DLD Flashcards
what is dld
A language disorder as defined by Bishop et al., (2017) is a term used for children whose language problems continue into middle childhood and which have a significant functional impact. DLD is a language disorder present without a known differentiating condition such as autism or intellectual disability. Many areas of language can be affected by DLD (Bishop et al., 2016, IASLT, 2017). These include morpho-syntax, phonology, vocabulary, and pragmatics. A child with DLD could struggle with one or all these areas, but as language is an integrated system, difficulty with one will likely have an impact on the efficacy of the child’s communication. In addition, effective communicators require language skills in two modalities (IASLT, 2017): receptive language - the ability to comprehend written and spoken language, and expressive language, - the ability to convey meaning using language.
icf
Any assessment carried out by an SLT should be centred around the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2001). This is a framework which views health through the biopsychosocial model of disability and thus is ideal for providing client-centred care. It includes biological, individual and social perspectives of health and acknowledges the complexities of their interactions. A language assessment should take all of its domains into account: it should examine any impairments to the client’s body structures and functions; as well as activity limitations, which are difficulties an individual may have in executing activities, for example, being unable to tell a coherent story to a friend; participation restrictions, - problems an individual may experience in involvement in life situations such as being unable to participate in “news time” school. SLTs should also examine environmental factors which are the physical, social, and attitudinal environment in which people live and conduct their lives, and any facilitators or barriers that come along with them. Conducting an assessment following the ICF is incredibly important, because it allows the SLT to understand what factors may be affected most by the language problem, which in turn can inform an intervention plan.
assessment aims (gen.)
The goal of carrying out assessment should be to obtain information to help you plan a therapy approach (Ballard et al., 2002). Firstly, we may assess to diagnose. Different language presentations which appear in clinic include children with delayed language who will catch up, children with DLD, and children with a language disorder associated with a differentiating condition. All of these presentations have different care approaches and a misdiagnosis may result in poorer outcomes for the child. A differential diagnosis can also be very beneficial to the family of the child, it can alleviate parent’s self-blame, allow them to obtain information about their child’s future, and help them access services in and out of school (Watson, 2008). The next assessment aim is to identify domains of language with which the child struggles and which may be a target for intervention. Additionally, the SLT should identify areas of strength for the child which may be built upon to scaffold their difficulties. Finally, an assessment will allow the therapist to liaise with the child and their family to discover what their biggest concerns and goals are, and use this information to set intervention goals which are achievable, measurable and meaningful.
assessment aims prelinguistic child
Assessment aims for this age group are: to guide interventions that are family based and occur within the child’s natural environment; to maximise communicative learning opportunities; to identify language supports the child may need; to identify further risk factors that require further assessment and/or referral; and finally to act as a support for the family unit. (Paul, Norbury & Gosse, 2018).
assessment procedures prelinguistic child
Assessing a prelinguistic child differs significantly from a typical language assessment. This is because the child is not yet displaying language. As a result the SLT should be assessing the child’s general development, identifying risk factors, and evaluating whether the child’s prelinguistic behaviours such as vocalisations and play are developmentally appropriate for their age.
case history prelinguistic child
The first part of the assessment should always be a case history. The SLT should use this to examine any risk factors present in the child’s medical history. For a prelinguistic child, these risk factors include exposure to alcohol, illegal drugs, environmental toxins and in utero infections; and prematurity or low birth weight. (Paul, Norbury & Gosse, 2018).
parent child communication
The next part of the assessment should be an observation of the parent-child communication. The SLT should observe for the following behaviours: pleasure and positive affect; responsiveness to the child’s cues of readiness and lack of readiness to interact; acceptance of the baby’s overall style and temperament; reciprocity and mutuality; appropriateness of choice of objects and activities for interactions; language stimulation and responsiveness; and encouragement of joint attention and scaffolding the baby’s participation. The purpose of this is not to tell the parents what they are doing wrong, or to shame them. It is to identify areas of strength, and areas where the parent could change their communication style to maximise the benefit of the interaction to the child. These suggestions should always be respectful and non-judgemental.
vocalisation
The next step should be an observation of the baby’s babble, specifically, the onset of canonical babble. Canonical babble (Oller et al., 1998) is the production of well-formed syllables that consist of at least one vowel-like element and one consonant-like element, connected in quick transition and containing sounds similar enough to speech to be transcribable. Failure to produce these syllables by ten months may predict delays in language and speech acquisition in the second year of life. By the end of the child’s first year, their babble should mimic the prosody of sentences.
intentionality
The next step of assessment for this age group is to assess their level of intentionality. Intentionality is the ability to represent ideas in one’s mind and to pursue goals through planned actions. Intentional communicators are children who convey their intentions through gestures but do not yet use conventional language. Children should reach this stage between 9 and 18 months. Intentionality can be observed through play formally or informally or through parental report.
Symbolic Play Test
intentionality can be assessed using the Symbolic Play Test (Lowe & Costello, 1988). The child is given objects to play with and scored based on the number and nature of responses and connections the child makes.
informal ax of intentionality
It can also be assessed informally by giving the child common objects that invite conventional and pretend play such as dolls, utensils and familiar household objects. The SLT should observe whether the child is demonstrating some recognition of common objects and their uses, such as putting a toy telephone to the ear, and can engage in simple pretend play schemes, such as pretending to eat from an empty spoon.
ax of intentional communication
If intentionality has been observed the SLT should determine the frequency and types of communication that the baby is demonstrating. Some examples of these intentional communicative behaviours include: requesting objects or actions, attempting to get an adult’s attention, initiating social interactions through greeting, calling or showing off.
language development for emergent communicators
This is the stage at which the child is transitioning from use of symbols to producing speech. Expressive vocabulary begins slowly, at 12 months they may produce 1-3 words; at 15 months, 10 words; at 18 months 50-100 words, and first word combinations. Comprehension precedes production and therefore the receptive vocabulary is larger - roughly 50 words at 15 months. Vocabulary increases dramatically between 18 and 24 months and new communicative intentions emerge: answering, acknowledging, and requesting information. The child will combine words more frequently and in larger amounts.
observational assessment of intentional communicators
The rest of the assessment will consist of direct observations, through formal or informal assessment. These observations should include the child’s production and comprehension of words and gesture, their behaviour and their play.
Examine the nature, type and focus of play they gravitate towards. Is it exploratory, manipulation and construction, or symbolic and imaginative. Is the type of play developmentally appropriate? Observe how long they attend to their play, if they play alone or invite others to join them. This is a good opportunity to assess joint attention skills. When assessing their communication through play, observe which modes of communication they engage in; whether they initiate an interaction or respond to one; who they communicate with - the parent or the SLT; what they communicate about - the present, or the past and future; and also their communicative functions - requesting, informing, asking, teasing, demanding or refusing.
assessment of a school-aged child
When assessing a school-aged child, it’s important to look for the typical difficulties they may be experiencing if they have a DLD. Some examples of these include: constructing a coherent narrative, forming sentences, understanding humour or jokes (particularly sarcasm and figurative language), word retrieval difficulties, vocabulary difficulties and difficulty with peer interaction (Conti-Ramsen & Botting 2004). Language difficulties which persist past the age of five are more likely to be caused by DLD, and/or require intervention. Therefore, it is especially important to watch for possible clinical markers of DLD which include: poor morphology, poor nonword repetition, circumlocution or an over-reliance on words they already know, and poor sentence repetition.
language demands of an adolescent
Adolescents are going through developmental changes and challenges and navigating new opportunities and expectations, which will have increasingly complex language demands. Some examples of these changes include changing peer relationships and interactions, the increased presence of social media in their lives and new academic expectations. One major area of change for adolescent’s use of language is pragmatics. There is a greater prevalence of non-literal language, which is when the intended meaning is not immediately evident from the concrete terms within the utterance. It includes, metaphor, similes, idioms, proverbs, ambiguity, sarcasm and slang. Adolescents who find these difficult may discover that their peer relationships suffer, and they become more isolated which has a huge impact on their mental health and well-being.
secondary school
Additionally, they are now in secondary school. This means they will have multiple teachers with different styles and expectations, multiple subjects with varied demands, more content to learn, the content is more complex, they have to monitor their own learning and plan their own study schedule, there is a greater need for critical thinking and there is a much higher language load across all subjects. An adolescent who has a language difficulty is going to find the transition into secondary school extremely difficult.
assessing an adolescent
There are many aspects of language which must be assessed when working with adolescents and these may be assessed using formal assessment tools or informal conversation with the adolescent. The first is their vocabulary or lexicon. This includes their word knowledge, foundation vocabulary, morphology, domain vocabulary (ie. curriculum-specific vocabulary), word relations, word retrieval, and word definitions. Some of these can be assessed formally, using the CELF-5. Others may be assessed using informal tools, one such example is the literate lexicon (Nippold, 2007) which consists of words necessary to function academically such as infer, compare, evaluate, analyse, interpret, summarise etc. Other informal assessment measures may include an expository test which is where the adolescent is asked to explain something simple such as how to make a cup of tea. The SLT can then note the sequencing, coherency and appropriateness of chosen vocabulary. This same approach may be taken for assessment of narrative. Another important aspect of assessing this age group is assessing their written language abilities. The SLT should ask for a written language sample from school and compare it with the client’s oral language. Additionally, the assessment should include a reading comprehension task. In this way, by comparing reading comprehension with oral comprehension and spoken language production with writing, the SLT can determine whether it is a comprehension/production problem or a specific reading difficulty. Reading should be assessed for vocabulary, inference, working memory, and domain knowledge. Writing should be assessed for idea generation and organisation, the use of language to express ideas, appropriate and effective vocabulary and syntactic structures. Pragmatics is also important in an academic context. The student is expected to use and understand non-literal language in the classroom, correctly navigate peer discourse as well as adult discourse, produce and comprehend narratives, and use negotiation and persuasion skills in essays and answers (explain, justify, and support your answer etc). It’s important to note that unlike children, adolescents are the key agent of change in an assessment. They can decide whether or not they want to be assessed or if they want to attend intervention.
case history
The first part of a language assessment should always be taking a case history. The first part of a case history interview should revolve around the presenting problem, which involves identifying the difficulty from the client’s perspective. It is usually activity and participation related, and provides a space for the client to express their goals for attending with an SLT. The SLT should also examine any possible risk factors present in the child or the family’s history. Some examples of these are: recurrent otitis media, no babble, limited reciprocal interaction/communication, poor joint attention, limited use of gesture, underdeveloped play skills and poor motor control (IASLT, 2017). Finally, the SLT should ask about protective factors. These are factors which mitigate language problems, such as a child being expressive through gesture, facial expression and body language. The case history should give insight into the child’s early history including their birth and feeding and communication during infancy; their developmental history - their motor, social, cognitive, and behavioural development, whether there were any concerns regarding any of these at any point in time or currently; any significant events that have occurred, including medical events such as a severe illness or injury, or social events such as moving house or school.
formal assessment
The next stage of assessment is a formal language assessment. Formal assessments are used because they are standardised, the SLT administers the test in a predetermined manner, the child’s responses are recorded and scored according to a standardised scoring system. The child’s score is then converted into a standardised score which can be compared to normative data to evaluate where the child falls in comparison to other children their age. This score has multiple uses. It can be used to give a diagnosis of DLD, or to access services. For example if a child scores two standard deviations below the mean on a standardised language assessment they may be eligible for entry into a language class - a special education class designed for primary school aged children with speech and language difficulties. Finally, the score can be used as a baseline measure to evaluate intervention efficacy. For example, the child may be assessed using the same language assessment after a block of therapy to see whether or not their score has improved. However, it is important to remember that formal tests have disadvantages too: they only measure what a child knows in that exact point in time - not how the child learns; additionally, communication is context sensitive, and as formal assessments do not take this into account and therefore may not be a completely accurate reflection of the child’s abilities. It is for this reason that formal assessment tools should be used in conjunction with other assessment methods in order to gain the most accurate and complete information possible.
CELF-5
One of the most common formal language assessments used in clinical practice is the Clinical Evaluation of Language Fundamentals 5th edition (CELF-5) (Wiig et al, 2017). The CELF-5 can be used on children and adolescents aged 5 to 21. It assesses multiple aspects of language across expressive and receptive abilities. Its subtests include word classes, following directions, formulated sentences, recalling sentences, understanding spoken paragraphs, word definitions, sentence assembly, semantic relationships, pragmatics profile. All of which give an excellent overview of the child’s language abilities. An SLT may not choose to administer all subtests, especially in the one session, they may pick and choose which subtests are most relevant based on referral and case history information. The CELF-5 provides valuable qualitative information as well as a standard score. It provides an in-depth profile of the child’s expressive and receptive language abilities including their strengths and weaknesses. This information allows SLTs to create targeted and measurable intervention plans.
CELF-PS
A common formal assessment used in clinical practice is the Clinical Evaluation of Language Fundamentals Preschool (2nd edition) (CELF-PS 2) (Wiig et al, 2006). This formal assessment may be used on children aged 3-6. It has seven main subtests: sentence structure, word structure, expressive vocab, concepts and following directions, recalling sentences, basic concepts, word classes; and four supplementary subtests: recalling sentences in context, phonological awareness, pre-literacy rating scale, descriptive pragmatics profile. All of which give an excellent overview of the child’s language abilities. An SLT may not choose to administer all subtests, especially in the one session, they may pick and choose which subtests are most relevant based on referral and case history information. The CELF-PS 2 provides valuable qualitative information as well as a standard score. It provides an in-depth profile of the child’s expressive and receptive language abilities including their strengths and weaknesses. This information allows SLTs to create targeted and measurable intervention plans.
Reynell
One formal assessment that can be used for very young children is the Reynell Development Language Scales (RDLS) (Reynell & Gruber, 1990). This is a formal language assessment which examines expressive and receptive language and may be administered on children from 2;0 - 7;06. It assesses selecting, naming and relating objects; verbs and verb morphology; sentence building and complex sentences; and pronouns, inference and grammar judgement. It consists of a comprehension scale which marks the child’s understanding of vocabulary items and grammatical features and a production scale which marks the child’s production of these same language features. One large advantage of this assessment is that it is administered using a mix of play-based activities, unlike other assessments such as the CELF which simply ask the child questions about what they see in a stimulus book. This makes the assessment far more interesting and engaging for the child, increasing the likelihood of them being able to sit for the whole thing. It also comes with a Multilingual Toolkit, which enables the SLT to adapt the scales for a child for whom English is a second language.
informal assessment
However, while formal assessments sare an excellent way to comprehensively assess language, sometimes they may not be appropriate. For example, a child may be too young, or they may have attention difficulties or hyperactivity in which case sitting still for the length of time required may be too difficult for them. Sometimes too, the child may simply find the assessment too difficult, leading to frustration and upset. In any of these cases it may be more appropriate to carry out an informal assessment. Informal assessment may be used by itself or it may be used in conjunction with specific formal subtests depending on the child and the situation. The main disadvantage of informal assessment is that it is not standardised. However, it allows the SLT to tailor the assessment towards the child’s interests and abilities.
informal assessment - observation
The first part of an informal assessment is observation. The SLT should observe the child interact in as many settings as possible. Unfortunately due to service delivery constraints it may not be possible for the SLT to observe the child directly in naturalistic settings such as home or school, instead, the SLT may ask the family for videos of the child at home, and call the child’s teacher from school or preschool to discuss their communication in the classroom. The SLT should observe all of the child’s interactions in the clinic. The SLT should note any difficulties the child may have in language comprehension, expression, social interaction or behaviour.
informal assessment conversation
Another part of informal assessment is conversation, the SLT may engage the child in conversation and make note of their expressive language, vocabulary, grammar, conversational skills, and any difficulties in finding words, constructing sentences or following conversational rules such as turn-taking.
informal assessment narrative
Another informal assessment task is a narrative task, this is when the SLT asks the child to tell a story, or relay an event they experienced, for example, “tell me what you did over the weekend. The SLT should note their ability to sequence events correctly, and their coherence.
informal assessment play
A major component of informal assessment is play-based assessment. This is when the SLT plays with the child either through imaginary play or with toys and games. The SLT can assess their expressive language skills by engaging in conversation through play, and also their receptive language skills by asking them play-related questions, or by giving instructions. The SLT can also assess if the child’s play skills are developmentally appropriate.
bilingual children considerations
When assessing bilingual children additional considerations must be taken into account. Ideally, the assessing SLT should be fluent in both of the child’s languages, unfortunately, this is not always possible, therefore we must work to make sure the information gathered in assessment is as accurate as possible to avoid misdiagnosis.
