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There's been debate over the new terminology for Developmental Language Disorder (DLD) at a meeting (SRCLD) in the USA. I've not got any of the nuance here, but I feel I should make a quick comment on one issue I was specifically asked about, viz:

As background: the field of children's language disorders has been a terminological minefield. The term Specific Language Impairment (SLI) began to be used widely in the 1980s as a diagnosis for children who had problems acquiring language for no apparent reason. One criterion for the diagnosis was that the child's language problems should be out of line with other aspects of development, and hence 'specific', and this was interpreted as requiring normal range nonverbal IQ (nviq).

The term SLI was never adopted by the two main diagnostic systems -WHO's International Classification of Diseases (ICD) or the American Psychiatric Association's Diagnostic and Statistical Manual (DSM), but the notion that IQ should play a part in the diagnosis became prevalent.

In 2016-7 I headed up the CATALISE project with the specific goal of achieving some consensus about the diagnostic criteria and terminology for children's language disorders: the published papers about this are openly available for all to read (see below). The consensus of a group of experts from a range of professions and countries was to reject SLI in favour of the term DLD.

Any child who meets criteria for SLI will meet criteria for DLD: the main difference is that the use of an IQ cutoff is no longer part of the definition. This does not mean that all children with language difficulties are regarded as having DLD: those who meet criteria for intellectual disability, known syndromes or biomedical conditions are treated separately (see these slides for summary).

The tweet seems to suggest we should retain the term SLI, with its IQ cutoff, because it allows us to do neatly controlled research studies. I realise a brief, second-hand tweet about Rice's views may not be a fair portrayal of what she said, but it does emphasise a bone of contention that was thoroughly gnawed in the discussions of the CATALISE panel, namely, what is the purpose of diagnostic terminology? I would argue its primary purpose is clinical, and clinical considerations are not well-served by research criteria.

The traditional approach to selecting groups for research is to find 'pure' cases - quite simply, if you include children who have other problems beyond language (including other neurodevelopmental difficulties) then it is much harder to know how far you are assessing correlates or causes of language problems: things get messy and associations get hard to interpret. The importance of controlling for nonverbal IQ has been particularly emphasised over many years: quite simply, if you compare language-impaired vs comparison (typically-developing, or td) children on a language or cognitive measure, and the language-impaired group has lower nonverbal ability, then it may be that you are looking at a correlate of nonverbal ability rather than language. Restricting consideration to those who meet stringent IQ criteria to equalise the groups is one way of addressing the issue.

However, there are three big problems with this approach:

1. A child's nonverbal IQ can vary from time to time and it will depend on the test that is used. However, although this is problematic, it's not the main reason for dropping IQ cutoffs; the strongest arguments concern validity rather than reliability of an IQ-based approach.

2. The use of IQ-cutoffs ignores the fact that pure cases of language impairment are the exception rather than the rule. In CATALISE we looked at the evidence and concluded that if we were going to insist that you could only get a diagnosis of DLD if you had no developmental problems beyond language, then we'd exclude many children with language problems (see also this old blogpost). If our main purpose is to get a diagnostic system that is clinically workable, it should be applicable to the children who turn up in our clinics - not just a rarefied few who meet research criteria. An analogy can be drawn with medicine: imagine if your doctor identified you with high blood pressure but refused to treat you unless you were in every other regard fit and healthy. That would seem both unfair and ill-judged. Presence of co-occurring conditions might be important for tracking down underlying causes and determining a treatment path, but it's not a reason for excluding someone from receiving services.

3. Even for research purposes, it is not clear that a focus on highly specific disorders makes sense. An underlying assumption, which I remember starting out with, was the idea that the specific cases were in some important sense different from those who had additional problems. Yet, as noted in the CATALISE papers, the evidence for this assumption is missing: nonverbal IQ has very little bearing on a child's clinical profile, response to intervention, or aetiology. For me, what really knocked my belief in the reality of SLI as a category was doing twin studies: typically, I'd find that identical twins were very similar in their language abilities, but they sometimes differed in nonverbal ability, to the extent that one met criteria for SLI and the other did not. Researchers who treat SLI as a distinct category are at risk of doing research that has no application to the real world.

There is nothing to stop researchers focusing on 'pure' cases of language disorder to answer research questions of theoretical interest, such as questions about the modularity of language. This kind of research uses children with a language disorder as a kind of 'natural experiment' that may inform our understanding of broader issues. It is, however, important not to confuse such research with work whose goal is to discover clinically relevant information.

If practitioners let the theoretical interests of researchers dictate their diagnostic criteria, then they are doing a huge disservice to the many children who end up in a no-man's-land, without either diagnosis or access to intervention.

References

Bishop, D. V. M. (2017). Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD). International Journal of Language & Communication Disorders, 52(6), 671-680. doi:10.1111/1460-6984.12335

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T., & CATALISE Consortium. (2016). CATALISE: a multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLOS One, 11(7), e0158753. doi:10.1371/journal.pone.0158753

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T., & CATALISE Consortium. (2017). Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology. Journal of Child Psychology and Psychiatry, 58(10), 1068-1080. doi:10.1111/jcpp.12721

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Developmental language disorder: the need for a clinically relevant definition

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There's been debate over the new terminology for Developmental Language Disorder (DLD) at a meeting (SRCLD) in the USA. I've not got any of the nuance here, but I feel I should make a quick comment on one issue I was specifically asked about, viz: As background: the field of children's language disorders has been a terminological minefield.

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THE PROBLEM

Estimates suggest that about 7-10% of children at school entry have a language disorder of unknown cause (Norbury et al, 2016; Tomblin, 1997). In general, this corresponds to about two children in every classroom. Despite the high prevalence, there is poor public awareness about language disorders. While characteristics of autism spectrum disorder, attention deficit hyperactivity disorder and dyslexia have become common knowledge, most people still know very little, if anything, about language disorders in children.

So why is there such limited awareness of language disorders? While multiple factors play a role, terminology is a key obstacle to awareness efforts. Across Canada and internationally, the terms developmental language disorder (DLD), specific language impairment (SLI), language delay, language learning impairment and others are used almost interchangeably to describe the same language problems in children. The variety of terminology poses a challenge to raising awareness. Simply put, how do you raise awareness of a disorder that doesn't have a consistent name?

THE SOLUTION

A recent project called CATALISE assembled a panel of experts - including speech-language pathologists, psychologists and teachers - to come to a consensus on which label should be used to describe language problems in children. They used a systematic method called the Delphi survey technique to review the potential of each proposed term as a clinical diagnostic label. During this survey, advantages and disadvantages were identified for each potential name. The expert panel eventually reached the consensus that developmental language disorder (DLD) was the best option. Efforts such as the Raising Awareness of Developmental Language Disorders (RADLD) campaign in the UK have since embraced the use of DLD as a common terminology with the goal of accelerating awareness efforts.

For an in-depth explanation of the CATALISE project, please watch RADLD's video Developmental Language Disorder (DLD): The Consensus Explained .

THE OBSTACLES

The goal of the RADLD campaign was to promote the use of developmental language disorder (DLD) as the universal name for language disorders in children. A common terminology for language disorders is long overdue and will benefit clients in numerous ways. In practice, however, convincing an entire profession to change its terminology is not an easy task. With DLD being new to many clinicians, some may have concerns or confusion about its merits over other labels. This next section addresses some concerns clinicians may have about incorporating DLD into their professional vocabulary.
1) What exactly is the definition of DLD? Is it the same as SLI?
Developmental language disorder (DLD) is a new label intended to replace the terms specific language impairment (SLI), language learning impairment and language delay. Experts on the CATALISE panel defined DLD as language problems that create obstacles to communication or learning in everyday life. To be considered a DLD these problems must be unlikely to resolve on their own and they must not be associated with a known biomedical condition (Bishop et al, 2017). If a child's language disorder is associated with a known biomedical condition, the label "language disorder associated with [name of condition]" is used instead.
2) Why is there so much emphasis on assigning labels to children?
The merits of labelling have been debated at length among professionals. In the fields of mental health and disability, many professionals worry that labelling will lead to stigmatization and low self-esteem. Despite these concerns, the use of labels is now common practice. In some cases, a label is required for a client to access resources and support.

Positive outcomes of labelling include improved communication among professionals and increased awareness among the general public. It has also been suggested that labels can positively affect self-esteem and reduce stigma in some cases (Lauchlan & Boyle, 2007). Many clients are relieved to receive a label because it explains the difficulties they have been experiencing. The presence of a label also helps teachers and peers understand a child's behaviour, which can contribute to acceptance of the child in the classroom.
3) Why choose to call it a "disorder"?
In the CATALISE project, members of the panel expressed concern with the word "disorder" because they felt it was associated with a negative stigma. However, others argued that words like impairment or delay don't capture the seriousness of the disorder. When discussing language disorders, we must be careful to not imply that the child might simply grow out of the disorder, or that it is no big deal. Research shows that children with DLD are unlikely to grow out of their difficulties without intervention (Stothard et al, 1998).

The word "disorder" has the benefit of being consistent with other neurodevelopmental diagnoses like autism spectrum disorder and attention deficit hyperactivity disorder. It is also compatible with the DSM-5 term language disorder and with planned terminology for the International Classification of Diseases (ICD) 11. Being consistent with these well-established classifications systems will emphasize the importance of DLD as a term and improve communication among professionals.

The term developmental language disorder (DLD) was selected following extensive discussion among a team of professionals. Although there may be drawbacks to using the word "disorder," the benefits of including the word were ultimately thought to outweigh these drawbacks. It is also important to note that throughout the CATALISE discussions, there was no term that was deemed to be perfect (Bishop et al, 2017). During the discussions, members of the panel brought forward criticisms for each of the proposed terms. In conclusion, DLD may not be the perfect term, but it is the best option we have.

The lack of public awareness of the term developmental language disorder (DLD) is a problem. Poor awareness means children with DLD have a lower likelihood of being identified early, have less community supports available to them, and receive less attention and funding in the research world. With the CATALISE project's well-reasoned choice of DLD as the new term, we have an exciting opportunity to establish a universally-recognized name for language disorders. Having a unified terminology will help the public understand DLD and connect clients to the support they need. Going forward, efforts must continue to inform clinicians of DLD and encourage them to incorporate it into their vocabulary. Now is our chance to collaborate using a common language to get the word out about DLD!

To help explain the DLD terminology to friends, colleagues, and clients, be sure to share RADLD's video

References:

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T., and the CATALISE‐2 consortium, Adams, C., House, A. (2017). Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 58(10), 1068-1080.

Ebbels, S. (n.d.). International consensus on diagnosis for children with problems with language development. Retrieved from http://naplic.org.uk/sites/default/files/Summary%20of%20CATALISE%20%28v3%29.pdf

Lauchlan, F., & Boyle, C. (2007). Is the use of labels in special education helpful? Support for Learning, 22(1), 36-42.

Norbury, C. F., Gooch, D., Wray, C., Baird, G., Charman, T., Simonoff, E., ... Pickles, A. (2016). The impact of nonverbal ability on prevalence and clinical presentation of language disorder: evidence from a population study. Journal of Child Psychology and Psychiatry, and Allied Disciplines, 57(11), 1247-1257.

Tomblin, J.B., Records, N.L., Buckwalter, P., Zhang, X., Smith, E., & O'Brien, M. (1997). Prevalence of speciﬁc language impairment in kindergarten children. Journal of Speech and Hearing Research, 40, 1245-1260.

Stothard, S.E., Snowling, M.J., Bishop, D.V.M., Chipchase, B.B., & Kaplan, C.A. (1998). Language-impaired preschoolers a follow-up into adolescence. Journal of Speech, Language, and Hearing Research, 41, 407-418.

About the author:

Alex Rice is a graduate student in her final year of the Speech-Language Pathology program at Western University. Prior to her studies at Western, Alex completed a Bachelor of Science degree at McMaster University, majoring in Biology and Psychology. She also currently volunteers as a Western Student Council representative for SAC and OSLA.

This blog post was completed under the guidance of Dr. Lisa Archibald and was submitted as a final project in the Developmental Language Disorders 2 graduate course in the speech-language pathology program at Western University. You can view more final projects for this course at http://www.uwo.ca/fhs/lwm/teaching/dld2.html and learn more about the course by following #WesternDLD2 and @larchiba6 on twitter.

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THE PROBLEM Estimates suggest that about 7-10% of children at school entry have a language disorder of unknown cause (Norbury et al, 2016; Tomblin, 1997). In general, this corresponds to about two children in every classroom. Despite the high prevalence, there is poor public awareness about language disorders.

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speech sound disorders; speech-language pathology; evidence based practice; ebp; speech and language therapy; communication; phonological disorder; childhood apraxia of speech; cas; developmental verbal dyspraxia; articulation; lisp; slp; slt; caroline bowen

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Trustworthy SLP/SLT information with a focus on children's speech sound disorders / clinical phonology.

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Dorothy Bishop had her epiphany in the back of a taxi.

"The taxi driver, the way they do, said, 'What do you work on?'" Bishop recalls. "I said, 'Specific language impairment,' and he had no idea what that was. He thought it might be something to do with learning a second language."

So she decided that the best way to explain language disorders was to say, "It's a bit like autism."

"And the idea that he could immediately know what autism was - even though it's a much rarer condition - seemed something quite wrong," she says.

Wrong - but all too common, she quickly realised, even within the education system.

This was originally published in Tes magazine. To get great content every week, click here.

Bishop is professor of developmental neuropsychology at the University of Oxford. Most of her academic work has been focused on specific language impairment, which is now called developmental language disorder (DLD). She believes that it is the most prevalent special educational need that most teachers have never heard of.

That day, in that taxi, Bishop decided that something needed to change. Too many children were being let down because too few teachers had any idea why they were struggling.

Language barriers

Put crudely, DLD is to spoken language what dyslexia is to written language.

"It can be helpful to say that it's like trying to function in a language that you have a little bit of knowledge of," Bishop says.

For example, imagine that you speak a small amount of French: you have some vocabulary, some knowledge of grammar. Then you go to stay with a Parisian family, whose dinner-table conversations take place entirely in French. You can make out occasional words - enough to determine what the conversation is about, but not the details or the nuance.

For instance, if you picked up the words "dog", "chase" and "boy" in a sentence, you would understand that there had been a chase involving a boy and a dog, but not whether it was the boy chasing the dog, or vice versa.

Understanding what is going on, therefore, requires constant effort and attention: you have to try really, really hard to keep up with what the conversation is - or might be - about. Ultimately, this becomes exhausting, and it is easier to tune out entirely and let the conversation flow around you.

"It's hard work [for those with DLD]," Bishop says. "Those casual, easy to-and-fro exchanges almost become painful for you to engage with. Whereas everybody else is just chatting away."

According to researchers in this field, around 7.5 per cent of children begin school with a language disorder that is unexplained by any other condition, with DLD the likely cause. A further 2.3 per cent have a language disorder linked to another condition, such as dyslexia or autism. In a class of 30 children, therefore, an average of two children will need therapeutic intervention for their language difficulties.

This is considerably more than the 1.1 per cent of the population who are on the autism spectrum.

Children with DLD will have higher than average rates of social and emotional behavioural problems, according to research conducted by Courtenay Norbury, professor of developmental language and communication disorders at UCL. They are also more likely than their classmates to have problems with their peers, and problems paying attention. Only around 11 per cent of these children meet curriculum targets.

So these are the children in your class who may have been labelled as underachievers, but whose underachievement will have often been blamed on background, disadvantage or low IQ.

"Often they're assumed to be children who are just not going to do very well," Bishop says. "They'd be looking like a very inattentive child who's a bit away with the fairies. In some cases, there will be bad behaviour, acting up a bit."

So why is there this collective blindspot where the condition is concerned?

Bishop believes that part of the problem comes down to - perhaps appropriately - language choices.

Until recently, the preferred term for the condition was "specific language impairment"; "developmental language disorder" was settled on only after considerable debate and research.

"All these choices of words are very loaded," Bishop says. "If I say 'impairment' or 'disorder' or 'disability', it makes a big difference.

"'Delay' is often used very loosely to mean that you've got trouble with your language. But it doesn't tell you anything about whether it's likely to improve or not. It suggests it's just a delay, but you'll catch up eventually."

Difficult to spot

Another issue is that the symptoms of DLD are more difficult to spot than those of many other special educational needs and disabilities, such as dyslexia, as they can be written off as behaviour or attention issues. They may also be more difficult for teachers to understand and empathise with, according to Norbury.

"I think maybe it's because we take language for granted," she says. "We all use it. We use language skills to negotiate and to calm other people down. We use it when watching TV, listening to the news, following instructions, talking to your friends, texting, knowing where to get on the Tube. Everything we do involves language.

"People with DLD often come across as not listening or not paying attention. And so people don't recognise language disorder as much as dyslexia or autism, and it's really hard for people to convey that this is a problem that needs support."

Because of widespread ignorance about the challenges they face, students with DLD can have an extremely difficult time in education.

Gemma Corby, special-needs coordinator at a school in Norfolk, encountered DLD when a student was diagnosed with the condition earlier this year, following an appointment she booked with a language specialist. The child had been identified in primary school as having speech and language difficulties, but had not been seen by a specialist for several years.

"He muddles by in school," Corby says. "But I knew he wasn't reaching his full potential. He had very high levels of anxiety - I wouldn't have known, but his dad told me."

Such "muddling by" is typical for children with DLD, Bishop believes. It is particularly common among girls; boys are more often identified as having DLD, because they tend to misbehave as a result of finding the classroom challenging.

"We think girls [with DLD] just sit quietly at the back of the class, and boys [with DLD] make more trouble," says Bishop.

In some cases, DLD will go hand in hand with other language disorders, such as dyslexia. But many pupils with DLD are able to read aloud when asked. It is only when asked questions about what they have just read that they struggle.

"Those children, the teachers might not be aware how little they're picking up as they go along," Bishop says.

This is another key reason why teachers may not spot children with DLD, according to Megan Dixon, director of literacy for Aspire Educational Trust. She specialises in literacy acquisition, and is, therefore, aware of DLD.

"Often, teachers will spot children who have problems forming phrases," she says. "But it might be that children with DLD have no problems expressing themselves, but have problems understanding what's coming in.

"That's quite hard, because people assume they're not listening, and they end up being labelled as naughty."

Alternatively, Bishop says, pupils learn to pass: to scrape by at the bottom of the class. Often, these children are assumed simply to be not very bright.

For example, an eight-year-old pupil may be capable of telling the teacher a story.

"And you think, 'That's fine; they haven't got a language problem,'" says Bishop. "But, when you analyse their sentences, they don't use any complex clauses. When you compare them with what an eight-year-old ought to be doing, you realise they were quite limited in what they could express. They've actually got quite limited language."

This is something that Dixon has also observed. Early in her teaching career, there was a boy in her class who would not speak.

"He stood in the corner, shivering," she says. "Literally quivering away."

Dixon assumed that the boy was on the autism spectrum. His previous school had labelled him as low-IQ, and had held him back in Reception.

"Actually, he had very severe language difficulties," Dixon says. "Can you imagine sitting in a classroom all day, every day, not understanding, and being told off for not doing things right?"

She believes that children with DLD may be misbehaving deliberately, in order to be removed from class. If this happens, she says, it is a failure of the teacher for jumping quickly to conclusions, rather than looking below the surface of the behaviour.

Unfortunately, better diagnosis of DLD will not automatically improve educational outcomes. Even when pupils with DLD are identified as needing speech and language therapy, this does not guarantee the right help for the right length of time.

Bishop has carried out a series of studies on twins, which demonstrates that there is a genetic component to DLD. There is not, however, one biological trigger - a particular gene that can be singled out as causing the condition. Instead, variations in a range of genes can tip a person one way or another.

Ongoing support

Environmental factors also play a role. Bishop draws an analogy with height: one's height depends on a complex combination of genetic and environmental factors.

"Your ultimate height might depend on lots and lots of factors, each of which might make you a little bit taller or a little bit shorter, but the individual effects are quite small."

Therefore, the go-to solution for language problems - a period of intensive speech and language therapy - can often fail to improve things for children with DLD.

"We've had this culture of expecting that a short-term blast of speech and language therapy will move children into the normal range," says Norbury. "More and more, I've come to accept that that's not the case."

The problem, she says, is that there is often a lot of talk of "closing the gap". But, by the start of key stage 2, there may be a two-year gap between pupils with language difficulties and those at the top of their class.

"That's a pretty big gap to fill, particularly as the demands of the classroom get more and more complex," Norbury says.

"I think education does a fantastic job of moving kids on. But those kids with language problems need ongoing support. If you've ever tried to learn another language - you can't do that in six to 12 sessions. And you have to keep practising. There are no quick fixes, unfortunately."

There is obviously a complicating factor here. Dixon explains that environmental factors - such as poverty or poor levels of parental literacy - can cause children to manifest many of the same symptoms as children with DLD.

"Teachers often don't understand that there's a difference between language delay and language impairment," she says. "A lot of children are below the level that they should be, that you'd expect, when they're coming into school. And it can be poverty-related."

These children tend to be given what Dixon refers to as a "short, sharp intervention", lasting six to 10 weeks.

"A language-delayed child will hopefully make quite sharp progress. A language-impaired child possibly won't," she says.

That short intensive session can still be useful for identification purposes, though. Dixon views it as a form of language triage: they will help sort those children with language delays from those with DLD, who require longer-term support.

Training teachers

But such labelling of a child would not be universally supported. Within the SEND community, the use of labels and the way in which those labels determine what subsequent support is available has been debated extensively.

Regarding DLD, Simon Knight, director of special-needs organisation Whole School SEND and former deputy headteacher at Frank Wise Special School in Oxfordshire, questions whether children would necessarily benefit from having the disorder attached to their names.

"My concern is that sometimes we end up using diagnostic labels naively," he says. "What are teachers going to do with that information? How are they going to meet those needs effectively?

"If we don't furnish teachers with a depth of understanding, there's a risk that they may respond to a caricatured understanding of what that label is."

There is then a danger, he adds, that certain resources and interventions will become the default means of addressing DLD in pupils, and that these will be used in place of a personalised response to a child's needs.

"I wouldn't want teachers to have a veneer of understanding of what needs are in the classroom," he says.

"We can raise awareness; we can ensure that children are assessed appropriately and effectively. But, if that's all we do, then children are not going to have their needs met appropriately. So we need to be training teachers as well, to make sure they have the skills necessary."

Bishop understands the nervousness about attaching labels to children.

Teachers have told her that they are concerned about medicalising normal variation among children, or about being seen as lowering expectations.

But she argues that, used properly, the advantages of such labelling outweigh the disadvantages.

"You hear a lot from paediatricians saying, 'I'll give this child an autism diagnosis,' if the child is on the margins, because then they'll get help," she says. "That wouldn't happen if there was active support for people with other conditions."

Targeted approach

The label, she believes, would allow for coherent, knowledgeable responses to pupils with DLD. For example, she says, pupils could be given visual support, to help them to access the words that the teacher is using. So a teacher telling the class about windmills, for example, would stand in front of an image of a windmill while talking.

"It sounds horribly like learning styles," Bishop says. "But it might be that kids have particular difficulty dealing with material where you're just describing something but there's no visual support."

And any speech and language therapy could also be specifically targeted to the needs of pupils with DLD. "With speech and language therapy, a lot of what's done isn't being subjected adequately to good trials," she says. "It's not that people don't want to, but they don't have the resources for trials. Lots of what's going on in schools is people making it up as they go along."

In the case of Corby's student, diagnosis has certainly led to improvements. The pupil has had weekly sessions with a speech and language therapist, as well as daily activities with a teaching assistant trained in dealing with speech and language difficulties.

"He's still very anxious - not really able to have a two-way conversation," Corby says. "But on a recent breaktime he came and knocked on my door and we had a conversation. He never would have done that last year. The thought of having to go and have a conversation with someone - especially an adult, and one who wasn't his tutor. He wouldn't have done it."

This student is one of the lucky ones. Too many children with DLD remain undiagnosed, and are condemned to a life of underachievement simply because people are unaware that DLD exists.

"People with autism, when in adulthood, they may be employed, because they have the ability to pass exams," says Bishop. "But often they wouldn't have relationships.

"With DLD, often it's the other way around: they can't pass exams, so they're restricted to manual jobs." She pauses.

"Which, of course, there are less and less of nowadays."
@adibloom_tes

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There is a special educational need more prevalent than autism - one that is likely to impact on children in every school. But very few teachers have heard of it and even fewer know how to help.

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Join the Tes team as we talk about some of the biggest topics of the week.

We discuss the paradox that despite real-terms per-pupil school funding increasing massively since 1997, schools are currently in deep financial difficulties.

We also hear about developmental language disorder - a special education need more common than autism, but little known by teachers.

Tune in and enjoy.
Want to keep up with the latest education news and opinion? Follow Tes on Twitter and Instagram, and like Tes on Facebook

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The Tes podcast: School funding, teacher recruitment and developmental language disorder

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Join the Tes team as we talk about some of the biggest topics of the week. We discuss the paradox that despite real-terms per-pupil school funding increasing massively since 1997, schools are currently in deep financial difficulties. We also hear about developmental language disorder - a special education need more common than autism, but little known by teachers.

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Professor Courtenay Norbury debunks some myths about children with this common but poorly understood condition

Developmental Language Disorder (DLD) is diagnosed when children fail to acquire their own language for no obvious reason. This results in children who have difficulty understanding what people say to them, and struggle to articulate their ideas and feelings. Recent research has shown that, on average, 2 children in every class of 30 will experience DLD severe enough to hinder academic progress.

In a previous post for Head Quarters about DLD, some of the reader comments reflected commonly held misconceptions about children with the condition. It is one of the most poorly recognized and understood disorders of childhood despite its prevalence. Here Prof Courtenay Norbury debunks some of the most common myths.

Myth 1: She'll grow out of it!

One of the most common reasons parents seek advice from GPs and health visitors is that the onset of their child's first words is delayed. Well-meaning friends and families may try to alleviate parent anxieties by sharing stories of children who didn't say a word until the age of 5 and then came out with complex sentences!

However, research strongly indicates that a child starting school with limited language is very likely to have language deficits throughout the school years (and even into adulthood).

My own work has shown that children with DLD maintain a 2-3 year gap in language skills during the first three years of primary school, with little evidence of 'catching up' with peers. As language is the foundation for learning, children with DLD struggle in the classroom. Thus, teachers should be alert to the signs that a child needs extra support to develop oral language competence.

Myth 2: He's just lazy (or naughty)!

Many children with DLD have difficulty understanding what other people say, especially when others talk fast or there are distractions in the environment. They also have trouble remembering long instructions or formulating responses to questions.

The net result is that they may not do what others are expecting them to do, or their responses to questions may be off the mark. This is often misconstrued as disobedience or poor attention to what people are saying. Language is also the key tool for expressing our feelings and regulating our emotional states, and negotiating with peers. Without the language to do this, many children with DLD become frustrated, and express that frustration through acting out.

It is not surprising then that children with DLD are twice as likely as peers with good language to be rated as having poor attention and behaviour. This is probably a consequence of having to navigate the world with limited language.

So if a child is having trouble following instructions or is acting out, it is worth considering whether DLD could be playing a role.

Myth 3: It's not the kids who have the problem - it's poor parenting!

There is a long standing association between language deficits and social disadvantage, giving rise to a picture in the popular press of uneducated parents who just don't talk to their children enough. In fact, we know that in most cases, DLD arises from genetic influences on early brain development. We don't know enough about specific genes to have a biological test for language disorder, but we do know that parents rarely cause their child's language difficulties.

Children with DLD grow into adults with language disorders. They are very likely to have lower levels of literacy and less likely to attend University or apply for skilled jobs, which reduces economic opportunity. Thus, social disadvantage could reflect these genetic influences.

It is also worth remembering that language is a two-way street. If a child is not talking and doesn't respond readily, parents may find interacting with that child challenging. And if talking and reading don't come naturally to parents, talking and reading to a young, silent child may seem a very odd thing to do indeed!

Children from disadvantaged backgrounds who present with language delays should be a high priority for services such as speech-language therapy, especially if there is a history of language, literacy, or learning difficulties within the family. Just because DLD has genetic influences doesn't mean we are powerless to change it. Therapists can support parents to adapt their ways of interacting to enhance language development.

Myth 4: Two languages makes DLD worse

In our multi-cultural society bilingual parents often ask if they should restrict their input to only one language, or just English. The research evidence here is pretty clear - exposure to two languages does not cause or complicate language disorder. Children need high-quality language input, so parents should continue to talk with their children in whatever language they themselves feel most comfortable speaking.

Identifying DLD is more complicated - ideally we want to know what the child's competencies are in all the languages he or she speaks, but practically we do not have the tools to assess all of the more than 300 different languages that are now spoken in the UK. In these cases, delayed language onset, coupled with family history and slow progress in learning English after school entry, are clear signs that extra support may be needed.

Myth 5: We should focus all our resources on early intervention - it is too late once they get to school

We need to recognise that like other developmental conditions such as autism or Down syndrome, "cure" is not the goal of intervention. Instead, we aim to maximise language capacity, enhance communication using whatever level of language a child possesses, and provide additional support that will reduce the longer term risks to learning, social well-being, and mental health.

While early intervention is important, many parents, health and education professionals point to adolescence, and the transition to secondary school, as a period when children with DLD are particularly vulnerable. This is due to the increasingly complex language demands of the curriculum and the nuanced language needed to manage social relationships during the teenaged years. Unfortunately, services for children with DLD tend to reduce post-primary school and services for adults with DLD are almost non-existent.

In sum, it's important to remember DLD123: (1) DLD is a problem with speaking and/or listening, (2) it is hidden but common, and (3) support can help to improve the quality of life of affected children and their families.

Find out more: This week sees the publication of a special issue of the Journal of Child Psychology and Psychiatry devoted to state of the art research on Developmental Language Disorder:[http://onlinelibrary.wiley.com/doi/10.1111/jcpp.2017.58.issue-10/issuetoc] Professor Courtenay Norbury is the issue editor.
Courtenay Norbury is a Professor of Developmental Language and Communication Disorders at University College London and the President of NAPLIC (Professionals Supporting Language and Communication Development Topics

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Developmental Language Disorder: The most common childhood condition you've never heard of

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Professor Courtenay Norbury debunks some myths about children with this common but poorly understood condition Developmental Language Disorder (DLD) is diagnosed when children fail to acquire their own language for no obvious reason. This results in children who have difficulty understanding what people say to them, and struggle to articulate their ideas and feelings.

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Fantastic padlet collating all the DLD123 activities across the globe! Thanks Becky Clarke!

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Fantastic padlet collating all the DLD123 activities across the globe! Thanks Becky Clarke!

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https://padlet.com/radld_contact/mm2stqkx9yii

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DLD and older students – unravelling the knot – Jude Philip – Grow Communication

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DLD and older students – unravelling the knot – Jude Philip – Grow Communication

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DLD is when a child or adult has difficulties talking and/or understanding language. It is a hidden disability that affects approximately two children in every classroom, affecting literacy, learning, friendships and emotional well-being. Support from professionals, including speech and language therapists and teachers, can make a real difference. Read on for one story of DLD.....

The DLD Knot: Hanna (name changed) was a 12 year-old who arrived on my caseload when she was at quite a low point. Her parents were really worried about their daughter and how she was feeling about school, the Learning Support teacher had tried everything she could thing to support literacy, and most importantly Hanna felt stuck, confused, had experienced some bullying because of her difficulties and was increasingly feeling anxious and full of dread at the thought of school.

Finding the first loose strand: Hanna had never had any Speech and Language Therapy (SLT) before. For a number of reasons the cause of her difficulties hadn't been identified, but her Educational Psychologist suggested that language difficulties might be at the root and recommended a full SLT assessment. And so Hanna came to me. As soon as her Mum described her difficulties over the phone DLD sprang to mind, the first loose strand was spotted and from there we set about unravelling the knot together.

Teasing the threads: We started a really detailed assessment looking at all aspects of the use and understanding of spoken language. Because Hanna was that bit older and was keen to engage with the process it became a dynamic assessment and as we did each part of our formal assessment we spoke about how Hanna thought about words, about what happened when she couldn't say the word she wanted, how it felt when there were too many words to process and when she wasn't able to follow what was being said, and best of all the ways that she had developed herself to compensate for the challenges. Each of those little discussions was another thread being teased loose.

Separating the strands: Together we identified the tricky bits, and shared the frustration. But we also uncovered many real strengths. Threads of kindness and empathy, hard-work and determination, an eye for detail, visual thinking and a very strong strand of creativity. As we separated out the strands and captured them together I saw the confidence start to grow. Once our assessment was completed we drew a big mind map, all colour coded and captured each of those strands and could identify what our next steps were.

Weaving: Because our time was limited to an initial block of 6 weeks I chose a metacognitive approach to developing strategies. This is where we began to weave the strands, together again, challenges and strengths supporting and strengthening each other. We developed a visual way to figure out the main idea of a piece of work or a text, and how to translate this into written and oral work. We created an ingenious little system to learn and store tricky words, and we worked on empowering Hanna to recognise when she hadn't understood and seek help.

A Fresh Weave: Hanna still has language difficulties. She can still get stuck for words, and overwhelmed by lots of spoken information. Word learning takes her extra effort and she still finds reading and tests hard. But Hanna has a good understanding of what helps her and of what her strengths are, and a strong sense of ownership of the strategies she uses. We were all proud last year when she scored highest in her year for study skills - surpassing other students for whom learning was a doddle. This was a real testament to all the hard work she put in and a great example of how she has woven herself a fresh story. The future feels much brighter to Hanna and her family, and understanding and herself has been a key part of this process.

If you want to find out more about Jude you can follow her on facebook @growsalt or her blog on www.judephilip.co.uk. There is also loads of information about DLD on the RADLDcam youtube channel - superb videos - and Naplic.org.

Follow the DLD Blog hop by clicking on these links:

A podcast on creating confident communicators in the early years by Catherine at Wise Old Owl

10 Strategies to support children with DLD by Elizabeth and Helen at Speechblog

Word-learning strategies by Anna Biavati Smith of Wordsteps SLT

DLD in Children and Young People on the Autism Spectrum by Lucy Sanctuary

A DLD Infographic by Martha at Mable

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DLD and older students - unravelling the knot

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Friday 22nd September is Developmental Language Disorder (DLD) awareness day. DLD is when a child or adult has difficulties talking and/or understanding language. It is a hidden disability that affects approximately two children in every classroom, affecting literacy, learning, friendships and emotional well-being. Support from professionals, including speech and language therapists and teachers, can make...

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Hidden disorder hinders speech of 860,000 children | News | The Times & The Sunday Times

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Hidden disorder hinders speech of 860,000 children | News | The Times & The Sunday Times

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At least 860,000 children in the UK are suffering from a little-known condition that causes learning difficulties and continues into adulthood, experts say.

Developmental Language Disorder (DLD), which appears to be genetic, affects about 7.5 per cent of children, or approximately two in every classroom. About half are undiagnosed.

Children with DLD have problems with speaking and listening such as a limited vocabulary, short and immature sentence structure, being unable to tell stories with structure and not understanding what they are being asked to do. As they get older they may struggle to find employment or form relationships.

Dorothy Bishop, professor of developmental neuropsychology at Oxford University, said: "It is a bit like when you slightly know a foreign language and you go abroad and...

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Hidden disorder hinders speech of 860,000 children

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At least 860,000 children in the UK are suffering from a little-known condition that causes learning difficulties and continues into adulthood, experts say. Developmental Language Disorder (DLD), which appears to be genetic, affects about 7.5 per cent of children, or approximately two in every classroom. About half are undiagnosed.

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DLD blog from a Mum and SLT whose son has DLD

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One year ago I wrote Reflections on Adoption One Year In. Somehow or other an entire annum has passed since and here I am again on the second anniversary of meeting my littlest bear, looking back, reflecting, analysing and considering what has changed.

I have been ruminating on this post for a while and knew that I wanted to somehow break adoption down into specific areas so that I could comment on each bit. I recently happened upon an article which has helped me to do just that. It was an article by Beacon House explaining the Neuro Sequential Model of Therapeutics as devised by Bruce Perry. It tells us that thinking solely about attachment is too narrow: it doesn't reflect all the aspects of a child that are impacted by having a traumatic start in life. In fact there are 7 key areas and they develop sequentially (giving parents and therapists a structure and order for working on trauma). I have decided to take those 7 areas of Developmental Trauma and use them as a basis for talking about Little Bear and how things have changed for him (and consequently us) over time.

In my weeks and weeks as a blogger I haven't ever written about Little Bear being 'traumatised'. He hasn't been physically abused or subjected to awful experiences. He hasn't moved about much compared to some care-experienced children. As such I have always felt a bit unsure about the use of the word 'trauma' in reference to him, especially in comparison to other adopted children's horrific backgrounds. However, what I have now come to understand is that being removed from your birth parents, whatever the circumstances that led to it, is traumatic. Equally, being removed from the Foster Carers that you have come to know and love (irrespective of the rights or wrongs of how well they did or did not care for you) is traumatic. Importantly, being neglected is in itself a significant developmental trauma.

For this week, the second anniversary of Little Bear's arrival in our lives, I am going to consider his progress against trauma.
Somatic/Sensory
This is the place where extremely traumatised children reside: a constant state of fight or flight. Some children cannot move beyond this without appropriate therapy.

We were lucky that Little Bear never solely functioned at this level. He could certainly be triggered into this place easily and always reacted with fight mode. That has undoubtedly changed over time: Little Bear is generally happy, settled and not fearful now. He can still be triggered into fight/flight though and I can't help feeling there is a close link with his communication difficulties here. If you cannot defend yourself verbally and if others exploit that, it would be easy to become anxious, defensive and consequently triggered. Therefore it is usually with his peers that fight mode arises.

Little Bear did have impaired sleep patterns (I didn't know this was a sign of trauma at the time) which I'm very happy to say have fully resolved.

Impulsivity is another sign of needs in this area. Little Bear was certainly extremely impulsive when he first arrived. Overall I would say he has made excellent progress with this. He can control himself much better now and tends to tell me if he's tempted to do something he knows he shouldn't. I do find that his ability to stop himself from doing it varies depending on how he is feeling. If he is dysregulated he is far more likely to go with the impulse. Little Bear's awareness of danger has improved hugely though and I think that has helped him to have fewer inappropriate urges e.g. to touch something sharp/ hot/ unsanitary etc.

Little Bear also has an active conscience and is now (sometimes) tuned in to how his behaviour might impact on others e.g. his brother and is able to stop himself from doing something if he thinks it might upset Big Bear, even if he really wants to do it. This is probably one of the biggest signs that he is generally functioning in his 'thinking brain'.
Attachment
Last year I wrote about how our attachment could still feel brittle at times and that we would take a few steps backwards if I didn't spend enough time with Little Bear. I would now describe us as having a consistently close and loving relationship. I haven't noticed the regression feeling recently, perhaps because I am available to him most of the time (I only work during school hours) and if anything Little Bear can be quite clingy to me now. He hasn't been well recently and at those points he is all about keeping me close. I sometimes feel as though he is trying to make up for the fact that we never had an actual umbilical cord!

I have to do far less acting and do genuinely enjoy spending as much time as I do with him. He is quite the comedic little buddy.

The dynamic within our family of 4 feels healthy and balanced now (most of the time). I have written about the changes in the relationship between the 2 Bears in Brothers.

Last year I wrote about Little Bear being quite rejecting of his grandparents. That has changed loads over the past 12 months and I would say he enjoys a close relationship with all three of them too. There is less of a gap between his behaviour with us and with them, where he used to test their boundaries far more. I think he trusts them now and understands their not-everyday but consistent role in his life. In fact, he has even slept over at my parents and not only did they live to tell the tale (!) but it went well.

Little Bear is friendlier in general and often plays with children he hasn't met before at parks etc. instead of pretending they don't exist.

All of that said I suspect that the testing of boundaries continues with those whom he is less attached to e.g. teachers and I would be very reluctant to leave him with anyone who didn't know him well.
Emotional Regulation
I think we saw the most progress in this area during the first year when Little Bear went from being a little ball of rage to mostly calm and happy. In general I would say that Little Bear's emotional regulation is fairly good. He experiences a range of emotions, as we all do, and is making ongoing progress with expressing how he feels with words. Although he can be stroppy, I wouldn't say that he shows extremes of emotion any more.
Behavioural Regulation
This is probably the main area in which we have experienced difficulties.

As with all aspects of Little Bear the progress he has made with his behaviour has been incredible but if there is one thing that is going to slide, it is generally this. Little Bear knows right from wrong in most situations and he can often verbalise what you want him to do or not do but if he's dysregulated he just cannot co-operate. The flash points are usually when he's hungry, tired or not feeling well and he can get quite out of control.

These days we are much more tuned in and can often pinpoint what is causing it fairly quickly and can help him to regulate. He is not yet able to identify things like his own hunger in order to self- regulate. If he is in the process of catching germs there is not much we can do and we sometimes puzzle over what on earth is going on with him until a few days later when the illness hits.

There are times when Little Bear is dysregulated that he does try to hurt us or himself. It is usually in a fairly low-level way: scratching, hitting, maybe a kick. At the time he wants to do it but afterwards he feels bad and usually, day to day, he would be upset if he hurt us even by accident.

This is the thing that most concerns me for the future. I hope that he is able to overcome his difficulties with regulation because a teenager or young man who sometimes wants to hurt you (or himself) is a very different prospect from a skinny 5 year old.
Self-esteem
I think that this is an area where Little Bear's difficulties have come more to the fore over his second year with us. It was probably harder to notice them before because we were focussed on the big, hard to ignore behaviour stuff. I wrote a bit about how Little Bear's lack of self-belief impacts on his ability to learn in Jigsaws. When it comes to most sitting down tasks Little Bear's default position tends to be to assume that he can't do it. He seems to put a lot of pressure on himself and if he cannot do something immediately e.g. stick a Lego brick where it needs to go, he becomes quickly frustrated and will sabotage the task or launch it across the room. He will often say "I'm rubbish" at x, y or z. This has a fairly major impact on school-style learning and is something we are working hard on at the moment.

Thankfully Little Bear tolerates and in fact thrives on praise so we are able to build him up, reassure, point out strengths and celebrate successes. We have to ensure we do this to keep Little Bear engaged with tasks otherwise he will withdraw and consequently feel worse about himself.

I hope that I am able to look back in another year and say that his confidence is going from strength to strength.
Dissociation
I can honestly say we haven't experienced any issues in this area.
Cognitive Problems
Little Bear's difficulties with information processing, memory and problem-solving are well documented throughout my blog. I'm guessing that the very fact I have been talking about it so much is a good sign: Little Bear must have made good progress in his limbic and brain stem development (the first 4 areas described above) or he would not be learning at all. Children with high levels of developmental trauma often have many needs in those areas and are not yet developmentally able to use the cortex or thinking part of their brain as their brain is stuck in survival mode.

Whilst Little Bear is learning at a rapid rate, he does experience difficulties commensurate with requiring additional funding and support at school. Over the last year observing his ability to overcome these barriers has been one of my biggest joys.

At the start of school Little Bear's Auditory Memory skills were poor - he could remember 2 to 3 items at best and it held him back from being able to count or learn blending skills for reading. He is now reading, remembering 6 word sentences and counting almost to 20. If we help with number 15, he can then get to 30. The post about jigsaws shows how rapidly his problem-solving can progress if the right support is in place.

In the early days, Little Bear couldn't engage with Duplo. He couldn't make a man sit in a Duplo bus without losing his temper. This week he has completed a Lego City model (recommended age 5-12) admittedly with help but he understood the instructions, could search for and locate the pieces and could add them appropriately to the model. He focused, overcame his urges to break it up and completed the whole aeroplane in one sitting. It was so lovely to watch him succeeding.

So there you go Trauma, we are slowly but surely kicking you to the curb.

After two years as an adopter I continue to be challenged but mainly in a good way. The more experienced I become, the more aware I am of what I don't know - I have ordered 2 books to fill some gaps during the writing of this post! I continue to adore my Bears and despite the harder days remain thankful that we chose to embark on this adoption adventure.

I have just done a quick straw poll of the other Bears to see what they think has changed over the past year:

Grizzly: Little Bear's language. It has come on loads and he is much calmer and more chilled out now.

Big Bear: I think his behaviour's changed: he's a good boy, aren't you mate?

Little Bear: I think I've got more toys.

*I apologise if any of the theory in this post is not quite right, it is very much written in my words, not the words of Bruce Parry.

**Though I'm desperate to include Little Bear's opinions in my blogs, I'm not sure he's quite up to answering my complex questions yet

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One year ago I wrote Reflections on Adoption One Year In. Somehow or other an entire annum has passed since and here I am again on the second anniversary of meeting my littlest bear, looking back, reflecting, analysing and considering what has changed.

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From RCSLT based on Norbury et al (2016)

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis https://t.co/xpCCey468T

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis pic.twitter.com/xpCCey468T
— RCSLT 💙 (@RCSLT) September 22, 2017

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis https://t.co/xpCCey468T

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis https://t.co/xpCCey468T

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Developmental Language Disorder affects 7.58% of children between 4;9 & 5;10 #DLD123 #devlangdis

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St John’s Fellows are at the forefront of research into language development disorders | St John's College, Oxford

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St John’s Fellows are at the forefront of research into language development disorders | St John's College, Oxford

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St John's Fellows are at the forefront of research into language development disorders

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This week sees the culmination of a five-year campaign to raise awareness of a condition among children that affects every aspect of their communication, with a lasting impact on their educational and emotional development.

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Your right to know: long-term social effects of language disorders | Banter Speech & Language

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Your right to know: long-term social effects of language disorders | Banter Speech & Language

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We speech pathologists need to talk more about some of the long-term, negative effects of developmental language disorders. We need to explain why getting help is so important. And not just for late talking toddlers and pre-schoolers. School-age children, older children, teens and young adults, too.

One reason I think we don't talk about long-term problems - despite knowing about most of then for over 20 years - is that we don't want to worry parents and carers. But they have a right to know this stuff, even if it's hard to talk about.

So here's what some of the peer-reviewed clinical research tells us:

1. Language disorders don't disappear when a child goes to school

Developmental language disorders:

are often not picked up in children (Cohen et al., 1998);

often cause peers and others to respond negatively to the affected child (Redmond & Rice, 1998);

can cause a child to be perceived by parents, teachers and other students as exhibiting challenging behaviours and/or emotional problems (e.g. Benner et al., 2002);

have a high persistence rate into adolescence, particularly for comprehension of language (e.g. Clegg et al., 2005); and

typically persist into adulthood (e.g. Johnson et al., 1999).

2. Language disorders affect social participation

Compared with typically developing kids, children with developmental language disorders, on average:

have fewer friends, poorer quality friendships and participate less in social activities (e.g. Durkin & Conti-Ramsden, 2007);

are more likely to show social difficulties, including social withdrawal and difficulties joining groups of peers (e.g. Hart et al., 2004; Mok et al., 2014);

converse less;

have difficulty persuading others; and

respond less sensitively to peer communications (e.g. Brinton et al., 1998; Vallance et al., 1999).

Children and young adults with developmental language disorders:

may withdraw socially in response to the effects of their disorder (which includes difficulty talking with others and being rejected by peers) (e.g. Hoff, 2006; Redmond, 2011);

report higher levels of anxiety and are diagnosed with anxiety disorders more frequently than typically developing peers (e.g. Beitchman et al., 2001; Maggio et al., 2014); and

may have deficits in social skills (e.g. Botting & Conti-Ramsden, 2008).

3. Language disorders are associated with heightened risks of social anxiety

There is some evidence that teens with developmental language disorders have higher rates of anxiety related to social interaction and avoidance of social situations than typically developing peers (Wadman et al., 2011).

New evidence from long-term studies suggests that young children diagnosed with developmental language disorders have higher rates of social phobia at ages 19 and report higher levels of social interaction anxiety symptoms at age 31. Despite some limitations in these studies (such as high drop-out rates), social anxiety symptoms tended to persist into adulthood, although not to the degree warranting a formal diagnosis of social anxiety disorder. In particular, young adults with a history of language disorders reported difficulties talking to others and asserting their perspectives (e.g. Brownlie et al., 2016).

4. Language disorders affect academic and work outcomes

Children's capacities at school entry are predictive of academic outcomes (e.g. Snow, 2006).

Early success at school is a strong indicator of ongoing and future success (e.g. Prior et al., 1993).

Teenagers with language disorders are at risk of poor academic progress, bullying and behavioural problems, like acting out in class (e.g. Snow & Powell, 2004).

Lots of teenagers with language problems give up, drop out and end up in unskilled, poorly paid jobs. And teenagers with language disorders are well over-represented in the youth justice system.

The negative effects of developmental language disorders are arguably growing, rather than dissipating:

For many teens and young adults, language disorders are "invisible disabilities" (Beitchman & Browlie, 2014). Having a language disorder can have big, long-term negative effects on your school, work and social participation across the lifespan. Older children and young adults affected by language disorders need to know this and get the help they need to stay engaged at school and work, and to have rewarding social lives.

Educating parents and carers of younger children with developmental language delays upfront about the longer-term issues their children may face is an important part of being a responsible speech pathologist. Even if the information is sometimes hard to discuss.

Principal source: Browlie, E.B., Bao, L., & Beitchman, J. (2016) Childhood Language Disorder and Social Anxiety in Early Adulthood. Journal of Abnormal Psychology, 44, 1061-1070.

Image: http://tinyurl.com/z7ncjk4

Banter Speech & Language

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Your right to know: long-term social effects of language disorders

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We speech pathologists need to talk more about some of the long-term, negative effects of developmental language disorders. We need to explain why getting help is so important. And not just for late talking toddlers and pre-schoolers. School-age children, older children, teens and young adults, too.

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Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl 
https://t.co/EQJgp15Vo9

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Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl 
https://t.co/EQJgp15Vo9 https://t.co/6b8fr3drKv

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Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl https://t.co/EQJgp15Vo9 pic.twitter.com/6b8fr3drKv
— IASLT (@iaslt) September 22, 2017

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Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl 
https://t.co/EQJgp15Vo9 https://t.co/6b8fr3drKv

# data[].attributes.attachment_link.metadata.attachment_props.original_text
Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl 
https://t.co/EQJgp15Vo9 https://t.co/6b8fr3drKv

# data[].attributes.attachment_link.metadata.attachment_props.text
Check out this poster! Can be used to raise awareness of DLD in your workplace #DLD123 #devlangdis #DLDActionIrl 
https://t.co/EQJgp15Vo9

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When should the term 'DLD' be used? #DLD123 #Devlangdis

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When should the term 'DLD' be used? #DLD123 #Devlangdis https://t.co/S57ojBIVPN

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When should the term 'DLD' be used? #DLD123 #Devlangdis pic.twitter.com/S57ojBIVPN
— RCSLT 💙 (@RCSLT) September 22, 2017

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When should the term 'DLD' be used? #DLD123 #Devlangdis https://t.co/S57ojBIVPN

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When should the term 'DLD' be used? #DLD123 #Devlangdis https://t.co/S57ojBIVPN

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When should the term 'DLD' be used? #DLD123 #Devlangdis

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10 strategies to support children with DLD – Speechbloguk

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10 strategies to support children with DLD – Speechbloguk

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A collection of blogs to celebrate #DLD123

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Today is DLD Awareness day. I'm sure there will be people reading this who don't know what DLD is, and that's why we need an awareness day! It stands for Developmental Language Disorder, and it is when children have a specific difficulty with language processing, which affects their understanding of what is said to them and/or their ability to express themselves. This is not a new difficulty, and it's actually quite common (affecting around 2 children in every class). However, it is a hidden disorder and generally people don't know about it. We need to change that, as it's really important that the problem is known about so that children can get the help they need! You can find out more about what DLD is in this video and this video.

One thing that hasn't helped with raising awareness is that until recently, lots of different names were used for DLD - language disorder, Specific Language Impairment and others. Now it has been agreed that DLD is the correct term to use. You can find out more about why the change in terminology happened here and here.

For DLD Awareness Day we have joined up with some other SLT bloggers in the UK to write a series of posts (and one podcast!) about DLD, what it is and how you can help. You can find links to the other posts in the series at the end of this post.

We are focussing on how you can help if you think a child may have a language difficulty such as DLD. Giving the right support is crucial and can make a huge difference, as you can see in this post. Firstly, make sure you refer them to a speech and language therapist. You can find out more about when and how to do this here. In addition, here are some strategies to try at home or in the classroom. There are 10 strategies altogether. Don't feel that you need to try them all at once - choose one and try it for a few days. Then try another. Which ones make a difference for the child you are working with?:-

Get the child's attention. If listening and understanding are hard work, it's easy to switch off. Get the child's attention by getting down to their level (or trying to get eye contact), saying their name and getting them to look. In the classroom, the child may need more breaks from listening than the others as it is tiring and difficult for them.

Reduce your language. Use short, simple sentences whenever you can. Say things in the order they need to be done. For example, instead of saying "before you put your book in the tray, put your pencil away" say "put your pencil away. Then put your book in the tray". Slow your rate of speech down a bit to give them a chance to process.

Show them. Often, visual support such as pictures, signs and demonstration can be really helpful for children with language difficulties. These will usually help other children too, not just those with DLD. Use as many senses as possible to teach a new concept. Look at it. Touch it if possible. Draw it. Show the child what to do.

Summarise. After you have given your classroom input or instructions to the class, summarise what you have said. Use short, simple sentences and simple words as far as possible. If there are several things that the children need to do, tell the children how many things there are to remember and count them off on your fingers, using simple words. If you can do this more than once, even better! You can do the same thing at home if you are giving a list of instructions.

Link words. Children with DLD often don't make links between words easily. Link new or harder words to simpler ones. Talk about all the aspects of a word - what does it sound like, what other words are similar in meaning, can you draw it or act it? There is so much you can do around vocabulary. For example, if you are teaching the word "orbit", draw it or use your fingers to show what happens. Check out Anna's post, or look at Word Aware which is a great whole class or whole school approach to vocabulary teaching.

Comment rather than question. It is natural to us in conversation to ask a lot of questions. For some children with language difficulties though, this can become difficult and pressurising. Question words in particular are difficult to understand and are confusing. Try to comment on what they are doing rather than asking a question.

Offer choices. Sometimes it can be hard for children with DLD to remember words. Rather than "what do you want to eat?" try "would you like apple or banana?". For very young children, show them the objects on offer as well to start with. You can do a similar thing with answering more complicated questions. For example, if "what did you see at the castle?" is too hard try "did we see armour or swimsuits?" Start by offering obvious choices to give them confidence but you can gradually try offering more similar options.

Add a word. If your child says a short phrase or sentence, say it back to them and add a word. For example, if your child says "doggy eating" you could say "yes, doggy's eating dinner". If your child says "the dog is eating dinner" you could say "yes, the dog is eating dinner hungrily".

Recast. If a sentence comes out in a muddle and there are grammatical errors, don't tell them they said it wrong. Instead, say it back for the child to hear with the errors corrected. This is called recasting. For example, if your child says "I goed shopping", you could say "that's right, you went shopping".

Check understanding. Check that the child has understood what they have been asked to do, or the concept they have been taught. For some children, asking them to say back what they have to do in their own words will be helpful. For others, this is too hard. Getting the child (or the whole class) to repeat the important bits can be really useful. I saw one teacher who would ask the whole class to say something back several times. For example, "we need to write the date. What do we need to write?.... Tell the person next to you, what do we need to write?.... Shout it as loud as you can, what do we need to write?... whisper it...." You get the idea!

For more ideas and strategies, check out our free handouts. Please read the other posts in our DLD Awareness Day blog hop too.
Catherine from Wise Old Owl Speech has a brand new podcast on the change of terminology for you to listen to here. Lucy Sanctuary has written about DLD and ASC here. Jude Philip has written a post entitled DLD and the older student - unravelling the knot here.
Anna from Word Steps SLT has written about helping children learn new vocabulary here.

Finally, please spread the word about DLD today, either by sharing this post or by sharing RADLD's video DLD 123.

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10 strategies to support children with DLD

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Today is DLD Awareness day. I'm sure there will be people reading this who don't know what DLD is, and that's why we need an awareness day! It stands for Developmental Language Disorder, and it is when children have a specific difficulty with language processing, which affects their understanding of what is said to them and/or their ability to express themselves.

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RCSLT adapted Venn diagram for SLCN and associated diagnoses

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis https://t.co/1mMoAcL550

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis pic.twitter.com/1mMoAcL550
— RCSLT 💙 (@RCSLT) September 22, 2017

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis https://t.co/1mMoAcL550

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis https://t.co/1mMoAcL550

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It's #DLD123! We'll be tweeting infographics throughout the - what will you be doing? #Devlangdis

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Academics end 200-year confusion on diagnosis of ‘hidden’ child condition

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Academics end 200-year confusion on diagnosis of ‘hidden’ child condition

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Academics end 200-year confusion on diagnosis of 'hidden' child condition

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Gina Conti-Ramsden, Professor of Child Language and Learning and Director of the Manchester Language Study, The University of Manchester said: "Many children and young people with language difficulties struggle in many aspects of their life including school, friendships and how they think about themselves.

"They are often mistaken as being "naughty" showing poor behaviour or "not trying hard enough" when they don't understand what is said to them. Many labels have been used to refer to these individuals and this has created confusion.

"Developmental Language Disorders (DLD) is the new streamlined term that will help us diagnose and support children and young people with this common but hidden condition".

Sophie, 37 said:"I was diagnosed with DLD when I was young. I've had great support from my parents, and specialist schooling and support including from speech and language therapists, so I have been able to succeed in more than I would ever expect. But, it is always there in my life, and something I have to find strategies to get by. I wish I could do things that other people could do, and take things in and remember things when told the first time. Having DLD does get me down. It causes me to have anxiety and low self-esteem."

By increasing awareness and recognition of DLD, the team aim to ensure any child affected is able to access specialist speech and language therapy and support they need.

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Academics end 200-year confusion on diagnosis of 'hidden' child condition

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New terminology, developed following a five year campaign by academics across the UK, is set to end 200 years of confusion in diagnosing a distressing disorder affecting two children in every classroom. The academics - including Professor Gina Conti-Ramsden from The University of Manchester - agreed a new terminology for the hidden condition...

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The Language Problem Language Problem: Building consensus on Developmental Language Disorder - YouTube

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The Language Problem Language Problem: Building consensus on Developmental Language Disorder - YouTube

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The Language Problem Language Problem: Building consensus on Developmental Language Disorder

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Around 7% of people suffer from a developmental language disorder, and yet not many people have even heard of them. Oxford's Dorothy Bishop realised that, if sufferers were going to get the help they need, the public would need to know about their condition.

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Developmental Language Disorder; The consensus explained by Professor Dorothy Bishop

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Developmental Language Disorder; The consensus explained by Professor Dorothy Bishop

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Developmental Language Disorder (DLD): The Consensus Explained

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Confusion over terminology for language difficulties has run for almost 200 years and this has hindered awareness and communication. Professor Dorothy Bishop and Professor Maggie Snowling led a consensus process to tackle this issue. In this film Dorothy Bishop explains the consensus process, the agreement to use the term Developmental Language Disorder (DLD) and the agreed criteria for this disorder.

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Welcome to the RADLD channel, created to Raise Awareness of Developmental Language Disorder or 'DLD'. (Previously RALLI campaign). Here you will find videos ...

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Developmental Language Disorder (DLD): The consensus explained

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Developmental Language Disorder (DLD): The consensus explained

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Developmental Language Disorder (DLD): The consensus explained

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We’ve got a new film starring @deevybee talking about  the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis

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Developmental Language Disorder (DLD): The Consensus Explained

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Confusion over terminology for language difficulties ran for almost 200 years and this has hindered awareness and communication. Professor Dorothy Bishop and...

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We’ve got a new film starring @deevybee talking about  the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis

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We’ve got a new film starring @deevybee talking about the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis
— RADLDcampaign (@RADLDcam) August 29, 2017

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Developmental Language Disorder (DLD): The Consensus Explained

# data[].attributes.attachment_link.metadata.attachment_props_source.data.entities.urls[].description
Confusion over terminology for language difficulties ran for almost 200 years and this has hindered awareness and communication. Professor Dorothy Bishop and...

# data[].attributes.attachment_link.metadata.attachment_props_source.data.text
We’ve got a new film starring @deevybee talking about  the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis

# data[].attributes.attachment_link.metadata.attachment_props.original_text
We’ve got a new film starring @deevybee talking about  the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis

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We’ve got a new film starring @deevybee talking about  the new DLD term and how it all happened https://t.co/cfxvAUaZTO #devlangdis

# data[].attributes.attachment_link.metadata.attachment_props.entities.urls[].title
Developmental Language Disorder (DLD): The Consensus Explained

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Confusion over terminology for language difficulties ran for almost 200 years and this has hindered awareness and communication. Professor Dorothy Bishop and...

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Developmental language disorder - Wikipedia

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Developmental language disorder - Wikipedia

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Developmental language disorder - Wikipedia

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Developmental language disorder ( DLD) is identified when a child has problems with language development that continue into school age and beyond. The language problems have a significant impact on everyday social interactions or educational progress, and occur in the absence of autism spectrum disorder, intellectual disability or a known biomedical condition.

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis https://t.co/vs1zVsk9fQ

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis pic.twitter.com/vs1zVsk9fQ
— RADLDcampaign (@RADLDcam) August 22, 2017

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis https://t.co/vs1zVsk9fQ

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis https://t.co/vs1zVsk9fQ

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Did you know through successful crowding funding we have two fantastic new films coming out to promote DLD #letsdothis #devlangdis

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Developmental Language Disorder (DLD) | Afasic Cymru

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Developmental Language Disorder (DLD) | Afasic Cymru

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Developmental Language Disorder (DLD)

A recent process led by Professor Dorothy Bishop and Maggie Snowling of RALLI aimed to reach a consensus about terminology in this area. After months of discussion and review we are delighted to confirm that the agreed term is now Developmental Language Disorder (DLD) and it replaces other terms such as Learning Language Impairment (LLI) and Specific Language Impairment (SLI). We hope this will help lead to improved awareness, identification and ultimately support.

Save the date - 22 September 2017
DLD affects approximately 2 students in every classroom. We know speech and language therapy and school support is beneficial for these students. We know this difficulty is often hidden and can be difficult to identify.

There will be a DLD Awareness Day on 22 September. We need your support to help us spread the word. More information to follow shortly.

Written By: The Editor on 21 August 2017 | No Comments

News Category: Research and best practice

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Developmental Language Disorder (DLD) | Afasic Cymru

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A recent process led by Professor Dorothy Bishop and Maggie Snowling of RALLI aimed to reach a consensus about terminology in this area. After months of discussion and review we are delighted to confirm that the agreed term is now Developmental Language Disorder (DLD) and it replaces other terms such as Learning Language Impairment (LLI) and Specific Language Impairment (SLI).

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Claire Westwood SLP - thanks @Claire_SLT

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Claire Westwood SLP - thanks @Claire_SLT

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A mind map on #devlangdis for a session with a young person

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall!

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall! https://t.co/rSQrIDyEpF

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall! pic.twitter.com/rSQrIDyEpF
— Claire Westwood (@Claire_SLT) August 21, 2017

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall! https://t.co/rSQrIDyEpF

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall! https://t.co/rSQrIDyEpF

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Quick mind map on #devlangdis for a session with a young person and couldn't bear to throw it away - so now it's on the wall!

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Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD) - V. M. Bishop - 2017 - International Journal of Language & Communication Disorders - Wiley Online Library

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Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD) - V. M. Bishop - 2017 - International Journal of Language & Communication Disorders - Wiley Online Library

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Discussion

Authors

Dorothy V. M. Bishop

Corresponding author

University of Oxford, Oxford, UK

Address correspondence to: Dorothy Bishop, University of Oxford, Tinbergen Building, South Parks Road, Oxford OX1 3UD, UK; e-mail: dorothy.bishop@psy.ox.ac.uk

Search for more papers by this author

Abstract

A recent project entitled CATALISE used the Delphi method to reach a consensus on terminology for unexplained language problems in children. 'Developmental language disorder' (DLD) was the term agreed by a panel of 57 experts. Here I reflect on points of difficulty that arose when attempting to reach a consensus, using qualitative information from comments made by panel members to illustrate the kinds of argument used. One issue of debate was the use of labels, in particular the term 'disorder', which was seen as having both pros and cons. The potential for labels to stigmatize or create low expectations was a particular concern. However, labels could also ensure language problems were not trivialized and could help avoid stigma by providing an explanation for behaviours that might otherwise meet with disapproval. Further debate surrounded issues of how best to identify cases of disorder. Although it was agreed there should be a focus on cases with a poor prognosis, it was recognized that our knowledge of factors related to prognosis was still incomplete. Furthermore, there was a tension between use of standardized tests, which allow for a relatively objective and reliable assessment of language, and more qualitative observations, which can capture functional aspects of communication that are not always picked up on formal assessment. Debate also surrounded the issue of the relationship between DLD and other conditions. Some favoured drawing a distinction between DLD and language disorders associated with other conditions, and others regarded such distinctions as unnecessary. We concluded that it was misleading to assume co-occurring conditions were causes of language disorder, but it was helpful to distinguish DLD from cases of language disorder associated with 'differentiating conditions' that had a known or likely biomedical origin, including brain injury, sensorineural hearing loss, genetic syndromes, intellectual disability and autism spectrum disorder. Furthermore, DLD could co-occur with milder neurodevelopmental disorders that did not have a clear biomedical aetiology. Normal-range non-verbal IQ has traditionally been incorporated in the diagnosis of DLD, but this was rejected as unsupported by evidence. DLD is a category that has utility in identifying children who would benefit from speech-language therapy services, but it should not be thought of as a well-defined condition. DLD has a multifactorial aetiology, is heterogeneous in terms of language features and overlaps with other neurodevelopmental disorders. Our notions of DLD are likely to be refined by further research into aetiology, associated characteristics and intervention effectiveness.

In 2015-16, an international group of experts, the CATALISE panel, came together with the aim of achieving consensus on diagnostic terminology for children's language disorders. Ebbels ( 2014) documented the history of this development, with the need for consensus being emphasized by several converging forces. First, there was mounting evidence that children's language disorders received scant research funding in relation to their frequency and severity (Bishop 2010). Then in 2012, a live debate entitled 'What IS Specific Language Impairment' took place at Moor House School, a specialist school for children and young people with speech and language difficulties. This failed to reach agreement about how to diagnose or define specific language impairment (SLI). In addition, a group that had started a campaign for Raising Awareness of Language Learning Impairments (RALLI) (Bishop et al. 2012) was confronted with the difficulty of raising awareness of a condition that was ill-defined, and where terminology was inconsistent. In 2013, Sheena Reilly, in the IJLCD Winter Lecture raised numerous questions about the usefulness and validity of the term 'SLI', using data from an Australian epidemiological study to argue that the 'specific' part of the label was counterproductive and misleading-views that were subsequently articulated in this journal (Reilly et al. 2014b). To complement that paper, I wrote a review outlining the major issues where consensus was lacking, and suggesting various solutions (Bishop 2014). Both papers appeared in a special issue of this journal (Ebbels 2014), accompanied by commentaries from experts covering a range of professional groups and interests. The authors of the original focus papers then collaborated to highlight the main points of agreement and disagreement in the debate (Reilly et al. 2014a).

Starting in 2015, a two-stage project, CATALISE (Criteria and Terminology Applied to Language Impairments: Synthesising the Evidence), was developed with the aim of yielding consensus statements about children's language disorders (Bishop et al. 2016, 2017). The method adopted was the Delphi Survey Technique (Hasson et al. 2000). This involves working with a panel of experts who are provided with a set of statements that they both rate and comment on. Panel members were encouraged to cite research evidence to justify their viewpoints. The process is iterative, with a new set of statements being formulated on the basis of the previous round. This exercise, when conducted online, has several advantages over in-person discussion. For a start, panel members have time to think about the issues and to complete their ratings at a time that is convenient. This makes it possible for people to take part from all over the world. 1 Furthermore, each person's ratings and comments are fed back anonymously to the whole panel. Anonymity avoids the discussion being dominated or derailed by a few forceful individuals. If the feedback indicates that one's point of view is unpopular, it is possible to present arguments and evidence to try to persuade others, or to revise one's ratings. Two moderators (Dorothy Bishop and Maggie Snowling), who were not part of the panel, integrated the information from each round, using the comments accompanying the ratings to identify the reasons for disagreement and to revise statements to address these. The first Delphi exercise focused on criteria and the second on terminology.

One outcome of this exercise was the recommendation that the term 'specific language impairment' (SLI) be abandoned in favour of 'developmental language disorder' (DLD). Rather than recapitulating the conclusions of the two Delphi exercises, which are covered in depth in two papers (Bishop et al. 2016, 2017), my aim here is to use the comments offered by panel members during these projects to reflect on the factors leading to change and in particular to note reasons for controversy in this area.

However, it is worth first emphasizing issues on which there was good agreement from the outset. All panel members recognized that some children have difficulties mastering their native language, and that these can be severe enough to impair their ability to function well in educational and social contexts. In many cases there is no obvious cause. A second point was that it was important to reach agreement, because lack of consensus had been damaging to the field, and did a disservice to affected children and their families.

It was also agreed that language disorders in children can take many forms. The classic 'textbook' case is of a child whose language level is well below that of their peers-for instance, a 4-year-old who talks more like a typical 2-year-old, with simplified grammar and limited vocabulary. Where the problems are as striking as this, language difficulties are not hard to recognize, but what of the child who has more subtle problems, or where the difficulties involve the use rather than the form of language? A core notion is that language is out of keeping with the child's general developmental level, but any attempt to turn this idea into more specific criteria is fraught with difficulties, not least because language is a complex, multidimensional skill, which changes rapidly with age.

We had expected that where there were disagreements about definitions and terminology these might divide along professional or national lines, but, as far as our analysis could establish, this was not the case. Rather, it seemed that where differences of opinion existed, it was because of lack of evidence, or else because all solutions that were discussed had disadvantages as well as advantages. In effect, there was no gold standard against which to evaluate terminology, and no ideal solution. This creates an unstable situation because whatever solution is adopted, problems will be noted, and there will therefore be pressure for further change.

It may seem counterproductive to highlight points of disagreement concerning the consensus statements that we arrived at. If we want people to endorse the new terminology, would it not be better to draw a veil over the more contentious aspects? In my opinion, this would reduce the credibility of the exercise by suggesting difficult issues were not grappled with. Furthermore, only by being aware of both pros and cons can we mitigate any negative consequences of new criteria and terminology, while promoting the benefits.

Why do we need categorical labels?

Before we address the question of which labels to use, a more primary question is whether it makes sense to use labels at all. Most panel members took the need for an agreed label as a given:

I think this is one of the reasons that children's language difficulties are not taken as seriously or recognized in the same way as other conditions such as dyslexia or ASD [autism spectrum disorder]. There are too many different terms, that are being used in too many different ways, so people are just not really paying attention any more.

This is important across the board-for epidemiological purposes, for clarity in individual research studies, and for policy makers and service providers.

Given the lack of awareness of language disorder in both professional and public fields, it is really important that we as professionals with knowledge of this area can reach a consensus on the terminology so that we can move forward with providing services and recognition for these children and their families.

However, labels influence how we think about constructs, with words dividing the world into distinct entities such as cats, dogs, desks and tables. Yet, in practice, some of these entities are not clearly demarcated: the boundary between desk and table, for instance, is not sharp. Diagnostic terms can create an insidious problem whereby the label is taken to mean that the child has a clear-cut disorder with distinctive 'symptoms', which can be distinguished from both typical development and other developmental disorders. In fact, there is no support for a sharp dividing line between language disorder and normality. Children develop language at different rates, and some will have problems severe enough to cause lifelong problems. But the differences between children appear to be quantitative rather than qualitative, and can take many different forms (Leonard 1991, Dollaghan 2011). Much research literature has focused on limitations of expressive syntax in children with DLD, but as our assessments become more fine-grained, it is evident that problems often affect understanding as well as production of complex language, and can involve phonology, semantics and pragmatics as well as grammatical structure.

It is all too easy for a label to become a master rather than a servant, if we over-interpret its significance, rather than regarding it as a useful shorthand. It is therefore important that if we use labels, we do so with full awareness of their limitations, and recognizing that our terms are socially constructed and historically specific. The term we agreed on, 'DLD', is defined in terms of behaviours that are complex, multifactorial and which vary on a continuum. It is an umbrella term that includes a wide range of problems, and the boundaries between DLD and typical development are fuzzy. One panel member noted that in the field of educational psychology some people were turning away from the label 'developmental dyslexia' for children with reading problems precisely because of arguments such as these (Elliott and Grigorenko 2014).

Another panel member noted a further problem caused by labels: their potential to stigmatize children:

I am increasingly concerned that the exercise risks generating labels/categories for children that will be operationalized to allocate resources and will discriminate against positive expectations for more than is scientifically justified.

Given these risks of misinterpretation, we need to consider whether we could do away with labels altogether. It was concluded, however, that this would create more problems than it solved. As I have discussed previously (Bishop 2014), diagnostic labels have utility in clinical as well as research contexts. Labels allow us to communicate efficiently in a common language: without labels, it would be difficult to plan services and to decide how to allocate them. This issue is not specific to DLD: it pervades all of psychiatry, including child psychiatry. As Sonuga-Barke ( 1998: 117) noted, categorization is a practical necessity in clinical practice:

To the extent that clinical economy depends on getting the right treatment to the right people, clinicians are, no matter what their philosophical bent or political point of view, categorisers. At a purely practical level this depends on a judgement being made that such and such a child belongs to the category of those who 'need help', whereas another child belongs to a (usually) larger category who do not.

Nonetheless, at the same time as we strive to get better resources to help those with DLD overcome their problems, we need to consider how best to create conditions to combat stigma. A first point to note is that research on children with DLD suggests that stigmatization is often a reaction to the child's communication difficulties (Macharey and von Suchodoletz 2008). And experience with other conditions suggests that labels can actually help reduce stigma by improving understanding. In the field of autism, for instance, a recent study found that university students were more accepting of socially atypical behaviour when they were told that the person had a clinical diagnosis (of Asperger syndrome, autism spectrum disorder (ASD) or schizophrenia) (Brosnan and Mills 2016). One study found that while a general label of 'special educational needs' was associated with low self-esteem, a more specific label (in the case of this study, 'dyslexia') was not (Taylor et al. 2010). In the field of mental health, there is some evidence that self-identifying with a stigmatized group can buffer the individual against some of the negative effects (Crabtree et al. 2010). Such research suggests that in raising awareness of terminology, we should aim to provide information in a way that will lead to better acceptance and willingness of others to make adjustments to take into account language limitations, and to facilitate individuals with DLD coming together for mutual support. Second, we need to communicate diagnosis to affected individuals and their families in a way that emphasizes that DLD does not preclude achieving well in non-linguistic domains and being a well-integrated member of society. We need to celebrate the achievements of those who have succeeded despite their language difficulties. It is worth noting that I have searched the internet for examples of positive role models of people with DLD and not been able to find any-in sharp contrast to dyslexia and ASD, where such role models are numerous.

Use of the term 'disorder'

Most of the panel welcomed the move towards a single agreed term to refer to children with persistent language problems, but there was much debate about the use of the term 'disorder'. As discussed by Bishop ( 2014), in the field of education other terms such as 'difficulties' and 'needs' have been used. Other options are 'impairment' and 'disability'. These are sometimes used interchangeably, and sometimes with subtly different meanings. 'Disorder' was preferred by the CATALISE panel for two reasons. First, it is the term used in DSM5 and ICD-11, both for language problems and for other neurodevelopmental conditions, especially ASD, attention deficit disorder, and developmental coordination disorder. It was deemed counterproductive to use terminology that was at odds with those widely used systems. Second, as one panel member said:

I feel it communicates the seriousness of the issue more effectively than 'impairment'.

A handful of panel members felt 'disorder' did not go far enough, and that a more medical-sounding label would be more effective:

We need a label with some authority. Once again, I really do have to go back to the suggestion of dysphasia, on analogy with dyslexia and dyspraxia. Terms like this have the advantage of sounding like real conditions (which is why parents will fight so hard for a 'diagnosis' of dyslexia). People sit up and take notice of it.

However, among commentators in the special issue, the label 'dysphasia' had been one of the most unpopular options. This illustrates a dilemma for the field: the labels that sound most 'medical' are seen as misleading by professionals, yet they are the terms that are most likely to attract sympathy and attention. The parallel with dyslexia is very moot here: although dyslexia is not a coherent syndrome (Elliott and Grigorenko 2014), moves to drop the term from DSM5 were strongly resisted, with the International Dyslexia Association mounting a petition for its reinstatement, citing concerns that diagnosis and intervention would be delayed if the more generic and neutral term 'specific learning disorder' were used instead (International Dyslexia Association 2012).

At the other extreme, there were concerns again about reification of the term DLD, and stigmatization and negative connotations.

The use of 'disorder' will be perceived as denoting a state of being essentially, categorically, different and distinct from those on the 'normal' distribution.

Although I agree with the term and the explanation given, the use of the word 'disorder' has very negative connotations for teachers and those within educational policy. ... There is no useful term that gets around this issue, however.

The different viewpoints illustrated by these quotes emphasize the difficulty of finding an ideal solution. If we use a term that reflects the fact that children have serious problems and need support, this comes across as negative and could create a self-fulfilling prophecy; however, if we use milder language that is not deemed stigmatizing, then we run the risk that children's problems may be trivialized, with consequent delays in identification and intervention.

Traditional distinction between 'disorder' and 'delay'

A quite different objection to the term DLD is that, at least in the UK and some parts of the Irish Republic, 'disorder' has been interpreted contrastively as a condition different from 'language delay'. Indeed, we learned that many speech-language therapists (SLTs) in the UK had been trained to make this distinction. It embodies the idea that there is a particular profile of language difficulties, where there is a large mismatch between non-verbal ability and language skills, and also an uneven profile of ability within the language domain. This profile is seen as the hallmark of 'disorder', whereas 'delay' is thought to be characterized by an even pattern of impairment, so that both verbal and non-verbal skills are like that of a younger child. This distinction has assumed considerable importance in some regions, where SLT services are allocated only to children with 'disorder', and not to those with 'delay'-presumably because 'delay' is interpreted literally as indicating that the child will catch up after a slow start.

It is hard to trace the origins of this distinction, but it is clear that, despite its superficial plausibility, it does not have empirical support. Thirty years ago, Bishop and Edmundson ( 1987) used longitudinal data to test the idea that an even pattern of language impairment had a better prognosis than a more 'spikey' profile, with selective weakness in some domains. Their results were opposite to prediction: those with more selective problems had the best outcomes, whereas those with more general across-the-board impairments had the worse prognosis. Thus, providers who restrict SLT services from those who have 'delayed' profiles are denying help to those children who are most in need. Nor is there any evidence that speech-language therapy is only effective for children with a large mismatch between language and non-verbal skills (Cole et al. 1990), which is why the American Speech-Language-Hearing Association does not support 'cognitive referencing', i.e., using the discrepancy between non-verbal IQ and language as a basis for allocating services (American Speech-Language-Hearing Association 2016). Given the widespread use of the delay/disorder distinction, it is vital that those using DLD are clear that, as used by the CATALISE panel, the term 'disorder' does not entail any discrepancies, either between verbal and non-verbal development, or between different language functions.

Criteria for language disorder: focus on poor prognosis

The definition of DLD agreed by the panel applies specifically to children with poor prognosis. This averted a concern that children with mild and transient difficulties might be labelled as 'disordered'. However, a focus on poor prognosis does raise concerns that children might be written off, or that parents will be discouraged if they are told that their child's problems are unlikely to resolve with time. Most panel members agreed that this criterion made sense, and indeed could lead to fairer allocation of resources, but it is clear that it needs to be applied cautiously:

I think the focus on prognosis is important. It also makes clear that the children who require intervention are the children with a poor prognosis. Currently in many areas of the UK children with poor prognosis are not receiving services because they clog up the system and can't be discharged easily! The focus on the tier 3 children who won't make progress without help may help to counter this shift in service delivery. 2

There were, however, two concerns: first, did we know enough about prognostic factors to be able to judge this appropriately?; and second, would this mean denying services to children who would benefit from intervention?

we need to look further into the research and agree more solid indicators of long-term language learning difficulties.

There was variable awareness among CATALISE members of existing research on predictors of outcome. Our panel included several experts who had been involved in running longitudinal studies and were in general supportive of using prognosis as a criterion, but others had concerns about the feasibility of identifying children who were likely to have longstanding problems. Between these extremes were those who thought that even if we have good predictors from research, they may apply only to the specific population that was studied, and prediction may also not be precise enough to make accurate judgements about individual children. Over and above this concern, was the question of whether children with good prognosis should be excluded from specialist help.

I think it is important not to exclude children who may have, for example, very poor expressive language, which is causing them considerable difficulties, but might respond very well to specialist input. ... Even if they do catch up reasonably quickly in relative terms, the children might still have lost ground and had a miserable couple of years, which might itself have long lasting effects.

This latter point emphasized that the criteria adopted could change the balance of which children would gain access to resources. Throughout the process, comments were made which indicated how seriously panel members took this: many thought that current allocation of SLT services was not fair, but others worried that a move to a different set of criteria might leave children who might benefit from SLT intervention without any help. The impression was that, for those with clinical caseloads, views were strongly influenced by personal experience: it was clear that most panel members were concerned that large numbers of children were unfairly excluded from access to services, but while some maintained that those with the most severe problems were denied help, others took the opposite view and noted that it was children with milder and more selective language difficulties who risked being excluded from intervention.

This debate emphasized the lack of a good evidence base for making rational decisions in this area. Of course, we do not want to expend scarce resources on children who will either improve without help, or who are unlikely to benefit from intervention. But in the absence of a strong evidence base, it seemed that subjective impressions were often used to distinguish these groups. One point where the evidence was clear concerned the difficulty of predicting outcomes in late-talking toddlers: a diagnosis of DLD would be difficult to justify in a child under 3 years of age unless there were notable comprehension difficulties. In cases where the prognosis is hard to judge, which would include many pre-school children, the more generic term 'speech, language and communication needs' (SLCN), already in widespread use in the UK, would seem more appropriate for flagging up problems than the more clinical diagnosis of DLD.

As reviewed by Bishop et al. ( 2017), we do have better prognostic indicators for children from around 5 years of age when it becomes reasonable to identify children whose problems are unlikely to resolve without help. Nevertheless, it is frustrating that even when we have evidence from longitudinal studies, the clinical application of the findings is often limited because of an emphasis on demonstrating that a predictor is statistically significant, rather than on its effectiveness in predicting individual outcomes.

Also, there can be difficult decisions even when evidence is available: should resources go to those who can easily be treated effectively, or to those with the most severe functional impairments? These are unlikely to be the same children.

In addition, this raises the question of what the goals of intervention should be. It might seem obvious that a successful intervention is one that improves the child's language skills so that they are at the level of the peer group. Yet for some children, more modest goals-of providing strategies to cope with language difficulties, and modifying the environment to make the language impairments less detrimental-may be more realistic. If evaluation studies focus solely on language tests as outcome measures, then this may underestimate the benefits of intervention. To get a more realistic impression of outcomes, measures of quality of life, family functioning, social integration and self-esteem should be included.

Overall, it became clear that a discussion that was on the surface about diagnostic criteria was heavily influenced by beliefs about which groups should be given priority when intervention resources were scarce.

Criteria for language disorder: How objective and standardized should we be?

Further tensions were revealed between those who felt it was important to use objective measures with strong psychometric credentials and to avoid reliance on subjective judgements, and those who thought that formal language assessments failed to capture key features of children's language problems and might both over- and under-diagnose problems.

The first quotation illustrates the former concern, the second the latter:

I have concerns about relying on parents/teacher identification. Parents may not have enough information about typical language development and/or may miss comprehension difficulties. Also, there are equity issues. Children whose caregivers are least able to identify language issues may be children particularly in need of support.

I agree that testing is important, however I feel that in order to establish severity, functional assessment (informal observation for example) must be included as well as standardized testing.

Concerns were also expressed about poor sensitivity and specificity of standardized language assessment batteries, and their inability to detect some important aspects of impairment, such as pragmatic difficulties:

single tests measuring single components of the language system often do not possess the most robust psychometric properties.

we need to discuss the tools that are used to identify these problems as they have many flaws and it is likely that a multiple of assessment types, different for each age and skill level will be needed.

The consensus of the CATALISE panel was that test scores provided useful information but should not be used as the sole criterion for identifying language disorder. It was key that there should be evidence of functional impairment, i.e., the language problem impacted on the child's social interaction and/or educational progress. Nevertheless, it was noted that we lack good assessments for many aspects of language, and that reliance on subjective judgements created scope for biased and inequitable decisions.

Differentiating conditions rather than exclusionary criteria

Exclusionary criteria have traditionally been a key part of the diagnosis of SLI, but this part of the definition has been roundly criticized, notably by Reilly et al. ( 2014b). The CATALISE panel had many deliberations over whether we should differentiate between children whose language difficulties had no obvious cause and those whose difficulties occurred in the context of a specific aetiology, such as brain damage, hearing loss or a genetic syndrome. We concluded that where there is a differentiating condition 'X', the term 'language disorder with X' would be used rather than DLD. This distinction is important in many research contexts, where it may be desirable to focus on a relatively homogeneous group.

The discussion revealed several different factors that led to tension. Implicit in the debate are three issues. First, can we regard a co-existing condition as the cause of the language disorder? Second, does the presence of a specific aetiology mean that no intervention should be offered for language disorder? Third, if intervention is offered, should it be of a different kind than for children with no obvious aetiology? In addition, the answers to all these questions will depend on exactly what we regard as a co-existing condition.

The first issue may be illustrated with the case of hearing loss. A severe or profound congenital hearing loss is a major risk factor for poor development of oral language. However, if the child has exposure to signed language, good language skills are usually demonstrated. Similarly, many children can make good progress in oral language if given a cochlear implant. Nevertheless, there are hearing-impaired children who have problems learning sign language, and others who have disproportionate difficulties with oral language acquisition after a cochlear implant (Hawker et al. 2008). And this should not surprise us: we should expect to see a proportion of children with hearing loss who also have genetic risk factors for language disorder. While this example illustrates the dangers of explaining away a child's language disorder in terms of an associated condition, it is not an argument for simply ignoring the associated condition when identifying language disorder. It is rather an argument for documenting carefully the range as well as the nature of language problems associated with a specific aetiology.

The discussion about causality was pervaded by concerns that if a child's language disorder was thought to be 'explained' by an associated condition, then no intervention would be offered. Although this has sometimes been used as a justification for denying services to children, it is not a logically coherent stance. If extended to medicine as a whole, it would mean that we would only offer treatment for conditions of unknown aetiology! The panel agreed that it is not appropriate to deny intervention to a child because they has a co-existing condition, provided the child meets criteria for language disorder (in terms of severity and prognosis).

[The term 'language disorder associated with X'] is a great idea not only because it explicitly describes the association, but also because it sends the important message that problems in one area do not 'protect' children from having other difficulties. Parents of children with associated difficulties (e.g. Down syndrome) are sometimes frustrated by the lack of recognition of their child having a language disorder on top of the language difficulties associated with Down syndrome. And of course there is the important work on ASD with and without language disorder.

On the third issue, many felt that a different approach to intervention might be required if the child's language problems occurred in the context of a known aetiology. To continue with the example of hearing loss, intervention might include giving the child a hearing aid or cochlear implant, and/or introducing sign language, or having an SLT focus on presenting information via the visual modality. It was noted that there were many disorders where it helped to make this distinction:

I do agree that there are children who have disordered language for various reasons who would not best fit into the traditional 'SLI' care pathways.

There was, however, a contrasting view that children with differentiating conditions might not be offered interventions which could be useful-just because it was assumed they would not work:

some children with ASD appear to have a primary grammatical language impairment which would not be typical of ASD, yet they are not offered the same intervention that other children showing these patterns of language learning would be offered.

it is important to note that they may NOT indicate a different treatment pathway. For example, milieu communication training has been shown to efficacious for children with language disorders associated both with ID and ASD.

I think our intervention research has been mostly directed to fairly narrowly defined categories, with some exceptions. So the presumed different intervention pathways might turn out to have more in common than we think-for example, similar approaches might affect significant change in the morpho-syntactic difficulties of a child with Down syndrome and morpho-syntactic difficulties in SLI.

The discussions of these issues made it clear that, once again, one reason for disagreements was lack of a good evidence base: very little was known about efficacy of language interventions for children with co-existing biomedical conditions. The need for more research explicitly comparing different conditions was highlighted by our study. The best way to counteract concerns that budget-holders would deny services to children with additional conditions would be to provide evidence that intervention is effective with these groups.

These arguments, together with the need for researchers to study relatively homogeneous groups, led to general agreement that we should distinguish between language disorder associated with a 'differentiating condition' and DLD, while recommending that in both cases the language disorder merited assessment and intervention.

The question, then, was what to include in 'differentiating conditions'. We settled on a definition that included biomedical conditions such as a genetic syndrome, a sensorineural hearing loss or neurological disease. The conditions of ASD and intellectual disability led to some debate, but it was decided to include these as differentiating conditions, because, on the one hand, impairments of communication are a reliable feature of these conditions and, on the other, accelerating genetic advances mean that a biomedical aetiology is becoming evident for a high proportion of affected children (McRae et al. 2017). In practice, a differentiating condition would typically be the main diagnosis, with language disorder seen as a component of the condition.

DLD in relation to other neurodevelopmental disorders

The notion of 'differentiating condition' does not encompass milder neurodevelopmental disorders of unknown origin, such as ADHD or developmental coordination disorder. These do not have a clear-cut aetiology, and their association with language disorder is weaker than for the differentiating conditions noted above. One reason for rejecting the previous term 'SLI' was because 'specific' could be taken to imply that the child had no difficulties except with language. In contrast, our definition of DLD emphasizes that these idiopathic neurodevelopmental disorders can co-occur with DLD. Because different professional groups are concerned with different conditions-educators with dyslexia, SLTs with DLD, paediatricians and psychiatrists with ADHD and ASD-children often receive a rather one-sided assessment, depending on the professional they see. We emphasized that the fact that a child may have ADHD or dyslexia does not preclude a diagnosis of DLD and does not mean that the SLT should not be involved. The ways in which children's problems manifest does not neatly divide up according to professional specialities.

This view of overlap between neurodevelopmental disorders is supported by research on aetiology, which has shown that the causes of these conditions are often complex and multifactorial, resulting from the combined impact of many small genetic and environmental influences: the precise profile of problems that is seen in a child may depend on the particular constellation of aetiological factors, so we do not see sharp boundaries between conditions, but rather different permutations and combinations of impairments. Furthermore, although different disorders co-occur at above chance levels, they can be dissociated, suggesting that they may be separate consequences of common risk factors.

Comments from panel members made it clear that the question of how to handle co-occurring disorders was easier if one avoided attempting to specify causal relationships, e.g., if a child has both attentional problems and language problems, it is useful to be aware of this, but it may be impossible to disentangle whether attentional problems cause language problems or vice versa:

co-occurring disorders could be defined as impairments in other cognitive or behavioural domains that can co-occur with language disorder and may affect prognosis, but which do not include impairments of communication as core symptoms. I would avoid discussion of cause.

The role of non-verbal IQ in diagnosis

As discussed by Bishop ( 2014) and Reilly et al. (2014), traditionally, the diagnosis of SLI has required a non-verbal IQ within normal limits. In some diagnostic systems, an even more stringent requirement of a large mismatch between verbal and non-verbal ability is required. The CATALISE panel considered the evidence for this and concluded this criterion was not valid. Many panel members were supportive of dropping it.

I agree in so far as I do not want any discrimination on the basis of (non-verbal or any other concept of cognitive) ability.

This is an important equity issue.

Again, the argument was that the focus should be on the child's language needs, rather than on putative aetiology. Others, however, noted this would be a major departure from current practice and expressed reservations about expanding the category of DLD, thereby placing pressure on services. Concern was expressed that a less restrictive definition of language disorder could lead to a watering down of the concept that would ultimately lead to a reduction in services:

If we lose the conceptualisation of language impairment as being a weakness in language skills relative to the child's average non-verbal ability, then service providers might take the view that if there is no distinction between children of low ability across the board (who do not usually access a high level of therapy) and children with (specific) language difficulties, then it is not necessary to provide enhanced levels of SLT to any of them.

There also was evidence of local differences in how intervention resources were allocated. As noted above, practitioners from the UK and Republic of Ireland noted that a selective language problem (with normal non-verbal ability) was usually required in order for the child to be offered SLT services, but in other places quite the opposite was described, and there was concern that children with more selective problems might lose out:

I regularly encounter situations where services have been denied to families because their children only presented with language impairments. The risk of under-treatment in these cases is also what our epidemiological data have been telling us.

Overall, the view of the panel was that resources should not dictate diagnostic criteria. Discrepancy between verbal and non-verbal ability is not indicative of underlying aetiology-for example, Bishop ( 1994) found that identical twins with language problems often had very similar language profiles, yet could vary in non-verbal ability, with one meeting traditional discrepancy criteria for SLI, and the other not. Furthermore, for a child without a biomedical syndrome, the level of non-verbal IQ does not appear to determine responsiveness to therapy. There does not, therefore, appear to be any justification for using a verbal-non-verbal discrepancy as a diagnostic criterion; the overall view of the panel was that if this change led to more children being identified with DLD, then the case should be made for adequate resources to offer services to all of them.

Note that this does not mean that intellectual level is totally disregarded. As noted above, where the child meets criteria for intellectual disability, then we would treat that as the primary diagnosis and talk of 'language disorder with intellectual disability'. The current DSM-5 definition of intellectual disability requires that the child shows both 'intellectual deficits and adaptive deficits that fail to meet the standards for personal independence' (Harris 2013, 261).

Our definition of DLD would, however, include a case where a child with language problems has a level of non-verbal ability that is neither impaired enough to justify a diagnosis of intellectual disability nor good enough to be discrepant with overall language level. These children have historically 'fallen through the cracks' of diagnostic systems, and hence been deemed ineligible for speech and language therapy services.

Conclusions

Many of the issues raised by this analysis apply not just to language disorders but to neurodevelopmental disorders more broadly. Indeed, questions about diagnosis and terminology pervade all of psychiatry (Sonuga-Barke 1998).

As we proceeded through the Delphi studies, we were confronted by a key question: How would we know when we had a good solution? In practice, in a Delphi exercise the goal is to achieve a reasonable agreement between experts, and we were satisfied to accept a solution where we had a set of statements that at least 75% agreed with. But, as is all too apparent in many walks of life, the fact that a lot of people agree with something does not make it true. Ideally we would like to be able to show that our solution worked better than what had gone before. But what does 'work better' mean?

The ideal would be to find a solution that 'carves nature at its joints', such that DLD would identify a group of children with a distinct aetiology, correlated features and response to intervention. However, as Sonuga-Barke noted, this may be an unrealistic ambition if the reality is more dimensional than categorical. In the case of DLD, we have heterogeneity of language problems, and overlap between disorders affecting language and other domains. Despite this heterogeneity we have made some progress: our knowledge of aetiology, characteristics and effective intervention in this area has advanced over the years. Nevertheless, to improve our classification we need more research that carefully documents the nature of children's language difficulties in relation to prognosis, associated factors and response to intervention. The validity of the term 'DLD' will depend on whether it helps us move forward to a better understanding of what is clearly a heterogeneous category, bearing in mind that, as Sonuga-Barke noted, the category is a hypothesis to be tested and refined. Meanwhile, it is to be hoped that a clearer specification of DLD and agreement about use of this term will lead to a more equitable and effective allocation of services to children who experience severe and persistent language problems.

Notes

1. 1
In CATALISE, we restricted the panel to participants from English-speaking countries; it is clearly important to extend to other languages, but we were aware that the debate would be complex enough without having to take onboard further linguistic and cultural differences that might affect how language disorders manifest and are treated.

2. 2
In a Response to Intervention framework, three tiers of intervention/prevention are identified, with tier 3 referring to the level of individualized intervention needed for children with the most severe problems.

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References

American Speech-Language-Hearing Association, 2016, Eligibility and dismissal in schools [online] (available at: http://www.asha.org/slp/schools/prof-consult/eligibility0 (accessed on 29 May 2017).

Bishop, D. V. M., 2010, Which neurodevelopmental disorders get researched and why?. PLOS One, 5, e15112.

Bishop, D. V. M., Clark, B., Conti-Ramsden, G., Norbury, C. F. and Snowling, M. J., 2012, RALLI: An internet campaign for raising awareness of language learning impairments. Child Language Teaching & Therapy, 28, 259-262.

Bishop, D. V. M. and Edmundson, A., 1987, Language-impaired four-year-olds: distinguishing transient from persistent impairment. Journal of Speech and Hearing Disorders, 52, 156-173.

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T. and The Catalise Consortium , 2016, CATALISE: a multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLOS One, 11, e0158753.

Brosnan, M. and Mills, E., 2016, The effect of diagnostic labels on the affective responses of college students towards peers with 'Asperger's Syndrome' and 'Autism Spectrum Disorder'. Autism, 20, 388-394.

Crabtree, J. W., Haslam, S. A., Postmes, T. and Haslam, C., 2010, Mental health support groups, stigma, and self-esteem: positive and negative implications of group identification. Journal of Social Issues, 66, 553-569.

Elliott, J. G. and Grigorenko, E. L., 2014, The Dyslexia Debate (Cambridge: Cambridge University Press).

Hawker, K., Ramirez-Inscoe, J., Bishop, D. V. M., Twomey, T., O'Donoghue, G. M. and Moore, D. R., 2008, Disproportionate language impairment in children using cochlear implants. Ear and Hearing, 29, 467-471.

International Dyslexia Association, 2012, International Dyslexia Association requests reinstatement of the term 'dyslexia' in American Psychiatric Association's DSM-5 [online] (available at: http://www.prnewswire.com/news-releases/international-dyslexia-association-requests-reinstatement-of-the-term-dyslexia-in-american-psychiatric-associations-dsm-5-157488625.html) (accessed on 29 May 2017).

Macharey, G. and Von Suchodoletz, W., 2008, Perceived stigmatization of children with speech-language impairment and their parents. Folia Phoniatrica et Logopaedica, 60, 256-263.

Mcrae, J. F., Clayton, S., Fitzgerald, T. W., Kaplanis, J., Prigmore, E., Rajan, D. et al., 2017, Prevalence and architecture of de novo mutations in developmental disorders. Nature, 542, 433.

Reilly, S., Tomblin, B., Law, J., Mckean, C., Mensah, F., Morgan, A., Goldfeld, S., Nicholson, J. and Wake, M., 2014b, SLI: a convenient label for whom? International Journal of Language and Communication Disorders, 49, 416-451.

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Dorothy V. M. Bishop

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University of Oxford, Oxford, UK

Address correspondence to: Dorothy Bishop, University of Oxford, Tinbergen Building, South Parks Road, Oxford OX1 3UD, UK; e-mail: dorothy.bishop@psy.ox.ac.uk

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Abstract

A recent project entitled CATALISE used the Delphi method to reach a consensus on terminology for unexplained language problems in children. 'Developmental language disorder' (DLD) was the term agreed by a panel of 57 experts. Here I reflect on points of difficulty that arose when attempting to reach a consensus, using qualitative information from comments made by panel members to illustrate the kinds of argument used. One issue of debate was the use of labels, in particular the term 'disorder', which was seen as having both pros and cons. The potential for labels to stigmatize or create low expectations was a particular concern. However, labels could also ensure language problems were not trivialized and could help avoid stigma by providing an explanation for behaviours that might otherwise meet with disapproval. Further debate surrounded issues of how best to identify cases of disorder. Although it was agreed there should be a focus on cases with a poor prognosis, it was recognized that our knowledge of factors related to prognosis was still incomplete. Furthermore, there was a tension between use of standardized tests, which allow for a relatively objective and reliable assessment of language, and more qualitative observations, which can capture functional aspects of communication that are not always picked up on formal assessment. Debate also surrounded the issue of the relationship between DLD and other conditions. Some favoured drawing a distinction between DLD and language disorders associated with other conditions, and others regarded such distinctions as unnecessary. We concluded that it was misleading to assume co-occurring conditions were causes of language disorder, but it was helpful to distinguish DLD from cases of language disorder associated with 'differentiating conditions' that had a known or likely biomedical origin, including brain injury, sensorineural hearing loss, genetic syndromes, intellectual disability and autism spectrum disorder. Furthermore, DLD could co-occur with milder neurodevelopmental disorders that did not have a clear biomedical aetiology. Normal-range non-verbal IQ has traditionally been incorporated in the diagnosis of DLD, but this was rejected as unsupported by evidence. DLD is a category that has utility in identifying children who would benefit from speech-language therapy services, but it should not be thought of as a well-defined condition. DLD has a multifactorial aetiology, is heterogeneous in terms of language features and overlaps with other neurodevelopmental disorders. Our notions of DLD are likely to be refined by further research into aetiology, associated characteristics and intervention effectiveness.

In 2015-16, an international group of experts, the CATALISE panel, came together with the aim of achieving consensus on diagnostic terminology for children's language disorders. Ebbels ( 2014) documented the history of this development, with the need for consensus being emphasized by several converging forces. First, there was mounting evidence that children's language disorders received scant research funding in relation to their frequency and severity (Bishop 2010). Then in 2012, a live debate entitled 'What IS Specific Language Impairment' took place at Moor House School, a specialist school for children and young people with speech and language difficulties. This failed to reach agreement about how to diagnose or define specific language impairment (SLI). In addition, a group that had started a campaign for Raising Awareness of Language Learning Impairments (RALLI) (Bishop et al. 2012) was confronted with the difficulty of raising awareness of a condition that was ill-defined, and where terminology was inconsistent. In 2013, Sheena Reilly, in the IJLCD Winter Lecture raised numerous questions about the usefulness and validity of the term 'SLI', using data from an Australian epidemiological study to argue that the 'specific' part of the label was counterproductive and misleading-views that were subsequently articulated in this journal (Reilly et al. 2014b). To complement that paper, I wrote a review outlining the major issues where consensus was lacking, and suggesting various solutions (Bishop 2014). Both papers appeared in a special issue of this journal (Ebbels 2014), accompanied by commentaries from experts covering a range of professional groups and interests. The authors of the original focus papers then collaborated to highlight the main points of agreement and disagreement in the debate (Reilly et al. 2014a).

Starting in 2015, a two-stage project, CATALISE (Criteria and Terminology Applied to Language Impairments: Synthesising the Evidence), was developed with the aim of yielding consensus statements about children's language disorders (Bishop et al. 2016, 2017). The method adopted was the Delphi Survey Technique (Hasson et al. 2000). This involves working with a panel of experts who are provided with a set of statements that they both rate and comment on. Panel members were encouraged to cite research evidence to justify their viewpoints. The process is iterative, with a new set of statements being formulated on the basis of the previous round. This exercise, when conducted online, has several advantages over in-person discussion. For a start, panel members have time to think about the issues and to complete their ratings at a time that is convenient. This makes it possible for people to take part from all over the world. 1 Furthermore, each person's ratings and comments are fed back anonymously to the whole panel. Anonymity avoids the discussion being dominated or derailed by a few forceful individuals. If the feedback indicates that one's point of view is unpopular, it is possible to present arguments and evidence to try to persuade others, or to revise one's ratings. Two moderators (Dorothy Bishop and Maggie Snowling), who were not part of the panel, integrated the information from each round, using the comments accompanying the ratings to identify the reasons for disagreement and to revise statements to address these. The first Delphi exercise focused on criteria and the second on terminology.

One outcome of this exercise was the recommendation that the term 'specific language impairment' (SLI) be abandoned in favour of 'developmental language disorder' (DLD). Rather than recapitulating the conclusions of the two Delphi exercises, which are covered in depth in two papers (Bishop et al. 2016, 2017), my aim here is to use the comments offered by panel members during these projects to reflect on the factors leading to change and in particular to note reasons for controversy in this area.

However, it is worth first emphasizing issues on which there was good agreement from the outset. All panel members recognized that some children have difficulties mastering their native language, and that these can be severe enough to impair their ability to function well in educational and social contexts. In many cases there is no obvious cause. A second point was that it was important to reach agreement, because lack of consensus had been damaging to the field, and did a disservice to affected children and their families.

It was also agreed that language disorders in children can take many forms. The classic 'textbook' case is of a child whose language level is well below that of their peers-for instance, a 4-year-old who talks more like a typical 2-year-old, with simplified grammar and limited vocabulary. Where the problems are as striking as this, language difficulties are not hard to recognize, but what of the child who has more subtle problems, or where the difficulties involve the use rather than the form of language? A core notion is that language is out of keeping with the child's general developmental level, but any attempt to turn this idea into more specific criteria is fraught with difficulties, not least because language is a complex, multidimensional skill, which changes rapidly with age.

We had expected that where there were disagreements about definitions and terminology these might divide along professional or national lines, but, as far as our analysis could establish, this was not the case. Rather, it seemed that where differences of opinion existed, it was because of lack of evidence, or else because all solutions that were discussed had disadvantages as well as advantages. In effect, there was no gold standard against which to evaluate terminology, and no ideal solution. This creates an unstable situation because whatever solution is adopted, problems will be noted, and there will therefore be pressure for further change.

It may seem counterproductive to highlight points of disagreement concerning the consensus statements that we arrived at. If we want people to endorse the new terminology, would it not be better to draw a veil over the more contentious aspects? In my opinion, this would reduce the credibility of the exercise by suggesting difficult issues were not grappled with. Furthermore, only by being aware of both pros and cons can we mitigate any negative consequences of new criteria and terminology, while promoting the benefits.

Why do we need categorical labels?

Before we address the question of which labels to use, a more primary question is whether it makes sense to use labels at all. Most panel members took the need for an agreed label as a given:

I think this is one of the reasons that children's language difficulties are not taken as seriously or recognized in the same way as other conditions such as dyslexia or ASD [autism spectrum disorder]. There are too many different terms, that are being used in too many different ways, so people are just not really paying attention any more.

This is important across the board-for epidemiological purposes, for clarity in individual research studies, and for policy makers and service providers.

Given the lack of awareness of language disorder in both professional and public fields, it is really important that we as professionals with knowledge of this area can reach a consensus on the terminology so that we can move forward with providing services and recognition for these children and their families.

However, labels influence how we think about constructs, with words dividing the world into distinct entities such as cats, dogs, desks and tables. Yet, in practice, some of these entities are not clearly demarcated: the boundary between desk and table, for instance, is not sharp. Diagnostic terms can create an insidious problem whereby the label is taken to mean that the child has a clear-cut disorder with distinctive 'symptoms', which can be distinguished from both typical development and other developmental disorders. In fact, there is no support for a sharp dividing line between language disorder and normality. Children develop language at different rates, and some will have problems severe enough to cause lifelong problems. But the differences between children appear to be quantitative rather than qualitative, and can take many different forms (Leonard 1991, Dollaghan 2011). Much research literature has focused on limitations of expressive syntax in children with DLD, but as our assessments become more fine-grained, it is evident that problems often affect understanding as well as production of complex language, and can involve phonology, semantics and pragmatics as well as grammatical structure.

It is all too easy for a label to become a master rather than a servant, if we over-interpret its significance, rather than regarding it as a useful shorthand. It is therefore important that if we use labels, we do so with full awareness of their limitations, and recognizing that our terms are socially constructed and historically specific. The term we agreed on, 'DLD', is defined in terms of behaviours that are complex, multifactorial and which vary on a continuum. It is an umbrella term that includes a wide range of problems, and the boundaries between DLD and typical development are fuzzy. One panel member noted that in the field of educational psychology some people were turning away from the label 'developmental dyslexia' for children with reading problems precisely because of arguments such as these (Elliott and Grigorenko 2014).

Another panel member noted a further problem caused by labels: their potential to stigmatize children:

I am increasingly concerned that the exercise risks generating labels/categories for children that will be operationalized to allocate resources and will discriminate against positive expectations for more than is scientifically justified.

Given these risks of misinterpretation, we need to consider whether we could do away with labels altogether. It was concluded, however, that this would create more problems than it solved. As I have discussed previously (Bishop 2014), diagnostic labels have utility in clinical as well as research contexts. Labels allow us to communicate efficiently in a common language: without labels, it would be difficult to plan services and to decide how to allocate them. This issue is not specific to DLD: it pervades all of psychiatry, including child psychiatry. As Sonuga-Barke ( 1998: 117) noted, categorization is a practical necessity in clinical practice:

To the extent that clinical economy depends on getting the right treatment to the right people, clinicians are, no matter what their philosophical bent or political point of view, categorisers. At a purely practical level this depends on a judgement being made that such and such a child belongs to the category of those who 'need help', whereas another child belongs to a (usually) larger category who do not.

Nonetheless, at the same time as we strive to get better resources to help those with DLD overcome their problems, we need to consider how best to create conditions to combat stigma. A first point to note is that research on children with DLD suggests that stigmatization is often a reaction to the child's communication difficulties (Macharey and von Suchodoletz 2008). And experience with other conditions suggests that labels can actually help reduce stigma by improving understanding. In the field of autism, for instance, a recent study found that university students were more accepting of socially atypical behaviour when they were told that the person had a clinical diagnosis (of Asperger syndrome, autism spectrum disorder (ASD) or schizophrenia) (Brosnan and Mills 2016). One study found that while a general label of 'special educational needs' was associated with low self-esteem, a more specific label (in the case of this study, 'dyslexia') was not (Taylor et al. 2010). In the field of mental health, there is some evidence that self-identifying with a stigmatized group can buffer the individual against some of the negative effects (Crabtree et al. 2010). Such research suggests that in raising awareness of terminology, we should aim to provide information in a way that will lead to better acceptance and willingness of others to make adjustments to take into account language limitations, and to facilitate individuals with DLD coming together for mutual support. Second, we need to communicate diagnosis to affected individuals and their families in a way that emphasizes that DLD does not preclude achieving well in non-linguistic domains and being a well-integrated member of society. We need to celebrate the achievements of those who have succeeded despite their language difficulties. It is worth noting that I have searched the internet for examples of positive role models of people with DLD and not been able to find any-in sharp contrast to dyslexia and ASD, where such role models are numerous.

Use of the term 'disorder'

Most of the panel welcomed the move towards a single agreed term to refer to children with persistent language problems, but there was much debate about the use of the term 'disorder'. As discussed by Bishop ( 2014), in the field of education other terms such as 'difficulties' and 'needs' have been used. Other options are 'impairment' and 'disability'. These are sometimes used interchangeably, and sometimes with subtly different meanings. 'Disorder' was preferred by the CATALISE panel for two reasons. First, it is the term used in DSM5 and ICD-11, both for language problems and for other neurodevelopmental conditions, especially ASD, attention deficit disorder, and developmental coordination disorder. It was deemed counterproductive to use terminology that was at odds with those widely used systems. Second, as one panel member said:

I feel it communicates the seriousness of the issue more effectively than 'impairment'.

A handful of panel members felt 'disorder' did not go far enough, and that a more medical-sounding label would be more effective:

We need a label with some authority. Once again, I really do have to go back to the suggestion of dysphasia, on analogy with dyslexia and dyspraxia. Terms like this have the advantage of sounding like real conditions (which is why parents will fight so hard for a 'diagnosis' of dyslexia). People sit up and take notice of it.

However, among commentators in the special issue, the label 'dysphasia' had been one of the most unpopular options. This illustrates a dilemma for the field: the labels that sound most 'medical' are seen as misleading by professionals, yet they are the terms that are most likely to attract sympathy and attention. The parallel with dyslexia is very moot here: although dyslexia is not a coherent syndrome (Elliott and Grigorenko 2014), moves to drop the term from DSM5 were strongly resisted, with the International Dyslexia Association mounting a petition for its reinstatement, citing concerns that diagnosis and intervention would be delayed if the more generic and neutral term 'specific learning disorder' were used instead (International Dyslexia Association 2012).

At the other extreme, there were concerns again about reification of the term DLD, and stigmatization and negative connotations.

The use of 'disorder' will be perceived as denoting a state of being essentially, categorically, different and distinct from those on the 'normal' distribution.

Although I agree with the term and the explanation given, the use of the word 'disorder' has very negative connotations for teachers and those within educational policy. ... There is no useful term that gets around this issue, however.

The different viewpoints illustrated by these quotes emphasize the difficulty of finding an ideal solution. If we use a term that reflects the fact that children have serious problems and need support, this comes across as negative and could create a self-fulfilling prophecy; however, if we use milder language that is not deemed stigmatizing, then we run the risk that children's problems may be trivialized, with consequent delays in identification and intervention.

Traditional distinction between 'disorder' and 'delay'

A quite different objection to the term DLD is that, at least in the UK and some parts of the Irish Republic, 'disorder' has been interpreted contrastively as a condition different from 'language delay'. Indeed, we learned that many speech-language therapists (SLTs) in the UK had been trained to make this distinction. It embodies the idea that there is a particular profile of language difficulties, where there is a large mismatch between non-verbal ability and language skills, and also an uneven profile of ability within the language domain. This profile is seen as the hallmark of 'disorder', whereas 'delay' is thought to be characterized by an even pattern of impairment, so that both verbal and non-verbal skills are like that of a younger child. This distinction has assumed considerable importance in some regions, where SLT services are allocated only to children with 'disorder', and not to those with 'delay'-presumably because 'delay' is interpreted literally as indicating that the child will catch up after a slow start.

It is hard to trace the origins of this distinction, but it is clear that, despite its superficial plausibility, it does not have empirical support. Thirty years ago, Bishop and Edmundson ( 1987) used longitudinal data to test the idea that an even pattern of language impairment had a better prognosis than a more 'spikey' profile, with selective weakness in some domains. Their results were opposite to prediction: those with more selective problems had the best outcomes, whereas those with more general across-the-board impairments had the worse prognosis. Thus, providers who restrict SLT services from those who have 'delayed' profiles are denying help to those children who are most in need. Nor is there any evidence that speech-language therapy is only effective for children with a large mismatch between language and non-verbal skills (Cole et al. 1990), which is why the American Speech-Language-Hearing Association does not support 'cognitive referencing', i.e., using the discrepancy between non-verbal IQ and language as a basis for allocating services (American Speech-Language-Hearing Association 2016). Given the widespread use of the delay/disorder distinction, it is vital that those using DLD are clear that, as used by the CATALISE panel, the term 'disorder' does not entail any discrepancies, either between verbal and non-verbal development, or between different language functions.

Criteria for language disorder: focus on poor prognosis

The definition of DLD agreed by the panel applies specifically to children with poor prognosis. This averted a concern that children with mild and transient difficulties might be labelled as 'disordered'. However, a focus on poor prognosis does raise concerns that children might be written off, or that parents will be discouraged if they are told that their child's problems are unlikely to resolve with time. Most panel members agreed that this criterion made sense, and indeed could lead to fairer allocation of resources, but it is clear that it needs to be applied cautiously:

I think the focus on prognosis is important. It also makes clear that the children who require intervention are the children with a poor prognosis. Currently in many areas of the UK children with poor prognosis are not receiving services because they clog up the system and can't be discharged easily! The focus on the tier 3 children who won't make progress without help may help to counter this shift in service delivery. 2

There were, however, two concerns: first, did we know enough about prognostic factors to be able to judge this appropriately?; and second, would this mean denying services to children who would benefit from intervention?

we need to look further into the research and agree more solid indicators of long-term language learning difficulties.

There was variable awareness among CATALISE members of existing research on predictors of outcome. Our panel included several experts who had been involved in running longitudinal studies and were in general supportive of using prognosis as a criterion, but others had concerns about the feasibility of identifying children who were likely to have longstanding problems. Between these extremes were those who thought that even if we have good predictors from research, they may apply only to the specific population that was studied, and prediction may also not be precise enough to make accurate judgements about individual children. Over and above this concern, was the question of whether children with good prognosis should be excluded from specialist help.

I think it is important not to exclude children who may have, for example, very poor expressive language, which is causing them considerable difficulties, but might respond very well to specialist input. ... Even if they do catch up reasonably quickly in relative terms, the children might still have lost ground and had a miserable couple of years, which might itself have long lasting effects.

This latter point emphasized that the criteria adopted could change the balance of which children would gain access to resources. Throughout the process, comments were made which indicated how seriously panel members took this: many thought that current allocation of SLT services was not fair, but others worried that a move to a different set of criteria might leave children who might benefit from SLT intervention without any help. The impression was that, for those with clinical caseloads, views were strongly influenced by personal experience: it was clear that most panel members were concerned that large numbers of children were unfairly excluded from access to services, but while some maintained that those with the most severe problems were denied help, others took the opposite view and noted that it was children with milder and more selective language difficulties who risked being excluded from intervention.

This debate emphasized the lack of a good evidence base for making rational decisions in this area. Of course, we do not want to expend scarce resources on children who will either improve without help, or who are unlikely to benefit from intervention. But in the absence of a strong evidence base, it seemed that subjective impressions were often used to distinguish these groups. One point where the evidence was clear concerned the difficulty of predicting outcomes in late-talking toddlers: a diagnosis of DLD would be difficult to justify in a child under 3 years of age unless there were notable comprehension difficulties. In cases where the prognosis is hard to judge, which would include many pre-school children, the more generic term 'speech, language and communication needs' (SLCN), already in widespread use in the UK, would seem more appropriate for flagging up problems than the more clinical diagnosis of DLD.

As reviewed by Bishop et al. ( 2017), we do have better prognostic indicators for children from around 5 years of age when it becomes reasonable to identify children whose problems are unlikely to resolve without help. Nevertheless, it is frustrating that even when we have evidence from longitudinal studies, the clinical application of the findings is often limited because of an emphasis on demonstrating that a predictor is statistically significant, rather than on its effectiveness in predicting individual outcomes.

Also, there can be difficult decisions even when evidence is available: should resources go to those who can easily be treated effectively, or to those with the most severe functional impairments? These are unlikely to be the same children.

In addition, this raises the question of what the goals of intervention should be. It might seem obvious that a successful intervention is one that improves the child's language skills so that they are at the level of the peer group. Yet for some children, more modest goals-of providing strategies to cope with language difficulties, and modifying the environment to make the language impairments less detrimental-may be more realistic. If evaluation studies focus solely on language tests as outcome measures, then this may underestimate the benefits of intervention. To get a more realistic impression of outcomes, measures of quality of life, family functioning, social integration and self-esteem should be included.

Overall, it became clear that a discussion that was on the surface about diagnostic criteria was heavily influenced by beliefs about which groups should be given priority when intervention resources were scarce.

Criteria for language disorder: How objective and standardized should we be?

Further tensions were revealed between those who felt it was important to use objective measures with strong psychometric credentials and to avoid reliance on subjective judgements, and those who thought that formal language assessments failed to capture key features of children's language problems and might both over- and under-diagnose problems.

The first quotation illustrates the former concern, the second the latter:

I have concerns about relying on parents/teacher identification. Parents may not have enough information about typical language development and/or may miss comprehension difficulties. Also, there are equity issues. Children whose caregivers are least able to identify language issues may be children particularly in need of support.

I agree that testing is important, however I feel that in order to establish severity, functional assessment (informal observation for example) must be included as well as standardized testing.

Concerns were also expressed about poor sensitivity and specificity of standardized language assessment batteries, and their inability to detect some important aspects of impairment, such as pragmatic difficulties:

single tests measuring single components of the language system often do not possess the most robust psychometric properties.

we need to discuss the tools that are used to identify these problems as they have many flaws and it is likely that a multiple of assessment types, different for each age and skill level will be needed.

The consensus of the CATALISE panel was that test scores provided useful information but should not be used as the sole criterion for identifying language disorder. It was key that there should be evidence of functional impairment, i.e., the language problem impacted on the child's social interaction and/or educational progress. Nevertheless, it was noted that we lack good assessments for many aspects of language, and that reliance on subjective judgements created scope for biased and inequitable decisions.

Differentiating conditions rather than exclusionary criteria

Exclusionary criteria have traditionally been a key part of the diagnosis of SLI, but this part of the definition has been roundly criticized, notably by Reilly et al. ( 2014b). The CATALISE panel had many deliberations over whether we should differentiate between children whose language difficulties had no obvious cause and those whose difficulties occurred in the context of a specific aetiology, such as brain damage, hearing loss or a genetic syndrome. We concluded that where there is a differentiating condition 'X', the term 'language disorder with X' would be used rather than DLD. This distinction is important in many research contexts, where it may be desirable to focus on a relatively homogeneous group.

The discussion revealed several different factors that led to tension. Implicit in the debate are three issues. First, can we regard a co-existing condition as the cause of the language disorder? Second, does the presence of a specific aetiology mean that no intervention should be offered for language disorder? Third, if intervention is offered, should it be of a different kind than for children with no obvious aetiology? In addition, the answers to all these questions will depend on exactly what we regard as a co-existing condition.

The first issue may be illustrated with the case of hearing loss. A severe or profound congenital hearing loss is a major risk factor for poor development of oral language. However, if the child has exposure to signed language, good language skills are usually demonstrated. Similarly, many children can make good progress in oral language if given a cochlear implant. Nevertheless, there are hearing-impaired children who have problems learning sign language, and others who have disproportionate difficulties with oral language acquisition after a cochlear implant (Hawker et al. 2008). And this should not surprise us: we should expect to see a proportion of children with hearing loss who also have genetic risk factors for language disorder. While this example illustrates the dangers of explaining away a child's language disorder in terms of an associated condition, it is not an argument for simply ignoring the associated condition when identifying language disorder. It is rather an argument for documenting carefully the range as well as the nature of language problems associated with a specific aetiology.

The discussion about causality was pervaded by concerns that if a child's language disorder was thought to be 'explained' by an associated condition, then no intervention would be offered. Although this has sometimes been used as a justification for denying services to children, it is not a logically coherent stance. If extended to medicine as a whole, it would mean that we would only offer treatment for conditions of unknown aetiology! The panel agreed that it is not appropriate to deny intervention to a child because they has a co-existing condition, provided the child meets criteria for language disorder (in terms of severity and prognosis).

[The term 'language disorder associated with X'] is a great idea not only because it explicitly describes the association, but also because it sends the important message that problems in one area do not 'protect' children from having other difficulties. Parents of children with associated difficulties (e.g. Down syndrome) are sometimes frustrated by the lack of recognition of their child having a language disorder on top of the language difficulties associated with Down syndrome. And of course there is the important work on ASD with and without language disorder.

On the third issue, many felt that a different approach to intervention might be required if the child's language problems occurred in the context of a known aetiology. To continue with the example of hearing loss, intervention might include giving the child a hearing aid or cochlear implant, and/or introducing sign language, or having an SLT focus on presenting information via the visual modality. It was noted that there were many disorders where it helped to make this distinction:

I do agree that there are children who have disordered language for various reasons who would not best fit into the traditional 'SLI' care pathways.

There was, however, a contrasting view that children with differentiating conditions might not be offered interventions which could be useful-just because it was assumed they would not work:

some children with ASD appear to have a primary grammatical language impairment which would not be typical of ASD, yet they are not offered the same intervention that other children showing these patterns of language learning would be offered.

it is important to note that they may NOT indicate a different treatment pathway. For example, milieu communication training has been shown to efficacious for children with language disorders associated both with ID and ASD.

I think our intervention research has been mostly directed to fairly narrowly defined categories, with some exceptions. So the presumed different intervention pathways might turn out to have more in common than we think-for example, similar approaches might affect significant change in the morpho-syntactic difficulties of a child with Down syndrome and morpho-syntactic difficulties in SLI.

The discussions of these issues made it clear that, once again, one reason for disagreements was lack of a good evidence base: very little was known about efficacy of language interventions for children with co-existing biomedical conditions. The need for more research explicitly comparing different conditions was highlighted by our study. The best way to counteract concerns that budget-holders would deny services to children with additional conditions would be to provide evidence that intervention is effective with these groups.

These arguments, together with the need for researchers to study relatively homogeneous groups, led to general agreement that we should distinguish between language disorder associated with a 'differentiating condition' and DLD, while recommending that in both cases the language disorder merited assessment and intervention.

The question, then, was what to include in 'differentiating conditions'. We settled on a definition that included biomedical conditions such as a genetic syndrome, a sensorineural hearing loss or neurological disease. The conditions of ASD and intellectual disability led to some debate, but it was decided to include these as differentiating conditions, because, on the one hand, impairments of communication are a reliable feature of these conditions and, on the other, accelerating genetic advances mean that a biomedical aetiology is becoming evident for a high proportion of affected children (McRae et al. 2017). In practice, a differentiating condition would typically be the main diagnosis, with language disorder seen as a component of the condition.

DLD in relation to other neurodevelopmental disorders

The notion of 'differentiating condition' does not encompass milder neurodevelopmental disorders of unknown origin, such as ADHD or developmental coordination disorder. These do not have a clear-cut aetiology, and their association with language disorder is weaker than for the differentiating conditions noted above. One reason for rejecting the previous term 'SLI' was because 'specific' could be taken to imply that the child had no difficulties except with language. In contrast, our definition of DLD emphasizes that these idiopathic neurodevelopmental disorders can co-occur with DLD. Because different professional groups are concerned with different conditions-educators with dyslexia, SLTs with DLD, paediatricians and psychiatrists with ADHD and ASD-children often receive a rather one-sided assessment, depending on the professional they see. We emphasized that the fact that a child may have ADHD or dyslexia does not preclude a diagnosis of DLD and does not mean that the SLT should not be involved. The ways in which children's problems manifest does not neatly divide up according to professional specialities.

This view of overlap between neurodevelopmental disorders is supported by research on aetiology, which has shown that the causes of these conditions are often complex and multifactorial, resulting from the combined impact of many small genetic and environmental influences: the precise profile of problems that is seen in a child may depend on the particular constellation of aetiological factors, so we do not see sharp boundaries between conditions, but rather different permutations and combinations of impairments. Furthermore, although different disorders co-occur at above chance levels, they can be dissociated, suggesting that they may be separate consequences of common risk factors.

Comments from panel members made it clear that the question of how to handle co-occurring disorders was easier if one avoided attempting to specify causal relationships, e.g., if a child has both attentional problems and language problems, it is useful to be aware of this, but it may be impossible to disentangle whether attentional problems cause language problems or vice versa:

co-occurring disorders could be defined as impairments in other cognitive or behavioural domains that can co-occur with language disorder and may affect prognosis, but which do not include impairments of communication as core symptoms. I would avoid discussion of cause.

The role of non-verbal IQ in diagnosis

As discussed by Bishop ( 2014) and Reilly et al. (2014), traditionally, the diagnosis of SLI has required a non-verbal IQ within normal limits. In some diagnostic systems, an even more stringent requirement of a large mismatch between verbal and non-verbal ability is required. The CATALISE panel considered the evidence for this and concluded this criterion was not valid. Many panel members were supportive of dropping it.

I agree in so far as I do not want any discrimination on the basis of (non-verbal or any other concept of cognitive) ability.

This is an important equity issue.

Again, the argument was that the focus should be on the child's language needs, rather than on putative aetiology. Others, however, noted this would be a major departure from current practice and expressed reservations about expanding the category of DLD, thereby placing pressure on services. Concern was expressed that a less restrictive definition of language disorder could lead to a watering down of the concept that would ultimately lead to a reduction in services:

If we lose the conceptualisation of language impairment as being a weakness in language skills relative to the child's average non-verbal ability, then service providers might take the view that if there is no distinction between children of low ability across the board (who do not usually access a high level of therapy) and children with (specific) language difficulties, then it is not necessary to provide enhanced levels of SLT to any of them.

There also was evidence of local differences in how intervention resources were allocated. As noted above, practitioners from the UK and Republic of Ireland noted that a selective language problem (with normal non-verbal ability) was usually required in order for the child to be offered SLT services, but in other places quite the opposite was described, and there was concern that children with more selective problems might lose out:

I regularly encounter situations where services have been denied to families because their children only presented with language impairments. The risk of under-treatment in these cases is also what our epidemiological data have been telling us.

Overall, the view of the panel was that resources should not dictate diagnostic criteria. Discrepancy between verbal and non-verbal ability is not indicative of underlying aetiology-for example, Bishop ( 1994) found that identical twins with language problems often had very similar language profiles, yet could vary in non-verbal ability, with one meeting traditional discrepancy criteria for SLI, and the other not. Furthermore, for a child without a biomedical syndrome, the level of non-verbal IQ does not appear to determine responsiveness to therapy. There does not, therefore, appear to be any justification for using a verbal-non-verbal discrepancy as a diagnostic criterion; the overall view of the panel was that if this change led to more children being identified with DLD, then the case should be made for adequate resources to offer services to all of them.

Note that this does not mean that intellectual level is totally disregarded. As noted above, where the child meets criteria for intellectual disability, then we would treat that as the primary diagnosis and talk of 'language disorder with intellectual disability'. The current DSM-5 definition of intellectual disability requires that the child shows both 'intellectual deficits and adaptive deficits that fail to meet the standards for personal independence' (Harris 2013, 261).

Our definition of DLD would, however, include a case where a child with language problems has a level of non-verbal ability that is neither impaired enough to justify a diagnosis of intellectual disability nor good enough to be discrepant with overall language level. These children have historically 'fallen through the cracks' of diagnostic systems, and hence been deemed ineligible for speech and language therapy services.

Conclusions

Many of the issues raised by this analysis apply not just to language disorders but to neurodevelopmental disorders more broadly. Indeed, questions about diagnosis and terminology pervade all of psychiatry (Sonuga-Barke 1998).

As we proceeded through the Delphi studies, we were confronted by a key question: How would we know when we had a good solution? In practice, in a Delphi exercise the goal is to achieve a reasonable agreement between experts, and we were satisfied to accept a solution where we had a set of statements that at least 75% agreed with. But, as is all too apparent in many walks of life, the fact that a lot of people agree with something does not make it true. Ideally we would like to be able to show that our solution worked better than what had gone before. But what does 'work better' mean?

The ideal would be to find a solution that 'carves nature at its joints', such that DLD would identify a group of children with a distinct aetiology, correlated features and response to intervention. However, as Sonuga-Barke noted, this may be an unrealistic ambition if the reality is more dimensional than categorical. In the case of DLD, we have heterogeneity of language problems, and overlap between disorders affecting language and other domains. Despite this heterogeneity we have made some progress: our knowledge of aetiology, characteristics and effective intervention in this area has advanced over the years. Nevertheless, to improve our classification we need more research that carefully documents the nature of children's language difficulties in relation to prognosis, associated factors and response to intervention. The validity of the term 'DLD' will depend on whether it helps us move forward to a better understanding of what is clearly a heterogeneous category, bearing in mind that, as Sonuga-Barke noted, the category is a hypothesis to be tested and refined. Meanwhile, it is to be hoped that a clearer specification of DLD and agreement about use of this term will lead to a more equitable and effective allocation of services to children who experience severe and persistent language problems.

Notes

1. 1
In CATALISE, we restricted the panel to participants from English-speaking countries; it is clearly important to extend to other languages, but we were aware that the debate would be complex enough without having to take onboard further linguistic and cultural differences that might affect how language disorders manifest and are treated.

2. 2
In a Response to Intervention framework, three tiers of intervention/prevention are identified, with tier 3 referring to the level of individualized intervention needed for children with the most severe problems.

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References

American Speech-Language-Hearing Association, 2016, Eligibility and dismissal in schools [online] (available at: http://www.asha.org/slp/schools/prof-consult/eligibility0 (accessed on 29 May 2017).

Bishop, D. V. M., 2010, Which neurodevelopmental disorders get researched and why?. PLOS One, 5, e15112.

Bishop, D. V. M., Clark, B., Conti-Ramsden, G., Norbury, C. F. and Snowling, M. J., 2012, RALLI: An internet campaign for raising awareness of language learning impairments. Child Language Teaching & Therapy, 28, 259-262.

Bishop, D. V. M. and Edmundson, A., 1987, Language-impaired four-year-olds: distinguishing transient from persistent impairment. Journal of Speech and Hearing Disorders, 52, 156-173.

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T. and The Catalise Consortium , 2016, CATALISE: a multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLOS One, 11, e0158753.

Brosnan, M. and Mills, E., 2016, The effect of diagnostic labels on the affective responses of college students towards peers with 'Asperger's Syndrome' and 'Autism Spectrum Disorder'. Autism, 20, 388-394.

Crabtree, J. W., Haslam, S. A., Postmes, T. and Haslam, C., 2010, Mental health support groups, stigma, and self-esteem: positive and negative implications of group identification. Journal of Social Issues, 66, 553-569.

Elliott, J. G. and Grigorenko, E. L., 2014, The Dyslexia Debate (Cambridge: Cambridge University Press).

Hawker, K., Ramirez-Inscoe, J., Bishop, D. V. M., Twomey, T., O'Donoghue, G. M. and Moore, D. R., 2008, Disproportionate language impairment in children using cochlear implants. Ear and Hearing, 29, 467-471.

International Dyslexia Association, 2012, International Dyslexia Association requests reinstatement of the term 'dyslexia' in American Psychiatric Association's DSM-5 [online] (available at: http://www.prnewswire.com/news-releases/international-dyslexia-association-requests-reinstatement-of-the-term-dyslexia-in-american-psychiatric-associations-dsm-5-157488625.html) (accessed on 29 May 2017).

Macharey, G. and Von Suchodoletz, W., 2008, Perceived stigmatization of children with speech-language impairment and their parents. Folia Phoniatrica et Logopaedica, 60, 256-263.

Mcrae, J. F., Clayton, S., Fitzgerald, T. W., Kaplanis, J., Prigmore, E., Rajan, D. et al., 2017, Prevalence and architecture of de novo mutations in developmental disorders. Nature, 542, 433.

Reilly, S., Tomblin, B., Law, J., Mckean, C., Mensah, F., Morgan, A., Goldfeld, S., Nicholson, J. and Wake, M., 2014b, SLI: a convenient label for whom? International Journal of Language and Communication Disorders, 49, 416-451.

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Dorothy V. M. Bishop

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University of Oxford, Oxford, UK

Address correspondence to: Dorothy Bishop, University of Oxford, Tinbergen Building, South Parks Road, Oxford OX1 3UD, UK; e-mail: dorothy.bishop@psy.ox.ac.uk

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Abstract

A recent project entitled CATALISE used the Delphi method to reach a consensus on terminology for unexplained language problems in children. 'Developmental language disorder' (DLD) was the term agreed by a panel of 57 experts. Here I reflect on points of difficulty that arose when attempting to reach a consensus, using qualitative information from comments made by panel members to illustrate the kinds of argument used. One issue of debate was the use of labels, in particular the term 'disorder', which was seen as having both pros and cons. The potential for labels to stigmatize or create low expectations was a particular concern. However, labels could also ensure language problems were not trivialized and could help avoid stigma by providing an explanation for behaviours that might otherwise meet with disapproval. Further debate surrounded issues of how best to identify cases of disorder. Although it was agreed there should be a focus on cases with a poor prognosis, it was recognized that our knowledge of factors related to prognosis was still incomplete. Furthermore, there was a tension between use of standardized tests, which allow for a relatively objective and reliable assessment of language, and more qualitative observations, which can capture functional aspects of communication that are not always picked up on formal assessment. Debate also surrounded the issue of the relationship between DLD and other conditions. Some favoured drawing a distinction between DLD and language disorders associated with other conditions, and others regarded such distinctions as unnecessary. We concluded that it was misleading to assume co-occurring conditions were causes of language disorder, but it was helpful to distinguish DLD from cases of language disorder associated with 'differentiating conditions' that had a known or likely biomedical origin, including brain injury, sensorineural hearing loss, genetic syndromes, intellectual disability and autism spectrum disorder. Furthermore, DLD could co-occur with milder neurodevelopmental disorders that did not have a clear biomedical aetiology. Normal-range non-verbal IQ has traditionally been incorporated in the diagnosis of DLD, but this was rejected as unsupported by evidence. DLD is a category that has utility in identifying children who would benefit from speech-language therapy services, but it should not be thought of as a well-defined condition. DLD has a multifactorial aetiology, is heterogeneous in terms of language features and overlaps with other neurodevelopmental disorders. Our notions of DLD are likely to be refined by further research into aetiology, associated characteristics and intervention effectiveness.

What this paper adds

What is already known on the subject

Children's language disorders have received far less recognition than other neurodevelopmental conditions such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder and developmental dyslexia. In part this is a result of inconsistent terminology and definitions of language disorder. As a consequence, there is disagreement as to which children should receive intervention.

What this paper adds to existing knowledge

In 2016-17, two linked projects were carried out using the Delphi method to work towards a consensus in the criteria and terminology used for children's language disorders. In this paper I use qualitative comments from the evaluation panel to explore the reasons for debate in this area. Although some disagreements reflect an inadequate research base, other issues involve fundamental questions about the impact and validity of diagnostic labels, and the criteria for deciding who receives intervention.

What are the potential or actual clinical implications of this work?

Clinicians who wish to adopt the new terminology from the CATALISE study may find these reflections helpful in clarifying the clinical and theoretical reasons behind the consensus statements. The paper also emphasizes that the category of 'developmental language disorder' (DLD) is a useful shorthand rather than a specific syndrome-a hypothesis to be refined in the light of new discoveries.

In 2015-16, an international group of experts, the CATALISE panel, came together with the aim of achieving consensus on diagnostic terminology for children's language disorders. Ebbels ( 2014) documented the history of this development, with the need for consensus being emphasized by several converging forces. First, there was mounting evidence that children's language disorders received scant research funding in relation to their frequency and severity (Bishop 2010). Then in 2012, a live debate entitled 'What IS Specific Language Impairment' took place at Moor House School, a specialist school for children and young people with speech and language difficulties. This failed to reach agreement about how to diagnose or define specific language impairment (SLI). In addition, a group that had started a campaign for Raising Awareness of Language Learning Impairments (RALLI) (Bishop et al. 2012) was confronted with the difficulty of raising awareness of a condition that was ill-defined, and where terminology was inconsistent. In 2013, Sheena Reilly, in the IJLCD Winter Lecture raised numerous questions about the usefulness and validity of the term 'SLI', using data from an Australian epidemiological study to argue that the 'specific' part of the label was counterproductive and misleading-views that were subsequently articulated in this journal (Reilly et al. 2014b). To complement that paper, I wrote a review outlining the major issues where consensus was lacking, and suggesting various solutions (Bishop 2014). Both papers appeared in a special issue of this journal (Ebbels 2014), accompanied by commentaries from experts covering a range of professional groups and interests. The authors of the original focus papers then collaborated to highlight the main points of agreement and disagreement in the debate (Reilly et al. 2014a).

Starting in 2015, a two-stage project, CATALISE (Criteria and Terminology Applied to Language Impairments: Synthesising the Evidence), was developed with the aim of yielding consensus statements about children's language disorders (Bishop et al. 2016, 2017). The method adopted was the Delphi Survey Technique (Hasson et al. 2000). This involves working with a panel of experts who are provided with a set of statements that they both rate and comment on. Panel members were encouraged to cite research evidence to justify their viewpoints. The process is iterative, with a new set of statements being formulated on the basis of the previous round. This exercise, when conducted online, has several advantages over in-person discussion. For a start, panel members have time to think about the issues and to complete their ratings at a time that is convenient. This makes it possible for people to take part from all over the world. 1 Furthermore, each person's ratings and comments are fed back anonymously to the whole panel. Anonymity avoids the discussion being dominated or derailed by a few forceful individuals. If the feedback indicates that one's point of view is unpopular, it is possible to present arguments and evidence to try to persuade others, or to revise one's ratings. Two moderators (Dorothy Bishop and Maggie Snowling), who were not part of the panel, integrated the information from each round, using the comments accompanying the ratings to identify the reasons for disagreement and to revise statements to address these. The first Delphi exercise focused on criteria and the second on terminology.

One outcome of this exercise was the recommendation that the term 'specific language impairment' (SLI) be abandoned in favour of 'developmental language disorder' (DLD). Rather than recapitulating the conclusions of the two Delphi exercises, which are covered in depth in two papers (Bishop et al. 2016, 2017), my aim here is to use the comments offered by panel members during these projects to reflect on the factors leading to change and in particular to note reasons for controversy in this area.

However, it is worth first emphasizing issues on which there was good agreement from the outset. All panel members recognized that some children have difficulties mastering their native language, and that these can be severe enough to impair their ability to function well in educational and social contexts. In many cases there is no obvious cause. A second point was that it was important to reach agreement, because lack of consensus had been damaging to the field, and did a disservice to affected children and their families.

It was also agreed that language disorders in children can take many forms. The classic 'textbook' case is of a child whose language level is well below that of their peers-for instance, a 4-year-old who talks more like a typical 2-year-old, with simplified grammar and limited vocabulary. Where the problems are as striking as this, language difficulties are not hard to recognize, but what of the child who has more subtle problems, or where the difficulties involve the use rather than the form of language? A core notion is that language is out of keeping with the child's general developmental level, but any attempt to turn this idea into more specific criteria is fraught with difficulties, not least because language is a complex, multidimensional skill, which changes rapidly with age.

We had expected that where there were disagreements about definitions and terminology these might divide along professional or national lines, but, as far as our analysis could establish, this was not the case. Rather, it seemed that where differences of opinion existed, it was because of lack of evidence, or else because all solutions that were discussed had disadvantages as well as advantages. In effect, there was no gold standard against which to evaluate terminology, and no ideal solution. This creates an unstable situation because whatever solution is adopted, problems will be noted, and there will therefore be pressure for further change.

It may seem counterproductive to highlight points of disagreement concerning the consensus statements that we arrived at. If we want people to endorse the new terminology, would it not be better to draw a veil over the more contentious aspects? In my opinion, this would reduce the credibility of the exercise by suggesting difficult issues were not grappled with. Furthermore, only by being aware of both pros and cons can we mitigate any negative consequences of new criteria and terminology, while promoting the benefits.

Why do we need categorical labels?

Before we address the question of which labels to use, a more primary question is whether it makes sense to use labels at all. Most panel members took the need for an agreed label as a given:

I think this is one of the reasons that children's language difficulties are not taken as seriously or recognized in the same way as other conditions such as dyslexia or ASD [autism spectrum disorder]. There are too many different terms, that are being used in too many different ways, so people are just not really paying attention any more.

This is important across the board-for epidemiological purposes, for clarity in individual research studies, and for policy makers and service providers.

Given the lack of awareness of language disorder in both professional and public fields, it is really important that we as professionals with knowledge of this area can reach a consensus on the terminology so that we can move forward with providing services and recognition for these children and their families.

However, labels influence how we think about constructs, with words dividing the world into distinct entities such as cats, dogs, desks and tables. Yet, in practice, some of these entities are not clearly demarcated: the boundary between desk and table, for instance, is not sharp. Diagnostic terms can create an insidious problem whereby the label is taken to mean that the child has a clear-cut disorder with distinctive 'symptoms', which can be distinguished from both typical development and other developmental disorders. In fact, there is no support for a sharp dividing line between language disorder and normality. Children develop language at different rates, and some will have problems severe enough to cause lifelong problems. But the differences between children appear to be quantitative rather than qualitative, and can take many different forms (Leonard 1991, Dollaghan 2011). Much research literature has focused on limitations of expressive syntax in children with DLD, but as our assessments become more fine-grained, it is evident that problems often affect understanding as well as production of complex language, and can involve phonology, semantics and pragmatics as well as grammatical structure.

It is all too easy for a label to become a master rather than a servant, if we over-interpret its significance, rather than regarding it as a useful shorthand. It is therefore important that if we use labels, we do so with full awareness of their limitations, and recognizing that our terms are socially constructed and historically specific. The term we agreed on, 'DLD', is defined in terms of behaviours that are complex, multifactorial and which vary on a continuum. It is an umbrella term that includes a wide range of problems, and the boundaries between DLD and typical development are fuzzy. One panel member noted that in the field of educational psychology some people were turning away from the label 'developmental dyslexia' for children with reading problems precisely because of arguments such as these (Elliott and Grigorenko 2014).

Another panel member noted a further problem caused by labels: their potential to stigmatize children:

I am increasingly concerned that the exercise risks generating labels/categories for children that will be operationalized to allocate resources and will discriminate against positive expectations for more than is scientifically justified.

Given these risks of misinterpretation, we need to consider whether we could do away with labels altogether. It was concluded, however, that this would create more problems than it solved. As I have discussed previously (Bishop 2014), diagnostic labels have utility in clinical as well as research contexts. Labels allow us to communicate efficiently in a common language: without labels, it would be difficult to plan services and to decide how to allocate them. This issue is not specific to DLD: it pervades all of psychiatry, including child psychiatry. As Sonuga-Barke ( 1998: 117) noted, categorization is a practical necessity in clinical practice:

To the extent that clinical economy depends on getting the right treatment to the right people, clinicians are, no matter what their philosophical bent or political point of view, categorisers. At a purely practical level this depends on a judgement being made that such and such a child belongs to the category of those who 'need help', whereas another child belongs to a (usually) larger category who do not.

Nonetheless, at the same time as we strive to get better resources to help those with DLD overcome their problems, we need to consider how best to create conditions to combat stigma. A first point to note is that research on children with DLD suggests that stigmatization is often a reaction to the child's communication difficulties (Macharey and von Suchodoletz 2008). And experience with other conditions suggests that labels can actually help reduce stigma by improving understanding. In the field of autism, for instance, a recent study found that university students were more accepting of socially atypical behaviour when they were told that the person had a clinical diagnosis (of Asperger syndrome, autism spectrum disorder (ASD) or schizophrenia) (Brosnan and Mills 2016). One study found that while a general label of 'special educational needs' was associated with low self-esteem, a more specific label (in the case of this study, 'dyslexia') was not (Taylor et al. 2010). In the field of mental health, there is some evidence that self-identifying with a stigmatized group can buffer the individual against some of the negative effects (Crabtree et al. 2010). Such research suggests that in raising awareness of terminology, we should aim to provide information in a way that will lead to better acceptance and willingness of others to make adjustments to take into account language limitations, and to facilitate individuals with DLD coming together for mutual support. Second, we need to communicate diagnosis to affected individuals and their families in a way that emphasizes that DLD does not preclude achieving well in non-linguistic domains and being a well-integrated member of society. We need to celebrate the achievements of those who have succeeded despite their language difficulties. It is worth noting that I have searched the internet for examples of positive role models of people with DLD and not been able to find any-in sharp contrast to dyslexia and ASD, where such role models are numerous.

Use of the term 'disorder'

Most of the panel welcomed the move towards a single agreed term to refer to children with persistent language problems, but there was much debate about the use of the term 'disorder'. As discussed by Bishop ( 2014), in the field of education other terms such as 'difficulties' and 'needs' have been used. Other options are 'impairment' and 'disability'. These are sometimes used interchangeably, and sometimes with subtly different meanings. 'Disorder' was preferred by the CATALISE panel for two reasons. First, it is the term used in DSM5 and ICD-11, both for language problems and for other neurodevelopmental conditions, especially ASD, attention deficit disorder, and developmental coordination disorder. It was deemed counterproductive to use terminology that was at odds with those widely used systems. Second, as one panel member said:

I feel it communicates the seriousness of the issue more effectively than 'impairment'.

A handful of panel members felt 'disorder' did not go far enough, and that a more medical-sounding label would be more effective:

We need a label with some authority. Once again, I really do have to go back to the suggestion of dysphasia, on analogy with dyslexia and dyspraxia. Terms like this have the advantage of sounding like real conditions (which is why parents will fight so hard for a 'diagnosis' of dyslexia). People sit up and take notice of it.

However, among commentators in the special issue, the label 'dysphasia' had been one of the most unpopular options. This illustrates a dilemma for the field: the labels that sound most 'medical' are seen as misleading by professionals, yet they are the terms that are most likely to attract sympathy and attention. The parallel with dyslexia is very moot here: although dyslexia is not a coherent syndrome (Elliott and Grigorenko 2014), moves to drop the term from DSM5 were strongly resisted, with the International Dyslexia Association mounting a petition for its reinstatement, citing concerns that diagnosis and intervention would be delayed if the more generic and neutral term 'specific learning disorder' were used instead (International Dyslexia Association 2012).

At the other extreme, there were concerns again about reification of the term DLD, and stigmatization and negative connotations.

The use of 'disorder' will be perceived as denoting a state of being essentially, categorically, different and distinct from those on the 'normal' distribution.

Although I agree with the term and the explanation given, the use of the word 'disorder' has very negative connotations for teachers and those within educational policy. ... There is no useful term that gets around this issue, however.

The different viewpoints illustrated by these quotes emphasize the difficulty of finding an ideal solution. If we use a term that reflects the fact that children have serious problems and need support, this comes across as negative and could create a self-fulfilling prophecy; however, if we use milder language that is not deemed stigmatizing, then we run the risk that children's problems may be trivialized, with consequent delays in identification and intervention.

Traditional distinction between 'disorder' and 'delay'

A quite different objection to the term DLD is that, at least in the UK and some parts of the Irish Republic, 'disorder' has been interpreted contrastively as a condition different from 'language delay'. Indeed, we learned that many speech-language therapists (SLTs) in the UK had been trained to make this distinction. It embodies the idea that there is a particular profile of language difficulties, where there is a large mismatch between non-verbal ability and language skills, and also an uneven profile of ability within the language domain. This profile is seen as the hallmark of 'disorder', whereas 'delay' is thought to be characterized by an even pattern of impairment, so that both verbal and non-verbal skills are like that of a younger child. This distinction has assumed considerable importance in some regions, where SLT services are allocated only to children with 'disorder', and not to those with 'delay'-presumably because 'delay' is interpreted literally as indicating that the child will catch up after a slow start.

It is hard to trace the origins of this distinction, but it is clear that, despite its superficial plausibility, it does not have empirical support. Thirty years ago, Bishop and Edmundson ( 1987) used longitudinal data to test the idea that an even pattern of language impairment had a better prognosis than a more 'spikey' profile, with selective weakness in some domains. Their results were opposite to prediction: those with more selective problems had the best outcomes, whereas those with more general across-the-board impairments had the worse prognosis. Thus, providers who restrict SLT services from those who have 'delayed' profiles are denying help to those children who are most in need. Nor is there any evidence that speech-language therapy is only effective for children with a large mismatch between language and non-verbal skills (Cole et al. 1990), which is why the American Speech-Language-Hearing Association does not support 'cognitive referencing', i.e., using the discrepancy between non-verbal IQ and language as a basis for allocating services (American Speech-Language-Hearing Association 2016). Given the widespread use of the delay/disorder distinction, it is vital that those using DLD are clear that, as used by the CATALISE panel, the term 'disorder' does not entail any discrepancies, either between verbal and non-verbal development, or between different language functions.

Criteria for language disorder: focus on poor prognosis

The definition of DLD agreed by the panel applies specifically to children with poor prognosis. This averted a concern that children with mild and transient difficulties might be labelled as 'disordered'. However, a focus on poor prognosis does raise concerns that children might be written off, or that parents will be discouraged if they are told that their child's problems are unlikely to resolve with time. Most panel members agreed that this criterion made sense, and indeed could lead to fairer allocation of resources, but it is clear that it needs to be applied cautiously:

I think the focus on prognosis is important. It also makes clear that the children who require intervention are the children with a poor prognosis. Currently in many areas of the UK children with poor prognosis are not receiving services because they clog up the system and can't be discharged easily! The focus on the tier 3 children who won't make progress without help may help to counter this shift in service delivery. 2

There were, however, two concerns: first, did we know enough about prognostic factors to be able to judge this appropriately?; and second, would this mean denying services to children who would benefit from intervention?

we need to look further into the research and agree more solid indicators of long-term language learning difficulties.

There was variable awareness among CATALISE members of existing research on predictors of outcome. Our panel included several experts who had been involved in running longitudinal studies and were in general supportive of using prognosis as a criterion, but others had concerns about the feasibility of identifying children who were likely to have longstanding problems. Between these extremes were those who thought that even if we have good predictors from research, they may apply only to the specific population that was studied, and prediction may also not be precise enough to make accurate judgements about individual children. Over and above this concern, was the question of whether children with good prognosis should be excluded from specialist help.

I think it is important not to exclude children who may have, for example, very poor expressive language, which is causing them considerable difficulties, but might respond very well to specialist input. ... Even if they do catch up reasonably quickly in relative terms, the children might still have lost ground and had a miserable couple of years, which might itself have long lasting effects.

This latter point emphasized that the criteria adopted could change the balance of which children would gain access to resources. Throughout the process, comments were made which indicated how seriously panel members took this: many thought that current allocation of SLT services was not fair, but others worried that a move to a different set of criteria might leave children who might benefit from SLT intervention without any help. The impression was that, for those with clinical caseloads, views were strongly influenced by personal experience: it was clear that most panel members were concerned that large numbers of children were unfairly excluded from access to services, but while some maintained that those with the most severe problems were denied help, others took the opposite view and noted that it was children with milder and more selective language difficulties who risked being excluded from intervention.

This debate emphasized the lack of a good evidence base for making rational decisions in this area. Of course, we do not want to expend scarce resources on children who will either improve without help, or who are unlikely to benefit from intervention. But in the absence of a strong evidence base, it seemed that subjective impressions were often used to distinguish these groups. One point where the evidence was clear concerned the difficulty of predicting outcomes in late-talking toddlers: a diagnosis of DLD would be difficult to justify in a child under 3 years of age unless there were notable comprehension difficulties. In cases where the prognosis is hard to judge, which would include many pre-school children, the more generic term 'speech, language and communication needs' (SLCN), already in widespread use in the UK, would seem more appropriate for flagging up problems than the more clinical diagnosis of DLD.

As reviewed by Bishop et al. ( 2017), we do have better prognostic indicators for children from around 5 years of age when it becomes reasonable to identify children whose problems are unlikely to resolve without help. Nevertheless, it is frustrating that even when we have evidence from longitudinal studies, the clinical application of the findings is often limited because of an emphasis on demonstrating that a predictor is statistically significant, rather than on its effectiveness in predicting individual outcomes.

Also, there can be difficult decisions even when evidence is available: should resources go to those who can easily be treated effectively, or to those with the most severe functional impairments? These are unlikely to be the same children.

In addition, this raises the question of what the goals of intervention should be. It might seem obvious that a successful intervention is one that improves the child's language skills so that they are at the level of the peer group. Yet for some children, more modest goals-of providing strategies to cope with language difficulties, and modifying the environment to make the language impairments less detrimental-may be more realistic. If evaluation studies focus solely on language tests as outcome measures, then this may underestimate the benefits of intervention. To get a more realistic impression of outcomes, measures of quality of life, family functioning, social integration and self-esteem should be included.

Overall, it became clear that a discussion that was on the surface about diagnostic criteria was heavily influenced by beliefs about which groups should be given priority when intervention resources were scarce.

Criteria for language disorder: How objective and standardized should we be?

Further tensions were revealed between those who felt it was important to use objective measures with strong psychometric credentials and to avoid reliance on subjective judgements, and those who thought that formal language assessments failed to capture key features of children's language problems and might both over- and under-diagnose problems.

The first quotation illustrates the former concern, the second the latter:

I have concerns about relying on parents/teacher identification. Parents may not have enough information about typical language development and/or may miss comprehension difficulties. Also, there are equity issues. Children whose caregivers are least able to identify language issues may be children particularly in need of support.

I agree that testing is important, however I feel that in order to establish severity, functional assessment (informal observation for example) must be included as well as standardized testing.

Concerns were also expressed about poor sensitivity and specificity of standardized language assessment batteries, and their inability to detect some important aspects of impairment, such as pragmatic difficulties:

single tests measuring single components of the language system often do not possess the most robust psychometric properties.

we need to discuss the tools that are used to identify these problems as they have many flaws and it is likely that a multiple of assessment types, different for each age and skill level will be needed.

The consensus of the CATALISE panel was that test scores provided useful information but should not be used as the sole criterion for identifying language disorder. It was key that there should be evidence of functional impairment, i.e., the language problem impacted on the child's social interaction and/or educational progress. Nevertheless, it was noted that we lack good assessments for many aspects of language, and that reliance on subjective judgements created scope for biased and inequitable decisions.

Differentiating conditions rather than exclusionary criteria

Exclusionary criteria have traditionally been a key part of the diagnosis of SLI, but this part of the definition has been roundly criticized, notably by Reilly et al. ( 2014b). The CATALISE panel had many deliberations over whether we should differentiate between children whose language difficulties had no obvious cause and those whose difficulties occurred in the context of a specific aetiology, such as brain damage, hearing loss or a genetic syndrome. We concluded that where there is a differentiating condition 'X', the term 'language disorder with X' would be used rather than DLD. This distinction is important in many research contexts, where it may be desirable to focus on a relatively homogeneous group.

The discussion revealed several different factors that led to tension. Implicit in the debate are three issues. First, can we regard a co-existing condition as the cause of the language disorder? Second, does the presence of a specific aetiology mean that no intervention should be offered for language disorder? Third, if intervention is offered, should it be of a different kind than for children with no obvious aetiology? In addition, the answers to all these questions will depend on exactly what we regard as a co-existing condition.

The first issue may be illustrated with the case of hearing loss. A severe or profound congenital hearing loss is a major risk factor for poor development of oral language. However, if the child has exposure to signed language, good language skills are usually demonstrated. Similarly, many children can make good progress in oral language if given a cochlear implant. Nevertheless, there are hearing-impaired children who have problems learning sign language, and others who have disproportionate difficulties with oral language acquisition after a cochlear implant (Hawker et al. 2008). And this should not surprise us: we should expect to see a proportion of children with hearing loss who also have genetic risk factors for language disorder. While this example illustrates the dangers of explaining away a child's language disorder in terms of an associated condition, it is not an argument for simply ignoring the associated condition when identifying language disorder. It is rather an argument for documenting carefully the range as well as the nature of language problems associated with a specific aetiology.

The discussion about causality was pervaded by concerns that if a child's language disorder was thought to be 'explained' by an associated condition, then no intervention would be offered. Although this has sometimes been used as a justification for denying services to children, it is not a logically coherent stance. If extended to medicine as a whole, it would mean that we would only offer treatment for conditions of unknown aetiology! The panel agreed that it is not appropriate to deny intervention to a child because they has a co-existing condition, provided the child meets criteria for language disorder (in terms of severity and prognosis).

[The term 'language disorder associated with X'] is a great idea not only because it explicitly describes the association, but also because it sends the important message that problems in one area do not 'protect' children from having other difficulties. Parents of children with associated difficulties (e.g. Down syndrome) are sometimes frustrated by the lack of recognition of their child having a language disorder on top of the language difficulties associated with Down syndrome. And of course there is the important work on ASD with and without language disorder.

On the third issue, many felt that a different approach to intervention might be required if the child's language problems occurred in the context of a known aetiology. To continue with the example of hearing loss, intervention might include giving the child a hearing aid or cochlear implant, and/or introducing sign language, or having an SLT focus on presenting information via the visual modality. It was noted that there were many disorders where it helped to make this distinction:

I do agree that there are children who have disordered language for various reasons who would not best fit into the traditional 'SLI' care pathways.

There was, however, a contrasting view that children with differentiating conditions might not be offered interventions which could be useful-just because it was assumed they would not work:

some children with ASD appear to have a primary grammatical language impairment which would not be typical of ASD, yet they are not offered the same intervention that other children showing these patterns of language learning would be offered.

it is important to note that they may NOT indicate a different treatment pathway. For example, milieu communication training has been shown to efficacious for children with language disorders associated both with ID and ASD.

I think our intervention research has been mostly directed to fairly narrowly defined categories, with some exceptions. So the presumed different intervention pathways might turn out to have more in common than we think-for example, similar approaches might affect significant change in the morpho-syntactic difficulties of a child with Down syndrome and morpho-syntactic difficulties in SLI.

The discussions of these issues made it clear that, once again, one reason for disagreements was lack of a good evidence base: very little was known about efficacy of language interventions for children with co-existing biomedical conditions. The need for more research explicitly comparing different conditions was highlighted by our study. The best way to counteract concerns that budget-holders would deny services to children with additional conditions would be to provide evidence that intervention is effective with these groups.

These arguments, together with the need for researchers to study relatively homogeneous groups, led to general agreement that we should distinguish between language disorder associated with a 'differentiating condition' and DLD, while recommending that in both cases the language disorder merited assessment and intervention.

The question, then, was what to include in 'differentiating conditions'. We settled on a definition that included biomedical conditions such as a genetic syndrome, a sensorineural hearing loss or neurological disease. The conditions of ASD and intellectual disability led to some debate, but it was decided to include these as differentiating conditions, because, on the one hand, impairments of communication are a reliable feature of these conditions and, on the other, accelerating genetic advances mean that a biomedical aetiology is becoming evident for a high proportion of affected children (McRae et al. 2017). In practice, a differentiating condition would typically be the main diagnosis, with language disorder seen as a component of the condition.

DLD in relation to other neurodevelopmental disorders

The notion of 'differentiating condition' does not encompass milder neurodevelopmental disorders of unknown origin, such as ADHD or developmental coordination disorder. These do not have a clear-cut aetiology, and their association with language disorder is weaker than for the differentiating conditions noted above. One reason for rejecting the previous term 'SLI' was because 'specific' could be taken to imply that the child had no difficulties except with language. In contrast, our definition of DLD emphasizes that these idiopathic neurodevelopmental disorders can co-occur with DLD. Because different professional groups are concerned with different conditions-educators with dyslexia, SLTs with DLD, paediatricians and psychiatrists with ADHD and ASD-children often receive a rather one-sided assessment, depending on the professional they see. We emphasized that the fact that a child may have ADHD or dyslexia does not preclude a diagnosis of DLD and does not mean that the SLT should not be involved. The ways in which children's problems manifest does not neatly divide up according to professional specialities.

This view of overlap between neurodevelopmental disorders is supported by research on aetiology, which has shown that the causes of these conditions are often complex and multifactorial, resulting from the combined impact of many small genetic and environmental influences: the precise profile of problems that is seen in a child may depend on the particular constellation of aetiological factors, so we do not see sharp boundaries between conditions, but rather different permutations and combinations of impairments. Furthermore, although different disorders co-occur at above chance levels, they can be dissociated, suggesting that they may be separate consequences of common risk factors.

Comments from panel members made it clear that the question of how to handle co-occurring disorders was easier if one avoided attempting to specify causal relationships, e.g., if a child has both attentional problems and language problems, it is useful to be aware of this, but it may be impossible to disentangle whether attentional problems cause language problems or vice versa:

co-occurring disorders could be defined as impairments in other cognitive or behavioural domains that can co-occur with language disorder and may affect prognosis, but which do not include impairments of communication as core symptoms. I would avoid discussion of cause.

The role of non-verbal IQ in diagnosis

As discussed by Bishop ( 2014) and Reilly et al. (2014), traditionally, the diagnosis of SLI has required a non-verbal IQ within normal limits. In some diagnostic systems, an even more stringent requirement of a large mismatch between verbal and non-verbal ability is required. The CATALISE panel considered the evidence for this and concluded this criterion was not valid. Many panel members were supportive of dropping it.

I agree in so far as I do not want any discrimination on the basis of (non-verbal or any other concept of cognitive) ability.

This is an important equity issue.

Again, the argument was that the focus should be on the child's language needs, rather than on putative aetiology. Others, however, noted this would be a major departure from current practice and expressed reservations about expanding the category of DLD, thereby placing pressure on services. Concern was expressed that a less restrictive definition of language disorder could lead to a watering down of the concept that would ultimately lead to a reduction in services:

If we lose the conceptualisation of language impairment as being a weakness in language skills relative to the child's average non-verbal ability, then service providers might take the view that if there is no distinction between children of low ability across the board (who do not usually access a high level of therapy) and children with (specific) language difficulties, then it is not necessary to provide enhanced levels of SLT to any of them.

There also was evidence of local differences in how intervention resources were allocated. As noted above, practitioners from the UK and Republic of Ireland noted that a selective language problem (with normal non-verbal ability) was usually required in order for the child to be offered SLT services, but in other places quite the opposite was described, and there was concern that children with more selective problems might lose out:

I regularly encounter situations where services have been denied to families because their children only presented with language impairments. The risk of under-treatment in these cases is also what our epidemiological data have been telling us.

Overall, the view of the panel was that resources should not dictate diagnostic criteria. Discrepancy between verbal and non-verbal ability is not indicative of underlying aetiology-for example, Bishop ( 1994) found that identical twins with language problems often had very similar language profiles, yet could vary in non-verbal ability, with one meeting traditional discrepancy criteria for SLI, and the other not. Furthermore, for a child without a biomedical syndrome, the level of non-verbal IQ does not appear to determine responsiveness to therapy. There does not, therefore, appear to be any justification for using a verbal-non-verbal discrepancy as a diagnostic criterion; the overall view of the panel was that if this change led to more children being identified with DLD, then the case should be made for adequate resources to offer services to all of them.

Note that this does not mean that intellectual level is totally disregarded. As noted above, where the child meets criteria for intellectual disability, then we would treat that as the primary diagnosis and talk of 'language disorder with intellectual disability'. The current DSM-5 definition of intellectual disability requires that the child shows both 'intellectual deficits and adaptive deficits that fail to meet the standards for personal independence' (Harris 2013, 261).

Our definition of DLD would, however, include a case where a child with language problems has a level of non-verbal ability that is neither impaired enough to justify a diagnosis of intellectual disability nor good enough to be discrepant with overall language level. These children have historically 'fallen through the cracks' of diagnostic systems, and hence been deemed ineligible for speech and language therapy services.

Conclusions

Many of the issues raised by this analysis apply not just to language disorders but to neurodevelopmental disorders more broadly. Indeed, questions about diagnosis and terminology pervade all of psychiatry (Sonuga-Barke 1998).

As we proceeded through the Delphi studies, we were confronted by a key question: How would we know when we had a good solution? In practice, in a Delphi exercise the goal is to achieve a reasonable agreement between experts, and we were satisfied to accept a solution where we had a set of statements that at least 75% agreed with. But, as is all too apparent in many walks of life, the fact that a lot of people agree with something does not make it true. Ideally we would like to be able to show that our solution worked better than what had gone before. But what does 'work better' mean?

The ideal would be to find a solution that 'carves nature at its joints', such that DLD would identify a group of children with a distinct aetiology, correlated features and response to intervention. However, as Sonuga-Barke noted, this may be an unrealistic ambition if the reality is more dimensional than categorical. In the case of DLD, we have heterogeneity of language problems, and overlap between disorders affecting language and other domains. Despite this heterogeneity we have made some progress: our knowledge of aetiology, characteristics and effective intervention in this area has advanced over the years. Nevertheless, to improve our classification we need more research that carefully documents the nature of children's language difficulties in relation to prognosis, associated factors and response to intervention. The validity of the term 'DLD' will depend on whether it helps us move forward to a better understanding of what is clearly a heterogeneous category, bearing in mind that, as Sonuga-Barke noted, the category is a hypothesis to be tested and refined. Meanwhile, it is to be hoped that a clearer specification of DLD and agreement about use of this term will lead to a more equitable and effective allocation of services to children who experience severe and persistent language problems.

Notes

1. 1
In CATALISE, we restricted the panel to participants from English-speaking countries; it is clearly important to extend to other languages, but we were aware that the debate would be complex enough without having to take onboard further linguistic and cultural differences that might affect how language disorders manifest and are treated.

2. 2
In a Response to Intervention framework, three tiers of intervention/prevention are identified, with tier 3 referring to the level of individualized intervention needed for children with the most severe problems.

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References

American Speech-Language-Hearing Association, 2016, Eligibility and dismissal in schools [online] (available at: http://www.asha.org/slp/schools/prof-consult/eligibility0 (accessed on 29 May 2017).

Bishop, D. V. M., 2010, Which neurodevelopmental disorders get researched and why?. PLOS One, 5, e15112.

Bishop, D. V. M., Clark, B., Conti-Ramsden, G., Norbury, C. F. and Snowling, M. J., 2012, RALLI: An internet campaign for raising awareness of language learning impairments. Child Language Teaching & Therapy, 28, 259-262.

Bishop, D. V. M. and Edmundson, A., 1987, Language-impaired four-year-olds: distinguishing transient from persistent impairment. Journal of Speech and Hearing Disorders, 52, 156-173.

Bishop, D. V. M., Snowling, M. J., Thompson, P. A., Greenhalgh, T. and The Catalise Consortium , 2016, CATALISE: a multinational and multidisciplinary Delphi consensus study. Identifying language impairments in children. PLOS One, 11, e0158753.

Brosnan, M. and Mills, E., 2016, The effect of diagnostic labels on the affective responses of college students towards peers with 'Asperger's Syndrome' and 'Autism Spectrum Disorder'. Autism, 20, 388-394.

Crabtree, J. W., Haslam, S. A., Postmes, T. and Haslam, C., 2010, Mental health support groups, stigma, and self-esteem: positive and negative implications of group identification. Journal of Social Issues, 66, 553-569.

Elliott, J. G. and Grigorenko, E. L., 2014, The Dyslexia Debate (Cambridge: Cambridge University Press).

Hawker, K., Ramirez-Inscoe, J., Bishop, D. V. M., Twomey, T., O'Donoghue, G. M. and Moore, D. R., 2008, Disproportionate language impairment in children using cochlear implants. Ear and Hearing, 29, 467-471.

International Dyslexia Association, 2012, International Dyslexia Association requests reinstatement of the term 'dyslexia' in American Psychiatric Association's DSM-5 [online] (available at: http://www.prnewswire.com/news-releases/international-dyslexia-association-requests-reinstatement-of-the-term-dyslexia-in-american-psychiatric-associations-dsm-5-157488625.html) (accessed on 29 May 2017).

Macharey, G. and Von Suchodoletz, W., 2008, Perceived stigmatization of children with speech-language impairment and their parents. Folia Phoniatrica et Logopaedica, 60, 256-263.

Mcrae, J. F., Clayton, S., Fitzgerald, T. W., Kaplanis, J., Prigmore, E., Rajan, D. et al., 2017, Prevalence and architecture of de novo mutations in developmental disorders. Nature, 542, 433.

Reilly, S., Tomblin, B., Law, J., Mckean, C., Mensah, F., Morgan, A., Goldfeld, S., Nicholson, J. and Wake, M., 2014b, SLI: a convenient label for whom? International Journal of Language and Communication Disorders, 49, 416-451.

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Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD)

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Discussion Corresponding author University of Oxford, Oxford, UK Address correspondence to: Dorothy Bishop, University of Oxford, Tinbergen Building, South Parks Road, Oxford OX1 3UD, UK; e-mail: dorothy.bishop@psy.ox.ac.uk Search for more papers by this author A recent project entitled CATALISE used the Delphi method to reach a consensus on terminology for unexplained language problems in children.

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Developmental language disorder: have you heard it?

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Developmental #Language Disorder – Have You Heard Of It? By Catherine Jackson https://t.co/2mtYMK3auy @WiseoldowlSLT #eytwitterpals #eyfs

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Developmental #Language Disorder – Have You Heard Of It? By Catherine Jackson https://t.co/2mtYMK3auy @WiseoldowlSLT #eytwitterpals #eyfs pic.twitter.com/DzsxPjlzaE
— Childcare & Education Expo (@childcareedexpo) July 12, 2017

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Developmental #Language Disorder – Have You Heard Of It? By Catherine Jackson https://t.co/2mtYMK3auy @WiseoldowlSLT #eytwitterpals #eyfs https://t.co/DzsxPjlzaE

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Changing terminology and diagnostic criteria: evidenced based decisions and practice

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Changing terminology and diagnostic criteria: evidenced based decisions and practice

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Dr. Ebbels and Prof. Norbury's presentation for RCSLT

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THROWBACK PUB: So, it's "Developmental Language Disorder" now? — The Informed SLP

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THROWBACK PUB: So, it's "Developmental Language Disorder" now? — The Informed SLP

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Interesting 2016 post from the informed SLP about #devlangdis

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Typically, when we pull a "Throwback Pub" for a review, we aim to cover just one study. However, this topic ended up requiring a bit more than that. The initial paper of interest was published July 2016, but not in a regular TISLP journal, thus not included in the July reviews. That consensus study was a summary recommendations from a panel of clinician and scientist experts on child language disorders (primarily from the U.K., but with representation from several English-speaking countries). The group convened to bring order to the diagnosis and description of child language disorders. Various points are covered in that article, but in this post we'll focus on terminology only, because it has been such a hot topic over the past few years. So, we ask:

For children with language disorders not associated with other conditions (e.g. autism, hearing loss), what is the term used for their language disorder?

In the consensus paper, the terms "Language Disorder" and "Developmental Language Disorder" are used.The recent uses "Language Disorder" as well. Dr. Susan Ebbels wrote a summary statement on the consensus , indicating that for kids without co-existing conditions, current best practice is to use " Developmental Language Disorder" (big movement on Twitter these days to normalize this term, using #devlangdis).

When I first noticed people using #devlangdis, it made sense why we'd want consistent terminology. After all, there is one term for autism, one term for dyslexia. Inconsistency in terms used to label developmental language disorder interferes with our ability to advocate for and treat these children. However, I couldn't quite figure out why we should use *this* term over others. I'm pretty accustomed to using "Specific Language Impairment," and wasn't particularly interested in parting with it (nor are others-see ). It wasn't until I read this commentary that I began to understand and get behind #devlangdis (the commentary kicks off a series of papers that provide a more in-depth rationale). And the core arguments are this: a) consistency in terminology is important for action, and b) rationales for using other terms, like "Specific Language Impairment", are problematic (e.g. SLI implies cognitive exclusionary criteria).

Still not convinced? Try these exercises, and you'll at least feel the frustration that has motivated the call for consistency:

Pretend you're a parent searching for information on your child's language disorder. You may start with Wikipedia (spoiler alert: it's a hot mess). Wikipedia isn't exactly a trustworthy resource, but it does tend to represents knowledge trends. And, as you'll see, there are multiple pages representing language disorders, each using different terminology (e.g. here & here) and pointing to reputable resources that only further confuse the reader. How on earth are parents, students, and non-SLPs supposed to make sense of anything if the same disorder is referred to with several different terms?

Now try visiting ASHA's website (!). You'll find that even ASHA needs some editing. They're pretty consistent with using "Language Disorder", but it's still a bit confusing when they have one page labeled "Spoken Language Disorders" and another page labeled "Preschool Language Disorders." And within the former, it presents language disorder and SLI as though they're entirely distinct diagnoses, confusing those who haven't read up on the topic.

So, time for TISLP to start translating "language impairment" and SLI to DLD (and specifying differences in study samples, as needed)? Alright, then: #devlangdis

Bishop, D.V.M., Snowling, M.J., Thompson, P.A., & Greenhalgh, T., & CATALISE consortium. (2016) CATALISE: A Multinational and Multidisciplinary Delphi Consensus Study. Identifying Language Impairments in Children. PLoS ONE, 11(7).

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THROWBACK PUB: So, it's "Developmental Language Disorder" now?

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Summary of CATALISE-2 findings by Dr. Susan Ebbels

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Continuing the #devlangdis discussion from yesterday's #spaconf workshop @NatalieMunro3 @JuliaStarling4

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Continuing the #devlangdis discussion from yesterday's #spaconf workshop @NatalieMunro3 @JuliaStarling4

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I think it is important to have the support from the professional associations. Speech Pathology Australia endorsed the use of developmental language disorder (SpeakOut), which increased the level of awareness within the profession.

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The IASLT have a position paper on #devlangdis

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The IASLT have a position paper on #devlangdis

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http://iaslt.ie/news.php?newsitem=1495619317&display=access

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What about children with delayed expressive phonological skills? Can we still use the term "delayed"?

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Is the umbrella term language disorder sufficient? 

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Is the umbrella term language disorder sufficient? 

# data[].attributes.headline
The term SLCN could be used for a range of presentations that are not yet able to be identified specifically.

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The term SLCN could be used for a range of presentations that are not yet able to be identified specifically.

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The SLCN venn diagram puts language disorder in the centre - love it!

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The SLCN venn diagram puts language disorder in the centre - love it!

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Not having a requirement for nonverbal IQ means that we don't have to push parents for this in order to get services

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Not having a requirement for nonverbal IQ means that we don't have to push parents for this in order to get services

# data[].attributes.headline
What terminology do we use for children under 5 years of age who have unexplained language problems but do not yet show persistent language disorder?

# data[].attributes.subject
What terminology do we use for children under 5 years of age who have unexplained language problems but do not yet show persistent language disorder?