Developmental Language Disorder BJ Cunningham, PhD, SLP(C), Reg. - - PowerPoint PPT Presentation

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., 2016)

Bishop et al.’s Delphi Studies

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

Fig 1. Flowchart showing stages in the Delphi consensus process.

(Bishop et al., 2016)

Bishop et al.’s – Study 1 (2016)

Fig 2. Final set of statements in precis form.

(Bishop et al., 2016)

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.’s – Study 1 (2016)

(Bishop et al., 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.’s – Study 1 (2016)

(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

• n 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)

• 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.’s – Study 2 (2017)

(Bishop et al., 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.’s – Study 2 (2017)

(Bishop et al., 2017)

• Statement 8. A child with a language disorder may have a low

level of nonverbal ability. This does not preclude a diagnosis

• f DLD.
• Statement 9. Co-occurring disorders are impairments in

cognitive, sensori-motor or behavioural domains that can co-

• ccur with DLD and may affect pattern of impairment and

response to intervention, but whose causal relation to language problems is unclear.

Bishop et al.’s – Study 2 (2017)

(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)

• 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.’s – Study 2 (2017)

(Bishop et al., 2017)

(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

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
• f 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

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

PSL Program Research Update

Phase 1

• Six broadly-focused categories identified
• SSD & LD further sub-categorized

Speech Sound Disorder Language Disorder Fluency Disorder Voice Disorder Feeding/ swallowing Emergent Literacy

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

PSL Program Research Update

• 38/54 SLPs participated in Round 1 (response rate = 70%)

Characteristics Number of panel members Years of clinical experience < 2 years 2-5 years 6-10 years +10 years 7 8 23 Impairments treated in the PSL Program Language Disorder Speech Sound Disorder Fluency Voice Feeding and/or Swallowing Emergent Literacy 38 37 32 23 23 33 Service-types provided in the PSL Program Assessment Caregiver consultation Community health screenings Group intervention Individual intervention Parent training 38 37 12 32 38 37

PSL Program Research Update

• Panelists reviewed proposed categories and

definitions and indicated a yes/no response to whether:

1)The list of impairment categories captured all of the children they saw on caseload/ at site 2)Each of definition for the broadly-focused categories and sub-categories were 3)They agreed with the way the impairments had been categorized and sub-categorized

PSL Program Research Update

• Clinicians also gave suggestions for expanding the

categories, modifying the sub-categories, improving clarity of definitions, and provided additional suggestions

• Between each round, data were analyzed and

categories, sub-categories, and definitions were revised based on expert feedback.

– Criteria for consensus in Delphi studies ranges from 50-80% (Keeney et al., 2011) – 90% agreement across al documents

PSL Program Research Update

Round 1 Results

• +90% consensus for the Language Disorders document

Broadly-focused Impairments Language Disorders Speech Sound Disorders Document captures all clinical cases

• Give specific clinical

examples

• resonance

Add pragmatic language as its own category (vs. syntax, semantics, pragmatics) Broaden the definition of articulation impairment

• remove age appropriate

errors for preschoolers Definition for LD is clear

• Specify

pragmatics/social communication Further differentiate LDx and DLD Indicate connections between categories Include ‘delay’ in addition to disorder Specify delay vs. disorder Further differentiate MSDs

PSL Program Research Update

• Documents revised based on feedback, literature review,

and consultation with experts

• Specific changes and rationale for things not changed
• utlined for clinicians as a preamble in Round 2
• In Round 2, clinicians reviewed revised categories, sub-

categories, and definitions and provided feedback

PSL Program Research Update

Round 2 Results

• +90% consensus for the Broadly-Focused Impairments and

Language Disorders documents

Broadly-focused Impairments Language Disorders Speech Sound Disorders Further specification of resonance Remove the term ‘delay’ from ‘delay and disorder’ Further specify the interconnection between SSDs with a clinical example Expand emergent literacy to include pre-literacy skills Further differentiate phonological & artic impairments Remove term ‘delay’ Reorganize AOS category Include ‘delay’ for MSDs

PSL Program Research Update

• Documents revised based on feedback, literature review,

and consultation with experts

• Specific changes and rationale for things not changed
• utlined for clinicians as a preamble in Round 3
• In Round 3, clinicians reviewed revised categories, sub-

categories, and definitions and provided feedback

PSL Program Research Update

Round 3 Results

• 90% + consensus for all documents

Broadly-focused impairments Language Disorders Speech Sound Disorders Remove ‘concern/at risk for disorder’ and replace with delay Remove ‘concern/at risk for disorder’ and replace with delay Remove ‘concern/at risk for disorder’ and replace with delay Apraxia of Speech - Diagnosis

PSL Program Research Update

• Final revisions based on feedback, literature review, and

consultation with experts

• Major revision for “concern/at risk for disorder”

– Special note – the word delay is used to refer to preschoolers whose skills are behind his/her peers – In preschoolers it is difficult to confirm a disorder – The term should not be used to contrast children with flat vs. uneven profiles – Clinicians will not differentiate between delay/disorder on the assessment tool

PSL Program Research Update

Prior to Delphi After Delphi

Speech Sound Disorder Language Disorder Fluency Disorder Voice Disorder Feeding/ swallowing Emergent Literacy

Speech Sound Delay

• r

Disorder

Language Delay or Disorder Fluency Disorder Voice and Disorders Feeding and/or swallowing Emergent Literacy Concerns

PSL Program Research Update

Prior to Delphi Language Disorder: An impairment in the comprehension and/or use

• f a spoken, written and/or other rule-based symbol system (Paul &

Norbury, 2012a, pp. 1). After Delphi Language Delay or Disorder: An impairment in the comprehension and/or use of a spoken, written and/or other rule-based symbol system (Paul & Norbury, 2012a, pp. 1). Language delays and disorders can relate to children’s Prelinguistic communication skills (e.g., vocal, gestural, and gaze behaviours); expressive or receptive language skills;

• r social communication skills (Paul & Norbury, 2012; Spencer, 2011).

PSL Program Research Update

After Delphi Prior to Delphi

PSL Program Research Update

Prior to Delphi Expressive language disorder refers to the ability to produce (speak, sign, write) language (Capone-Singleton, 2014 p. 4). After Delphi Expressive Language Delay or Disorder: Children with delayed or disordered expressive language skills have difficulty producing

• language. Difficulties could present through speech, gesture, sign,

writing, or other non-verbal communication symbols (e.g., AAC). Impairments can be related to children’s use of morphology, syntax, and/or semantics (Capone-Singleton, 2014, p. 4). Examples in preschoolers include limited use of sign or vocabulary, restricted length of utterance, and missing grammatical markers.

PSL Program Research Update

Prior to Delphi After Delphi

PSL Program Research Update

Prior to Delphi Phonological Impairment: A cognitive-linguistic difficulty with learning the phonological system of a language. Phonological impairment is characterized by pattern-based speech errors (McLeod & Baker, 2017, pp. 38). Children with phonological impairments have speech that is characterized by phonological processes including…(McLeod & Baker, 2017, pp. 154-156) After Delphi Phonological delay or disorder: A cognitive-linguistic difficulty with learning the phonological system of a language. Phonological delays and disorders are characterized by pattern-based speech errors. These can include error patterns that are typical in the speech of younger children, but no longer considered appropriate for the child’s chronological age (e.g., fronting, stopping, cluster reduction), and patterns that are not typical of the speech of younger children (e.g., initial consonant deletion, backing) (McLeod & Baker, 2017, pp. 38-40). Other examples of phonological processes seen in the speech of children with phonological concerns/disorder include…(McLeod & Baker, 2017, pp. 154-156)

PSL Program Research Update

• Purpose: to develop and begin to validate the assessment tool
• Over 90% consensus across all documents and definitions was reached
• Front-line clinicians included in all phases of this research to ensure the

tool would be clinically valid.

• Next step 1 - to use the agreed-upon documents to develop a data

collection form that clinicians can use to indicate the impairments with which a child presents at assessment (using the agreed-upon documents as a reference).

• Next step 2 – to conduct reliability testing using this form across Ontario’s

PSL Program to ensure clinicians complete it with adequate reliability.

• Next step 3 – implement the form for province-wide data collection

– Compliments data collected by FOCUS/CFCS – Allows us to stratify outcomes by impairment

Questions

References

• Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalagh, T., and the

CATALISE consortium (2016). CATALISE: A multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLoS ONE, 11(7), 1-26.

• Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalagh, T. and the

CATALISE-2 consortium (2017). Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development:

• Terminology. Journal of Child Psychology and Psychiatry 58(10), 1068–1080.
• Cunningham, B.J., Kwok, E.Y., Turkstra, L. & Oram Cardy, J. (2018). Developing and

validating a data collection tool to categorize preschoolers’ speech and language impairments at assessment. Under review at Journal of Communication Disorders.

• Keeney, S., Hasson, F. & McKenna, H. (2011). The Delphi Technique in nursing and

health research. Oxford, UK: Wiley-Blackwell.

• Shriberg LD, Tomblin JB, McSweeny JL (1999) Prevalence of speech delay in 6-year-
• ld children and comorbidity with language impairment. J Speech Lang Hear Res

42: 1461–1481. PMID: 10599627