Developmental Language Disorder BJ Cunningham, PhD, SLP(C), Reg. CASLPO Early Words, Hamilton ON June 12, 2018
Outline 1. Discuss two new studies that addressed issues in pediatric SLP 2. Review recommendations for (a) identifying children with language disorder, and (b) terminology in SLP 3. PSL Program research update 4. Questions
Background • Language disorders are common in children • Prevalence of language impairment in kindergarten is approximately 7% (Schriberg et al., 1999) • Little agreement about how to identify & classify = barriers to identifying children requiring services (Bishop et al., 2016) • Large variation in terminology = confusion in research and practice (Bishop et al., 2016)
Delphi Studies • Bishop et al. (2016, 2017) conducted two Delphi studies with experts in pediatric language disorders to: 1. Determine a criteria for identifying children who need language supports. 2. Establish a consistent/agreed-upon terminology for pediatric language disorders
What’s a Delphi Study? • A method for establishing consensus • Expert panelists provide anonymized ratings and feedback (up to 3 rounds) • Panelists get feedback about their responses and can make comments (seen by other panelists) • Rounds continue consensus is reached, or until it is clear there will be no consensus (Keeney, Hasson & McKenna, 2011)
Bishop et al.’s Delphi Studies (Bishop et al., 2016)
Bishop et al.’s – Study 1 (2016)
Bishop et al.’s – Study 1 (2016) • Purpose: to establish an agreed upon criteria for identifying children who need language supports • Panelists read 25 statements and rated how much they agreed (5-point scale) • Comments about each statement • Statements revised between rounds based on ratings, comments, and advice from a moderator
Bishop et al.’s – Study 1 (2016) Fig 1. Flowchart showing stages in the Delphi consensus process. (Bishop et al., 2016)
Bishop et al.’s – Study 1 (2016) (Bishop et al., 2016) Fig 2. Final set of statements in precis form.
Bishop et al.’s – Study 1 (2016) • Need for greater understanding of what constitutes age appropriate language (and variations around this) • Practitioners should be well-informed about expected language skills at each age • Practitioners should watch for poor response to intervention (Bishop et al., 2016)
Bishop et al.’s – Study 1 (2016) • Greater clinical competence for assessing and treating social communication skills • Programs should not differentiate delay/disorder – (e.g., children with uneven profiles prioritized for intervention) • Intervention is needed even if language issues may be associated with social disadvantage (Bishop et al., 2016)
Bishop et al.’s – Study 2 (2017)
Bishop et al.’s – Study 2 (2017) Purpose: To establish a consistent. agreed-upon • terminology for pediatric language disorders
Bishop et al.’s – Study 2 (2017) • Panelists read 11 statements and rated how much they agreed (5-point scale) • Comments about each statement • Statements revised between rounds based on ratings, comments, and discussions at meetings (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 1 . It is important that those working in the field of children’s language problems use consistent terminology • Statement 2 . The term ‘language disorder’ is proposed for children who are likely to have language problems enduring into middle childhood and beyond, with a significant impact on everyday social interactions or educational progress (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 3 . Research evidence indicates that predictors of poor prognosis vary with a child’s age, but in general language problems that affect a range of skills are likely to persist – Under Three – Three to Four – Five years+ (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 4 . Some children may have language needs because their first or home language differs rom the local language, and they have had insufficient exposure to the language used by the school or community to be fully fluent in it. This should not be regarded as language disorder, unless there is evidence that the child does not have age appropriate skills in any language • Statement 5 . Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co-occurring conditions. (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 6 . Differentiating conditions are biomedical conditions in which language disorder occurs as part of a more complex pattern of impairments. This may indicate a specific intervention pathway. We recommend referring to ‘ Language disorder associated with X ’, where X is the differentiating condition. • Statement 7 . The term Developmental Language Disorder (DLD) is proposed to refer to cases of language disorder with no known differentiating condition (as defined in Statement 6). Distinguishing these cases is important when doing research on aetiology, and is likely also to have implications for prognosis and intervention. (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 8 . A child with a language disorder may have a low level of nonverbal ability. This does not preclude a diagnosis of DLD. • Statement 9 . Co-occurring disorders are impairments in cognitive, sensori-motor or behavioural domains that can co- occur with DLD and may affect pattern of impairment and response to intervention, but whose causal relation to language problems is unclear. (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 10 . Risk factors are biological or environmental factors that are statistically associated with language disorder, but whose causal relationship to the language problem is unclear or partial. Risk factors do not exclude a diagnosis of DLD. • Statement 11 . Developmental language disorder is a heterogeneous category that encompasses a wide range of problems. Nevertheless, it can be helpful for clinicians to pinpoint the principal areas for intervention, and researchers may decide to focus on children with specific characteristics to define more homogeneous samples for study. We suggest here some guidelines for more in-depth analysis of language problems. (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) • Statement 12 . It can be useful to have a superordinate category for policymakers, because the number of children with specific needs in the domain of speech, language and communication has resource implications. The term Speech, Language and Communication Needs (SLCN), already in use in educational services in the United Kingdom, is recommended for this purpose. (Bishop et al., 2017)
Bishop et al.’s – Study 2 (2017) Brain injury, acquired epileptic aphasia, certain neurodegenerative conditions, cerebral palsy, sensorineural hearing loss, genetic conditions (e.g., DS), ASD and/or intellectual disability (Bishop et al., 2017)
PSL Program Research Update • PSL Program uses the FOCUS and CFCS to collect participation- based outcomes data • Using these data, we have learned how children’s communicative participation skills develop, and identified predictors of growth • Unable to explore outcomes by different impairments (Cunningham, Kwok, Turkstra & Cardy, 2018)
PSL Program Research Update • From a clinical perspective, the most reliable way to identify children’s impairments would be to administer (possibly multiple) standardized tests in addition to completing the FOCUS and CFCS • Need a simple, valid, and reliable tool SLPs can use to identify the functional impairments children present with at assessment • Use Delphi surveys to establish expert consensus on the types of impairments children present with in the PSL Program (Cunningham, Kwok, Turkstra & Cardy, 2018)
PSL Program Research Update • Two phases – Phase 1 – Identify impairments seen in children accessing PSL Program services and define each impairment – Phase 2 – Establish consensus about impairment categories and sub-categorizations, and about definitions of each
PSL Program Research Update Phase 1 • Surveyed 4 PSL Program sites to generate inventory lists of the standardized tests used by SLPs to identify impairments • Manual review to identify the constructs measured • Impairment categories added based on clinical experience and consultation with expert clinicians
PSL Program Research Update Phase 1 • Six broadly-focused categories identified Speech Language Fluency Voice Feeding/ Emergent Sound Disorder Literacy Disorder Disorder swallowing Disorder • SSD & LD further sub-categorized
PSL Program Research Update • All 31 coordinators invited to submit the names of 2 (or more) SLPs who could participate in the Delphi surveys • The names of 54 SLPs from 19 PSL Program regions • A recruitment email was sent to the 54 SLPs thanking them, explaining the study and providing instructions for participating online
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