SLP answer the question of an age discrepancy. A criterion is an expected skill associated with an expected age. A well-known criterion for children’s language development is the production of a rst word near the rst birthday. There are established criteria for many receptive and expressive language skills that can be applied by
SLPs and audiologists when considering referral for assessment or when conducting assessments with children.
Table 1 has some well-established criteria for children developing language in expected ways at expected ages. Criterion-referenced decisions differ from norm-referenced information. The criterion may have been established based on studying smaller groups of children than a normative sample, or the criterion may be known from many studies but study measurements were not standardized.
AGE RANGE
Table 1. Expected Speech and Language Skills for Children by Age
EXPECTED SPEECH AND LANGUAGE SKILLS
3–6 months
Babies do not only cry. They make vowel and “cooing” sounds (“ah,” “oh,” “goo”), although they may not sound like older children’s or adults’ sounds Attention and interest is noted by the infant looking toward faces and in response to sounds and talking
6–10 months
The sounds babies make now include strings of syllables, “babbling” (“bahbahbah,” “muhmuhmuh,” and “bahduhguh”)
10–12 months
Before their rst birthdays, infants show understanding of common words in the environment (turning to look when they hear “daddy”)
Infants respond by turning or stopping activity when they hear their name called
Infants begin to use gestures and vocalizations to signal that they want something (reaching toward an object while looking at the adult; reaching and vocalizing together; pointing)
Children imitate or produce conventional gestures (waving “bye-bye”)
Babies play baby games like peek-a-boo or patty-cake showing anticipation of what will happen next
12 months
Around their rst birthday, children produce a rst word. Although it may not sound like the adult word, it has consistent meaning. Common examples are “mama,” “dada,” “hi,” “uh-oh,” “ball”
One year olds make a variety of consonant sounds when they babble. As many as 10 different sounds may be heard and could include p, b, m, t, d, n, k, g, s, h, w,y
18–24 months
Before they turn 2, and often much earlier, toddlers develop a spoken vocabulary of 50 words
Toddlers begin to put 2 words together in short utterances, “Daddy bye-bye” and “my cup”
AGE RANGE
EXPECTED SPEECH AND LANGUAGE SKILLS
One well-established procedure for assessing the expressive language skills of children of all ages is language sampling. Language sampling involves recording a child talking in one or more situations for a selected amount of time or until a number of spontaneous utterances have accumulated (i.e., 15–30 minutes or 50–100 utterances, respectively). Language samples can be collected during play with young children or during conversations and storytelling for older children, and they can include varied conversational partners—parents, siblings, or peers— instead of the SLP who may be meeting the child for the rst time.
Several measures of language form and content are calculated from language samples. One well- established measure of length and complexity is mean length of utterance or MLU. MLU is calculated by getting the average number of morphemes per utterance for the sample. Various researchers (e.g., Rice, Redmond, & Hoffman, 2006; Rice, Smolik, Perpich, Thompson, Rytting, &
2 years
By age 2 years, typically developing children speak in 2 to 4 word phrases and sentences
Between 2 and 3 years, children’s utterances get longer (increasing from many 2-word utterances to some that have 7–8 words) and their vocabulary increases, from 50 spoken words to 300–500 spoken words with many more words understood
Toddlers follow simple commands and answer questions (“Go get your shoes,” “Where’s the doggy?”), particularly when the speakers or activities are familiar or accompanied by gestures
3 years
Preschool-age children continue to expand their vocabulary, and now they develop knowledge of concepts such as colors, shapes, and categories like farm animals and foods
The speech of 3 year olds is clearer and easier to understand than that of 2 year olds. The words are more adult-like and can be understood most of the time, even if they are noticeably in error
Utterances are longer and preschoolers begin to talk about events that took place in the past, such as a trip to the park
Increasingly, preschoolers follow commands, sometimes with 2 or more steps, without any gestures or context clues to support the words
4–5 years
After age 4 years, speech is intelligible to strangers. That is, unfamiliar listeners can understand the words 90–100% of the time, even when some errors are noticeable (“wabbit” for “rabbit”)
Rhyming and other sound awareness skills (“ball” starts with “b”) are present to support learning to read
Children initiate and respond in conversations, keeping a topic going for at least 2 turns. They change their speech to be polite with teachers or to talk to younger children and babies
6 years
School-age children have skills for longer discourse or narratives. They can retell short stories including some key details about the beginning, the middle, and the end. They also can share their own “stories,” talking about events that have happened in the past with long, complex utterances
Six year olds are beginning readers and writers in school environments, demonstrating consistent gains in their comprehension skills
Blossom, 2010) and clinical databases (e.g., Miller & Chapman, 2008) have established criteria for the MLUs of children who are typically developing starting from age two years.
A sampling measure to evaluate semantic skill is number of different words (NDW). NDW is a count of each word used in a sample. Unlike a count of the total words (i.e., number of total words or NTW) in which every word is counted every time it’s spoken, NDW only counts the rst time a unique word is produced. SLPs understand these counts and can calculate them but computerized programs are available to compute these automatically after a language sample is entered.
KNOWLEDGE CHECK: MORPHEME AND WORD COUNTS PART 1
Practice counting morphemes and words for the consecutive utterances taken from a play- based sample for a 7-year-old boy.
Utterance
It’s a cross.
Yeah, this is supposed to go there.
Every time I do that it comes off.
See look.
I guess I’ll just have to use something heavy to keep that down.
Finger.
Look what he can do.
I know what to see if everything works.
If you do it like that and make it stay that way, you can make it jump.
That’s cool. It ts.
These people go together.
# Morphemes
#Words #Different Words
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KNOWLEDGE CHECK: MORPHEME AND WORD COUNTS PART 2
For the above sample:
Sampling Measure
Compute MLU (1 of 3)
Calculation Procedure
Add the total number of morphemes for all utterances:
Answer
Compute MLU (2of3)
Compute MLU (3of3)
Compute NTW Compute NDW
Add the total number of utterances:
Divide the total number of morphemes by the number of utterances:
Add the total number of words for all utterances:
Add the number of different words for all utterances:
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You will recall that one important decision during assessment is the distinction between a language disorder and a language difference based on cultural or linguistic variation. This is a critical concern because children from different dialects have been mistakenly identied as having communication disorders when in fact they were speakers of legitimate language variations. Furthermore, children from nonmainstream backgrounds and children from low literacy households have been overidentied and under-identied for special education in school settings, because they did not have the same background or sufcient exposure to the kinds of activities expected in mainstream American schools (for further information, see Bedore & Pena, 2008; Laing & Kamhi, 2003).
Two assessment tools used to reduce this problem are dynamic assessment and response to intervention. Dynamic assessment is a test–teach–retest process that emphasizes the ability of the child to learn a language skill. For children who haven’t had as much practice with
the standard version of American English, then dynamic assessment taps the child’s skills for learning language skills, rather than testing what they don’t know about the standard dialect.
Similarly, federal laws for educational practices now require response to intervention (RTI), a three-tiered educational process. The rst tier is ensuring good educational practices for all children regardless of their capabilities. This is critical so that if a child is performing poorly then it is less likely to be due to poor instruction. The second tier allows for struggling students to receive classroom accommodations and some small-group or individualized instruction without having to undergo assessments or be labeled as eligible for special education. This minimizes the likelihood that children who were underprepared but not language disordered will be inaccurately identied with a disorder. Children who continue to struggle after tier two RTI proceed to tier three to undergo assessment to determine the presence of developmental language disorder or other learning disability. RTI is just one example of federal laws and initiativ es that impact the professions of speech-language pathology and audiology in school settings.
Language Disorder and Related Developmental Disabilities
SLPs and audiologists are often the rst professionals seen by families when there is a suspected language impairment or developmental delay. When a one year old is not responding in the environment, particularly to sounds and speech, or not beginning to talk, the rst step is to consider hearing impairment or developmental language disorder. Some children referred for assessment have a primary developmental language disorder. That is, an age discrepancy in language performance is identied and there are no additional developmental concerns. When the developmental language disorder is primary it means that this is the only aspect that is different from age-level expectations. This is also termed specic language impairment, as you saw in the video of Seb at the start of this chapter.
A language disorder is dened by measuring an age discrepancy for some aspects of language performance, and this measurement of the language decit is the inclusionary criterion (i.e., the key feature that needs to be present) for a primary language disorder. Additionally, there is a set of exclusionary criteria used to establish that the language disorder is primary or specic to
language. These exclusionary criteria (i.e., factors that are ruled out when a language disorder is primary or specic) include hearing impairment, cognitive or intellectual disability, motor or physical disabilities, gross neurological decits or seizure disorder, and social-emotional disorders.
When the developmental language disorder co-occurs with impairment in one or more of these other aspects of development, then the child may be determined to have a secondary developmental language disorder. In other words, an established impairment such as sensorineural hearing impairment may be considered primary and a co-occurring language disorder is secondary to that condition.
Thus, an additional challenge for assessment is the determination of a primary developmental language disorder versus a secondary developmental language disorder. As mentioned earlier, SLPs and audiologists frequently serve babies and young children in neonatal intensive care nurseries, at-risk follow-up clinics, and early intervention settings. Given this role, SLPs and audiologists understand the need to consider assessment of other aspects of children’s development for optimal identication and service planning. Sometimes SLPs and audiologists are directly assessing these correlated areas, but frequently teams of professionals (e.g., psychologists, physicians, occupational therapists, and many others) are consulted to evaluate other aspects of development.
KNOWLEDGE CHECK: CASE PRESENTATION
Read the following case presentation:
Gabriel is a seven-year-old boy who was referred to the SLP in the school after making limited progress for reading in small group instruction. His rst grade teacher said he is a full school year behind in reading, struggling to sound out new words and not recalling previously practiced words. Gabriel’s mother, Ms. Juarez, reported that Gabriel has had trouble expressing his ideas and comprehending others in conversation since preschool. She waited an extra year to send him to kindergarten because he seemed immature. She said her pregnancy was unremarkable but Gabriel aspirated meconium at birth and required emergency medical treatment and an extended hospital stay.
Gabriel sat at 8 months and walked at 12 months, but he didn’t say his rst word until age 2 years. As a preschooler, he had several ear infections treated with antibiotics. Ms. Juarez said that her brother had trouble reading in school and Gabriel’s cousin (her brother’s son) is in speech therapy to correctly pronounce speech sounds.
Now apply your knowledge and critical thinking skills to answer the following questions: How do you think this information was collected?
What specic information do you think the SLP wanted to collect?
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What tier of RTI has Gabriel reached?
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What domains of language do you think the SLP will plan to test?
Name several other team members who might work with the SLP to support Gabriel’s assessment and intervention.
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POPULATIONS EXHIBITING PRIMARY DEVELOPMENTAL LANGUAGE DISORDERS
Spoken Language Disorders
As described above, specic language impairment (SLI) is a label for children who have measurable language decits but no other identiable cause or other developmental delay. It can be considered synonymous with primary language disorder. Other developmental disorders, like hearing impairment, intellectual disability, or seizure or neurological impairments, are ruled out as causal or contributing factors for the child. The disability therefore is “specic” to language skills and not explained by decits in motor or social or emotional development, for example.
SLI is a label frequently applied by researchers seeking to understand both normal language development and language disorders. That is, researchers study the language processes displayed by children who have SLI in order to describe the common or core features of a language disorder. Because no other developmental delays are evident, then any decits observed in a population of children with SLI might be assumed to be due to the language disorder and not the result of other developmental decits such as intellectual disability. Of course, any simple description of language impairment for groups of children has not been easy to establish, and the label SLI is less consistently used in clinical or non-research settings. Instead, SLPs and other team members acknowledge developmental language disorders.
Recall from the start of the chapter when we met Seb that SLI can be a hidden impairment. If the developing child does not present with speech impairment so that his or her speech is hard to
understand, then adults may not realize that the child is not developing spoken language like his or her age-level peers. Likewise, talkativeness can be misinterpreted as good expressive language, although the child might not be expressing ideas clearly in words and well-formed utterances.
Young children with receptive language decits may not be identied as language impaired because adults mistakenly interpret their behavior as noncompliant or associated with attention or intellectual limitations, rather than understanding the nature of language impairment. For these reasons, SLPs and audiologists have an important role in assisting parents and teachers to observe and identify subtle signs of language disorder that could be interfering with communication in the home and school.
The prevalence estimate for children with SLI or a primary language disorder is about 7% (Leonard, 2014). Although each child with a developmental language disorder is unique such that there is substantial heterogeneity, there are patterns of homogeneity in the decits associated with SLI. This results in behavioral descriptions that can be helpful when planning assessment and treatment, and it also has resulted in efforts to describe subgroups of children with SLI. For example, some children who display a spoken language disorder are described as having decits for expressive language skills, SLI-E, but not receptive language. This compares with children who have a mixed receptive or expressive language disorder.
Other classications have been proposed based on relative weaknesses for different aspects of language; that is, relatively greater phonologic and syntactic impairment versus relatively greater semantic and pragmatic impairment (Leonard, 2014). Fey (1986) proposed, for intervention purposes, that children with SLI be classied based on their pragmatic skills, because conversational participation would impact practice opportunities for intervention goals. No subtyping system for SLI has been adopted or found to be stable, but it is increasingly important to pinpoint dening features for developmental language disorders so that phenotypes can be used in scientic discovery of genotypes.
What are the core decits for children with a primary developmental language disorder? As described previously, they may exhibit late language emergence as an early concern. In the preschool and school-age years, children with developmental language disorders typically exhibit shorter, simpler utterances or a decreased MLU when compared to other children their same chronological age (Rice et al., 2010).
Critical decit areas for children with SLI can be observed in their knowledge and production of grammatical morphology (Leonard, 2014; Redmond, 2016). That is, they exhibit omissions of inectional morphemes, such as the third person present tense -s sufx or the past tense -ed sufx. A boy with SLI who was four years two months said, “Whoa, that car jump” for past tense action instead of the correct form, “Whoa, that car jumped.” Another utterance was, “This sign on train” for the correct form “This sign’s on the train,” omitting a form of “is” for the verb and the article, “the” before “train.”
Difculty in tasks that involve sentence repetition and nonword repetition is also characteristic of SLI. That is, children with SLI consistently display weaknesses for repeating back sentences of increasing length and complexity (e.g., “The book was not returned to the library by the teacher.”) or repeating strings of syllables that are not real words (e.g., “vachipe” or “doytowvab”). These two tasks expose verbal memory weaknesses for children with developmental language disorders.
The spoken language of children with SLI can include extra words and repetitions as they try to formulate specic utterances to express their ideas. For example, one boy with developmental language disorder, age six years seven months, was recorded saying, “First we need to put the train [*on] the (these the) top [*of] these. The words in brackets with an asterisk were not
spoken. That is, the boy omitted the function words of “on” and “of.” The words in parentheses are repetitions that do not add any information, so they are not counted for MLU.
Up to this point, developmental language disorders have been described based on talking and listening weaknesses, but language also includes reading and writing. A large percentage, 40– 80%, of preschool children with spoken language disorders are identied with written language disorders when they reach school age.
Written Language Disorders
Specic reading disability and specic learning disability are two labels for written language disorders, similar to SLI. That is, the term “specic” indicates that the identied performance decit—in a skill such as reading—cannot be explained by another developmental disability such as intellectual disability or autism spectrum disorder. These labels are applied when children are school age, the age when children are expected to learn to read and write.
Although most research (see Bishop & Snowling, 2004) suggests that a developmental language disorder underlies the written language disorders of reading, writing, and spelling, some children who are underperforming in the school setting may not have been identied as language impaired before struggling in school. Written language, successful reading in particular, consists of recognizing or reading aloud words and sounding out new words and syllables based on knowledge of the sounds associated with letters and letter combinations. Word recognition is only the rst step, however. Then, word meanings must be invoked and ideas associated with sentences and whole passages are generated for reading comprehension.
Dyslexia is a term for a specic reading disability. Many people associate dyslexia with reading letters and words backward; however, that description of reading errors does not capture the phonological, semantic, and syntactic or morphological weaknesses that often contribute to the reading disability. Bishop and Snowling (2004) proposed that the term dyslexia can be more narrowly used when word recognition problems are primary. A broader label, such as specic reading disability or learning disability, is preferred when weaknesses in reading comprehension are also manifested.
Populations Exhibiting Secondary Language Disorders
For SLPs and audiologists assessing children, one challenge is to differentiate language impairment from other developmental disorders that can have similar characteristics or may co- occur with language impairment. For example, a child with hearing impairment may not comprehend the teacher’s instructions (a weakness in spoken language skill), but the hearing impairment is considered the primary disorder. A school-age child with attention decit/hyperactivity disorder (ADHD) who talks off topic in disruptive ways could appear to have expressive language impairment, but careful assessment can discriminate between the child with ADHD only, language impairment, or ADHD and co-occurring language impairment (Redmond, 2016).
Some developmental disorders, Down syndrome for example, place a child at high risk for language impairment. The majority of children with Down syndrome or developmental delays associated with intellectual disability also show receptive and expressive language impairment and speech impairment, and until the recent changes in the diagnosis of autism spectrum disorder in the DSM-5, criteria to diagnose autism included the presence of a language disorder. SLPs and audiologists who serve children and their families strive to be knowledgeable about factors frequently associated with language impairment.
Hearing Impairment
When young children are not talking or responding in the environment, the rst concern is hearing. Fortunately, the majority of babies born in US hospitals undergo infant hearing
screening, a rst step toward early identication of signicant hearing impairments. Newborn hearing screening is not sufcient, however. Children may develop hearing impairments, and repeated ear infections during childhood can impact functional hearing and the development of speech and language.
Spoken language, and
even aspects of written
language, relies upon
hearing. Hearing is a
necessary skill to
develop a complete
knowledge of the
sounds of a language,
the phonology, which
underpins both spoken
and written language
skills. Cochlear
implants have improved outcomes for children with hearing impairment, particularly children with severe to profound sensorineural hearing impairments, but even children who receive cochlear implants at relatively young ages perform more poorly academically than their hearing peers (e.g., Sarrant, Harris, & Bennett, 2015). Chapter 6 in this text on Hearing Disorders and (Re)habilitation by Peters is designed to support your introductory understanding of the nature of hearing and the role of SLPs and audiologists assessing and serving children with hearing impairment.
Autism Spectrum Disorders
Increasingly, children with language impairment also have a primary developmental disability, an autism spectrum disorder (ASD). The US Centers for Disease Control and Prevention (CDC; Christensen et al., 2016) reported that the prevalence of ASD in 2012 for children aged 8 years and older is 1 child among 68 children and, worse yet, 1 boy in 42 boys. ASD prevalence has increased distressingly from 1990 to 2010 and this represents an important shift in pediatric practice for SLPs and audiologists because SLPs and audiologists are among the rst professionals to evaluate young children with late language emergence, who could have ASD or another developmental disability. Sidebar for the Learn the Signs. Act Early campaign of developmental milestones.
The DSM-5 (American Psychiatric Association, 2013) denition of ASD includes decits in two primary areas: (1) impairments in social interaction or social communication and (2) displays of restricted and repetitive behaviors. To assign a diagnosis of ASD, more than one behavior that is atypical and occurs in multiple contexts is observed or reported before the age of three years. Impairments in social interaction can include limited initiation of social contact, reduced sharing with others of interests and emotions, and poor turn-taking in conversations. For young children who have late language emergence, these social interaction limitations may be seen as restricted gesture use with few showing gestures and limited use of eye gaze to direct others’ behaviors or attention. The second criterion of restricted interests and repetitive behaviors may be manifested by repetitive speech or movements, ritualized activities and play behaviors, and a focus on few or unusual interests. Severity of ASD is greatly varied: There is signicant intellectual disability and little to no verbal communication for some children and adults with ASD, and yet others test as gifted intellectually or display no language decits other than social communication or pragmatic skill weaknesses.
KNOWLEDGE CHECK: VIDEO OBSERVATION: ASD PART 1
To see an example of a child with ASD and to consider what you’ve learned about the two dening characteristics of ASD, go to the CDC website for Early Warning Signs of Autism and
The CDC provides training and information free of charge to educators, health providers, and families in order to promote early identication and intervention for children who have developmental disabilities. The campaign is “Learn the Signs. Act Early.” The CDC hasfr ee handouts in English and Spanish that describe developmental milestones from age two months through ve years in motor, social or emotional, and language skills in checklist format for parents and providers.
watch the two-minute video of Joseph, a four-year-old boy with ASD (i.e., Observation: Difculty with Transitions: Joseph, four years four months). After observing this video of Joseph in his home with his family, list at least one behavior for each of the following features of ASD:
1. Social interaction or social communication impairment:
2. Restricted, repetitive behaviors, interests, and activities:
KNOWLEDGE CHECK: VIDEO OBSERVATION: ASD PART 2
The video showed Joseph throwing a tantrum. Of course, tantrums are typical of many children who do not have ASD or other developmental delays. If you are not sure how Joseph’s development is different from other children, watch the video of Harrison, a three-year-old boy throwing a tantrum. What do you see in Harrison’s behavior, a much younger boy, that wasn’t observed for Joseph?
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Intellectual Disability
As briey explained above, ASD is a denable disorder that is characterized by heterogeneous skills in many areas of development including intellectual functioning. Children with ASD may or may not also have intellectual disability. So how do we describe intellectual disability? In earlier versions of the Diagnostic and Statistical Manual of Mental Disorders, the term mental retardation was dened with an emphasis on IQ scores. The DSM-5 (American Psychiatric Association, 2013) continues to include the use of intelligence testing when diagnosing intellectual disability, but adaptive skills and varying levels of severity are important considerations.
More specically, intellectual disability (ID) is a signicant impairment in general cognitive abilities such as memory, information processing, attention, and discrimination, and these skill decits often impact the development and expected achievements for language, reading, social functioning, and self-help skills. ID, although manifested in childhood, may not be diagnosed
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during early development. Instead, a child who is not achieving developmental milestones at expected ages [See again the sidebar above with the links to the CDC Learn the Signs. Act Early video and handouts to understand key milestones across aspects of development from birth to age ve years] may be considered developmentally delayed, instead of labeled ID, until nine years old.
Down syndrome is the most commonly diagnosed chromosomal condition in the United States, affecting about 1 in every 700 children born (See CDC fact sheet). Although there is a broad range of functioning for individuals with Down syndrome, many experience ID. SLPs and audiologists frequently serve people with Down syndrome because of associated speech, language, and hearing impairments (Chapman & Hesketh, 2000). Individuals with Down syndrome commonly present with a set of facial features affecting the nasal bridge and cheekbones, eye shape, and relative size or position of the tongue in the mouth. Down syndrome is most often due to an extra chromosome at pair #21, but this mutation typically is not inherited. The greatest known risk factor for Down syndrome is advanced maternal age.
Another chromosomal abnormality is Fragile X syndrome, which is a known cause of inherited ID. Fragile X is inherited via an X sex chromosome. Because the male sex chromosomes are one X and one Y, Fragile X syndrome occurs four times more often in boys than girls and boys typically exhibit more severe impairments. Often girls, who have two X chromosomes only one of which has the genetic mutation, are carriers of the FMRX1 gene or they exhibit milder versions of the syndrome.
Some common physical features of Fragile X syndrome include a long, narrow face shape, cupped ears, and hyperextensible joints. Language, learning, behavior, and speech are often impaired for individuals with Fragile X, and the severity is impacted by the degree of ID. ASD occurs more often among people with Fragile X than other populations with developmental delay.
Environmental Factors Associated with ID
Some factors associated with ID and language disorder are more preventable perhaps than the chromosomal abnormalities described for Down syndrome and Fragile X syndrome. Fetal alcohol spectrum disorder is a broad label for a class of birth defects associated with known alcohol use by the mother during pregnancy and it can be the cause of fetal death. Children affected by fetal alcohol spectrum disorder may be born with a low birth weight and show decreased growth patterns. Some children will have extreme neurological impairment and severe ID, but others present with language disorder and learning disability as primary concerns. A dening facial feature is a thin upper lip with a attened groove between the lip and nose.
Alcohol is just one known teratogen associated with language disorders and ID. Cigarette smoking or drug use, including illegal drugs like cocaine and prescription drugs such as those given for acne, can impact development. Viral agents can be teratogens, including cytomegalovirus (which is known to cause hearing impairment) and rubella (which increases risk for ASD). Substances such as mercury from sh and lead in drinking water or paint have neurotoxic effects on the developing fetus and can cause neurobehavioral disorders and ID in children.
Neglect and abuse are also risk factors for language disorder and ID. An all too common form of physical abuse and infant death, shaken baby syndrome can result an acquired brain injury, a cause of language disorder, learning disability, ID, and other physical and neurological disabilities. As shocking as physical abuse is, physical and social neglect or maltreatment have been associated with signicantly reduced performance for language and learning. One example comes from studies of children adopted from orphanages associated with countries from the former Soviet Union that lacked adequate care or social interaction. Reports of language
disorder and ADHD were six times more frequent for these children than non-adopted children, sometimes into adolescence (Beverly, McGuinness, & Blanton, 2008).
INTERVENTION FOR CHILDREN WITH DEVELOPMENTAL LANGUAGE DISORDERS
Guiding Principles to Support Effective Treatment
Licensed and certied SLPs and audiologists have a lot of autonomy for choosing treatment methods, within ethical and legal frameworks, of course. Thisautonomy results in a broad range of options and two professionals might approach a case very differently. Despite this, there are recognized models and standards to guide the practice decisions of SLPs and audiologists.
Individualized Treatment
One important principle in intervention is individualized services or a treatment plan designed specically for the child being treated. Treatment methods are matched to that child’s level of functioning and his or her needs using a descriptive-developmental approach. Instead of focusing on a label (i.e., specic language impairment or Fragile X), a descriptive-developmental approach is based on an understanding of the specic skills exhibited by the child and the clinician’s knowledge of the next set of skills needed by that child to increase performance in targeted settings.
Regardless of the labels or disorders determined in the assessment process, it is the child’s actual language behaviors that lead to treatment planning. There is not one autism treatment to be applied to all children with ASD, nor is there one Down syndrome communication intervention to carry out with all clients who have Down syndrome. The age ranges, skills variation, and heterogeneous nature of developmental language disorders require that SLPs and audiologists tailor their practice to meet children’s individual needs at their current level of functioning.
Contextualized Services
In addition to creating treatment that is individualized, treatment occurs in several important contexts. This is really true for all language and communication activities. A speaker can produce a well-formed utterance that is not communicative for the person, time, or place. For example, a child with ASD is not communicating effectively during a November treatment session when she asks the SLP, “Can I be Ariel for Halloween?” The child’s utterance was well formed and understandable but it didn’t show an understanding of the conversational partner or the context of the conversation. Think about how often the words we use or the ideas we discuss are only correct or appropriate in specic contexts or activities. For this reason, language intervention requires a focus on context or use, not just form and content.
The two important contexts to be considered in language intervention are the home and the school. SLPs and audiologists conduct assessment and intervention that are family centered. Family-centered services recognize the family’s central role. This is particularly important for children from birth to age three years, but continues to be signicant for many school-age children or adults who require signicant home and family support because of ID or other developmental disabilities.
The home is viewed as a natural context for assessment and treatment; after all, the child would not be interacting with you in a clinic if he or she wasn’t exhibiting communication impairment at home. In the past decade there has been increased scientic support for parents to serve as the primary provider of intervention services (Roberts & Kaiser, 2011). But even when the SLP or audiologist is the direct service provider, families support children’s success when they are fully included in the goal setting and treatment progress. Children from nonmainstream backgrounds
can also receive optimal intervention when the clinician adopts a family-centered approach, because the family and home setting enable the clinician to understand the cultural background of the child and to meet his or her needs within that environment.
The majority of school-age children in the United States spend as many or more waking hours at school than at home, so school and school-related activities are critical contexts for language intervention. A school-based approach to assessment and intervention is termed curriculum- based services. Assessment methods can include interviewing the school-age client and teachers about performance in various classrooms with differing content, texts, and teaching styles. Classroom observations can yield valuable information regarding how the school-age child uses his or her receptive and expressive, spoken and written language skills to perform daily in school. Once identied as eligible for school-based services, federal laws impacting special education require that SLPs and audiologists align treatment goals and activities with the academic needs of their clients.
Interprofessional Practice
As mentioned above, SLPs and audiologists are autonomous in their practice certication for serving children with developmental language disorder; however, we rarely work alone to serve a client. The nature of a developmental language disorder, even one that is considered primary, requires a team perspective during both assessment and intervention services. The rst team members are the child and his or her family plus his or her caregivers (e.g., grandparents, daycare workers) or teachers. For children who have suspected or known developmental disabilities with a secondary language disorder, a multidisciplinary team is inevitable and invaluable.
ASHA has recently recognized the importance of interprofessional education for professionals in training (like yourselves) to support optimal interprofessional practice. First, team members work together in respectful ways, valuing the contributions of members’ expertise and maintaining high ethical standards of practice. Second, team members know their own role and the responsibilities of other members so that the needs of the patient can be met. The third and fourth competencies stress effective communication and engaged team-building processes, respectively.
Evidenced-Based Practices
ASHA (2005) has emphasized three key aspects or a triangle model for understanding evidence- based practices or EBP. The most frequently discussed aspect is scientic evidence. That is, SLPs and audiologists as well as other allied health professionals (e.g., occupational therapists, physical therapists), nurses, and teachers need to employ methods that are known to be effective for their clients based on high-quality research. This standard of a high quality research base, although desirable, has not been met for many intervention practices in speech pathology, audiology, nursing, allied health, or education. For this reason as well as the future education of SLPs and audiologists, there remains a high need for well-trained Ph.D. faculty and researchers in speech-language pathology and audiology who can carry out scientic inquiry with clinical populations and in clinical settings.
Scientic or research evidence alone is inadequate, which brings us to the other two sides of the EBP triangle that support good patient outcomes. SLPs and audiologists are also expected to recognize and incorporate the needs of the child and family to make clinical EBP decisions. And the third leg is clinical experience. Professionals make clinical decisions based on their own experiences with intervention methods, and this is best supported by acquiring and maintaining knowledge and skills in our professions.
One important mechanism for EBP is progress monitoring. When professionals employ intervention techniques that lack a scientic or research basis then there is a greater need for the clinician to track the client’s progress to determine treatment success. Progress monitoring consists of getting baseline measurements of the target skills and then conducting ongoing
measurements to determine if there is behavior change associated with the treatment activities. The rst step for progress monitoring is the establishment of measurable treatment goals.
Treatment Goals
In all treatment settings—homes, schools, clinics—SLPs and audiologists are expected to generate in writing the specic goals to be addressed in intervention. This is critical for accountability. Our clients, agencies, schools, and third-party payers (i.e., private or federally funded medical insurance policies that cover treatment costs) have a right to have written notice of the goals of intervention.
Treatment goals are written in specic ways to support accurate measurement of behavior change. In general, goals for children with developmental language disorders will address increasing receptive and expressive language skills in spoken and written contexts. As needed, goals focus on the semantic, pragmatic, or syntactic aspects of language. Goals can be written for short-term or long-term change depending on the nature of the treatment setting. For example, school-age children have a federally mandated treatment plan, the Individualized Education Plan or IEP, that is revised annually at a minimum. Other clinic or out-patient, hospital-based settings might revise or renew treatment goals monthly. The following are examples of specic, measurable treatment goals relevant to children with developmental language disorders:
1. Jonah will produce 2–4 word utterances (e.g., “my car”; “I want that”; “give me the ball”) to request a desired activity when playing with his mother 8 times in 30 minutes.
2. Tyesha will follow 2-step verbal commands (e.g., “get the block and put it in the bucket”; “stand up and wave your hand”; “touch the picture of the bird and circle the elephant”) during structured treatment activities using pictures and objects with 80% accuracy.
3. Bennett will initiate 2 conversational topics (e.g., “Do you have homework tonight?” “How was your weekend?”) when interacting with his peer mentor during lunch time for 3 consecutive lunch periods.
4. After silent reading, Kim will summarize the main idea of a paragraph of nonctional text in her own words with 75% accuracy (6 of 8 paragraphs).
KNOWLEDGE CHECK: TREATMENT GOALS PART 1
This activity is designed to check your understanding of writing treatment goals for children with developmental language disorders as well as the relationship between specic disorder areas and the possible target skills.
Match the treatment goal to the client description by entering the client description letter in the answer column that corresponds to the most likely treatment goal.
Answer
Enter the letter of the client description to match the treatment goal
Treatment Goal
The parents will hold their child and sing and talk while looking face-to-face, weekly.
The child will produce at least 10 sounds as tracked in a weekly diary by the parents.
Client Descriptions
a. Ali, age 2 years, had a sensorineural hearing loss and associated speech and language impairment.
b. Susan will receive weekly classroom-based speech-language services for a specic learning disability.
The child will answer simple “who” and “where” questions accurately
The child will listen with 75% accuracy as measured by teacher observation 3 of 4 opportunities each day.
Given a graphic organizer, the student will produce a cohesive 5 paragraph essay that includes topic sentences, transitions, and conclusion.
c. Carl was diagnosed with autism spectrum disorder at age 3, and now at age 7 was integrated for rst grade into a regular education classroom with SLP support.
d. Bethany, a newborn baby born preterm, was discharged from the Neonatal Intensive Care Unit at the regional hospital and sent home with her parents after 10 weeks.
e. Jorge has a signicant language impairment with poor receptive language skills for his chronological age of 5 years.
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KNOWLEDGE CHECK: TREATMENT GOALS PART 2
Step Two:
The best treatment goals need to include a good description of the specic behavior, the context for the behavior, and a measurable criterion for achievement. Rewrite the underlined part of the treatment goal to make it more specic.
1. The parents will hold their child and sing and talk while looking face-to- face, weekly.
2. The child will produce at least 10 sounds as tracked in a weekly diary by the parents.
3. The child will answer simple “who” and “where” questions accurately (i.e., answer “who” with a person, “where” with a place).
4. The child will listen with 75% accuracy as measured by teacher observation 3 of 4 opportunities each day.
5. Given a graphic organizer, the student will produce a cohesive 5 paragraph essay that includes topic sentences, transitions, and conclusion.
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Language Treatment Options
Fey (1986) outlined a continuum of treatment methods still used as a framework for pediatric language intervention. On one end of the continuum were well-established methods based on the principles of behavioral psychology. These methods, labeled clinician-directed approaches, incorporate specic stimuli carefully structured by the clinician to elicit predetermined, goal- directed responses from the client. On the opposite end of this continuum are child-centered approaches, derived from social interaction principles and built on techniques that take advantage of natural contexts and the client’s perspective. (See Hoff [2006] for a summary of social and environmental factors, such as parent education level, birth order, and interaction styles, that impact language development.)
Midway on this treatment continuum are a group of treatments considered hybrid approaches, because they combine elements from the clinician-directed and child-centered philosophies. SLPs and audiologists are expected to participate in lifelong learning or continuing education in order to stay abreast of scientic research supporting EBP. As described earlier, SLPs and audiologists consider scientic research in combination with their clinical experience and individual client and family needs to select the treatment methods that will effectively target the treatment goals. The following are examples of pediatric language intervention methods– clinician-directed, child-centered, and hybrid versions–with an emerging or better research evidence base.
Sentence Combining for Written Language and Syntax
SLPs and audiologists who serve adolescent children with communication disorders may be addressing written language skills, particularly grammatical aspects to support grade level success. Explicit or clinician-directed methods for teaching writing have been found effective based on scientic studies (see Datchuk & Kubina, 2013; Scott & Nelson, 2009).
More specically, the technique of sentence combining has resulted in measurable increases in students’ production of longer, more complex sentences. Sentence combining can be taught in mini-lessons or drill activities structured by the clinician. Students are explicitly taught to use conjunctions (e.g., “and,” “but,” and “because”) to build complex sentences from simple sentences.
For example, the simple sentences, “My neighbor went on vacation” and “She saw the Grand Canyon” can be combined to “My neighbor went on vacation and saw the Grand Canyon.”
Students are also taught to embed information from one simple sentence within another simple sentence. For example, the ideas from two simple sentences, “My neighbor is nice” and “My neighbor brought me fresh berries” can be combined to say, “My nice neighbor brought me fresh berries.” Both conjoining and embedding result in more complex sentences for improved writing, and students taught sentence combining show increases in syntax and writing skills, particularly when proong or revising their writing drafts. To practice sentence combining, try your skills on t his online quiz.
Indirect Language Stimulation Using Recasts
See a mother using recasts while reading a book to her son, Indirect Language Stimulation and R ecasts. Write down three recasts spoken by this mother. What did the child say rst? What type of recast was this? In other words, in what way was the mother’s recast sentence different from the child’s utterance? Did you see an example of the child then producing a more adult-like utterance based on his mother’s recast?
On the opposite side of the treatment continuum from clinician-directed methods are child- centered approaches. Indirect language stimulation, an approach implemented during young children’s play, is one example. Indirect language stimulation typically consists of several strategies employed by the SLP or audiologist to elicit expressive language skills from children with language disorders. These strategies include the clinician talking about his or her play or tal king about the child’s play.
The effectiveness of one specic technique, recasts, has been shown (e.g., Cleave, Becker, Curran, Owen Van Horne, & Fey, 2015; Hassink & Leonard, 2010). A basic recast is when the adult speaker repeats back the child’s utterance with some changes to increase the correctness or complexity of the child’s utterance. For example, when a child says, “car go,” the adult might then say, “Yes, the car’s going.” There are many variations on recasts. Some recasts correct a mispronounced speech sound or grammatical errors. Other adult recasts extend the child’s utterance to include an additional idea and vocabulary content (e.g., the adult recast might be, “The car goes fast down the hill”). Many SLPs talk about recasts as a change in sentence type— from a simple, active, declarative utterance to a question form or negative utterance. So, when a child says, “car go,” the adult might say, “Is the car going?” or “This car is not going.”
In addition to the many forms of recasts, recasts often are one technique within a more comprehensive approach, like indirect language stimulation. For these reasons, researchers have found varying levels of effectiveness. Cleave et al. (2015) concluded that recasts were most effective when adding grammatical information and when used frequently with focus on a single target or two. Note that more frequent, focused recasts may be better suited to a hybrid treatment approach, because a truly child-centered treatment approach tends to have broad treatment goals, such as “increase overall amount of talking,” not specic goals, such as “consistently produce articles before nouns.”
Milieu Teaching
Perhaps the best known hybrid approach is Milieu Teaching in various forms, including Milieu Communication Training, Prelinguistic Milieu Teaching, and Enhanced Milieu Teaching. Milieu Teaching is considered to have research-based evidence for improving communication and language skills for young children with developmental language disorders including SLI, ASD, and ID (e.g., Kaiser & Yoder, 1992; Mancil, 2009).The approach builds from incidental teaching techniques that occur in the child’s environment such as the preschool classroom or in typical developmental activities, for example, tossing a ball or reading a book. SLPs, teachers, and parents who use Milieu Teaching often start by observing what the child wants to do, the idea of following the child’s lead.
For treatment sessions, the clinician may plan an activity that will tempt the child to participate and communicate. Although Milieu Teaching starts in these natural environments and conditions, the key techniques are based on behavioral methods associated with adult-directed approaches. This combination of a natural context with directive methods is characteristic of hybrid treatment approaches.
Techniques utilized in Milieu Teaching are time delay or “wait” and mand-model. With time delay, the adult purposefully pauses or does not speak after engaging with the child or presenting the tempting activity. In this manner, the child has an opportunity to initiate the interaction or speak spontaneously. After several seconds (often 5–7 seconds), if the child has not spoken spontaneously, the adult produces a model. That is, he or she produces an utterance that ts the child’s language goals. Depending on the child, this could be a pointing gesture, a spoken word (“ball”), or even a whole sentence (“My turn to roll the ball.”).
When children do not imitate the adult’s communication, then the adult can add a mand, a question or direction to prompt the child. For example, the clinician might ask, “What’s this?,” or more specically instruct the child, “Say, ‘ball’,” while withholding the ball until the child produces the target utterance. To see a step-by-step description of Enhanced Milieu Teaching, a variation of Milieu Teaching focused on training the parents of children with language disorders, you can access this seven-minute video on YouTube.
SUMMARY
SLPs and audiologists serve children from birth into adulthood who present with developmental language disorders. Typical language development in children builds on early vocalizations and gestures within caregiver interactions, and four year olds who are not impaired present with clear, conversational speech consisting of long sentences, social turn-taking, the ability to talk about past events, and correct use of vocabulary and many grammatical elements.
Children with developmental language disorders may be late to start talking or they may be identied because they differ from their siblings or peers. The nature of a language disorder is described using assessment procedures such as language sampling, standardized measures, and planned observations. Receptive orexpressive language skills, in spoken or written activities, that are signicantly below a child’s age-level expectations indicate a language disorder, which may be primary(i.e., the only developmental concern is specic to language) or secondary to other developmental disorders such as autism spectrum disorders, hearing impairment, and Down syndrome.
Children with language disorders continue to grow and develop, making progress in their language development and communication skills, and in response to language intervention in home, school, and clinic settings. SLPs and audiologists work with other educational and medical team members (e.g., teachers, doctors, psychologists, nurses, physical therapists, and occupational therapists) to develop individualized treatment plans targeting decit language skills. Intervention methods vary depending on the goal areas and the ages and needs of the clients, but understanding evidence-based principles supports selection of the best treatment methods.
TERMS TO REMEMBER
These ashcards include important terms selected from the chapter. You should be able to dene these terms by 1) providing the word when you see the denition and 2) providing the denition when you see the word. Although these words were specically selected because they will help you study for the end-of-chapter quiz, remember that you are responsible for all information presented in the course.
GLOSSARY OF TERMS
This chapter uses two methods to highlight important terms: cursor hovering and bold formatting. Hover terms appear in red and are underlined with a red dashed line. If you hover your cursor over those words, a denition will pop-up on your screen. Words that are formatted in bold are terms that may need more explanation than a quick pop-up and are explained further in the text. You can nd all the terms in the following glossary.
All A B C D E F G H I J K L M N O P Q R S T U V W X Y Z
age discrepancy
attention decit/hyperactivity disorder autism spectrum disorder (ASD) autonomy
baseline
bound morphemes
child directed speech
child-centered approaches clinician-directed approaches communication
content
criterion
criterion-referenced
cultural competence
curriculum-based services descriptive-developmental approach developmental language disorder dialects
disorder
Down syndrome
Click the card or button to ip. Click “previous” and/or “next” to move through cards. Use “face up” and “face down” option to set default card state.
CHILD DIRECTED SPEECH
Flip Card
Shufe Face Up << Previous1 of 24 Next >> Face Down
dynamic assessment
dyslexia
English language learners evidence-based practice (EBP) expressive language
family centered
Fetal alcohol spectrum disorder form
Fragile X syndrome
free morphemes
genotypes
gross
hearing impairment (hearing loss) heterogeneity
homogeneity
hybrid approaches
hyperextensible
Individualized Education Plan (IEP) individualized services
intellectual disability (ID)
intentional
language
language delay
language difference
language sampling (language sample) late language emergence
Linguists
mand
mean length of utterance (MLU) metalinguistic
Milieu Teaching
model
morpheme
morphology
nonmainstream
nonverbal communication norm-referenced
number of different words (NDW) number of total words (NTW) parent responsiveness
phenotypes
phonemes
phonology
phonotactics
pragmatics
Prelinguistic
primary developmental language disorder (specic language impairment (SLI)) prognosis
progress monitoring recasts
receptive language reliability
response to intervention (RTI)
secondary developmental language disorder
semantics
sentence combining
shaken baby syndrome
sign language
social communication disorder
specic language impairment (primary language disorder) specic reading disability (specic learning disability) speech
speech disorder
standard
standardized assessments
syntax
teratogen
time delay
traumatic brain injury
unintentional
use
validity
CH 4: STUDY GUIDE: DEVELOPMENTAL LANGUAGE DISORDERS
Using the space provided, answer each study guide question. Save your work often! It is a good idea to press save after each question. If your instructor requires the study guide for course credit, make sure you submit your work when nished. Otherwise, your instructor will not receive your answers.
1. Compare and contrast communication, speech, and language.
2. Explain how Baby
Signs® impacts language development.
3. Describe form, content, and use and how they relate to semantics, pragmatics, phonology, morphology, and syntax. Can you think of a way to represent this in a diagram or chart?
4. What is the key question posed during assessment of developmental language disorders?
5. This chapter contains a table describing criteria for language development at specic age ranges. How would you summarize this table?
6. How is standardized testing different from language sampling?
7. List some characteristics of SLI.
8. List populations who exhibit secondary language disorders.
9. This chapter describes several guiding principles to support effective treatment (individualized treatment, contextualized services, interprofessional practice, and evidence- based practices). List a brief description for each.
10. Several treatment goals are listed in the “treatment goal” section of the chapter. What underlying language function is targeted by each goal (i.e., expressive language, social communication, reading comprehension, receptive language, reading uency, etc.)?
11. Provide one example of clinician-directed, child-centered, and hybrid treatment approaches.
12. What are two treatment techniques used in Milieu Teaching?
13. Does the use of child- directed speech aid
language development? Explain your answer.
14. Compare and contrast phoneme vs. morpheme.
15. Why is cultural competence important for an SLP or audiologist?
CHAPTER 4 QUIZ
Availability Start Date:
Jul 30, 2017 @ 10:00 PM PDT
Availability End Date:
Jun 05, 2018 @ 09:59 PM PDT
Instructions:
Please use the following link to access the quiz. The quiz consists of 10-15 items about the chapter, and you can use this quiz guide to understand how to navigate the quiz. Please remember to press submit answer for each question!
Your Status:
Begin your attempt.
L L L I I I N N N K K K L L L I I I B B B R R RA A A R R R Y Y Y
The following are links to the external content presented throughout this chapter. They have been compiled here for convenient access.
Scope of practice for SLPs (ASHA)
Spoken Language Disorders (ASHA)
ASHA’s Literacy Gateway (Reading and Writing)
Late Language Emergence
Autism Spectrum Disorders
Hearing Impairment (Permanent Childhood Hearing Loss)
Social Communication Disorders (School-Age Children)
RALLI Campaign
A Parent’s Perspective of SLI: Meet Suzanne
Meet Seb
Baby Signs®
Stephen Hawking (White House)
Kanzi in the Kitchen: Primates and Communication
Dolphins: Even Smarter Than You Thought – Nat Geo Live
Discriminate differences among speech sounds (Tuning in to Speech Sounds) Professional Issues in School Settings (ASHA)
Learn the Signs. Act Early.
Free Development Handouts
Early Warning Signs of Autism
Video of Harrison (Early Warning Signs of Autism)
CDC fact sheet (Facts about Down Syndrome)
Interprofessional practice (IPE IPP Overview)
Sentence Combining Quiz
Indirect Language Stimulation and Recasts (Conversation Recast – Molly, Taylor, Christa, Jessica)
Enhanced Milieu Teaching CAP

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