Slides from talk given at Afasic study day, Bangor, UK, 26th April 2018

1. DLD Summary:
International consensus on diagnosis for
children with problems with language
development
Dorothy V. M. Bishop
Department of Experimental Psychology,
University of Oxford
1

2. 2
“I do research
on specific
language
impairment.”
“What d’you do then?”
“I do research
on dyslexia ”
“What’s that?”
“Oh, they had a
programme on the
telly about it last
week.”
“I do research
on autism ”
“Oh, my
grandson’s got
autism.”

3. 3
NIH funding over time for
neurodevelopmental disorders
$K
0
100000
200000
300000
400000
500000
600000
700000
800000
900000
2000-
2001
2002-
2003
2004-
2005
2006-
2007
2008-
2009
Attention deficit
hyperactivity
disorder
Autistic spectrum
disorder
Dyslexia/SLI/speech
/dyscalc/DCD
Data from: Bishop, D. V. M. (2010). Which neurodevelopmental disorders get
researched and why? PLOS One, 5(11), e15112.
Could constellation of language functions give a clue?

4. 5
Labels used for unexplained language problems
Prefix Descriptor Noun
Google Scholar: 1994-2013.
Of 168 possible combinations, 130 found at least once.
33 distinct terms were used 600 times or more during that period

5. Hypothetical 8-yr-old: George
6
• Late to start to talk
• Didn’t speak in sentences until 4 years old
• Otherwise developed normally
• Weak vocabulary for his age
• Struggles with reading: has extra support
• Doesn’t always remember what his teacher
says
• Teased for not understanding jokes
• Loves art and constructing things
• Parental concern; he is now reluctant to go
to school
• Hates being singled out and made to feel
different from others.

6. Educational psychology assessment
7
• Nonverbal IQ of 103
• Vocabulary and
comprehension levels are
lower, with scaled score
equivalents of 85
• Poor scores on tests of verbal
memory
• Reading ability is at a 7-year-
old level

7. What should be done about George?
8
• Nothing
• Extra classroom support
• Referral to speech and
language therapist
• Something else?

8. Would George benefit from any
kind of label?
9
• Speech, Language and
Communication Needs (SLCN)
• Specific Language Impairment
(SLI)
• Social Communication Disorder
• Developmental dyslexia
• Something else
• None of the above

9. Questions about impact of label:
Might labels do more harm than good?
10

10. Tension between education and medicine
Education
• General dislike of
medical labels
• Prefer ‘needs’ or
‘problems’ to
‘disability’ or
‘disorder’
• Focus on social
rather than
biological causes
Medicine
• Diagnostic labels
– International
Classification of
Diseases (ICD10)
– DSM5
• Emphasise
neurobiological
origins/genetics
11

11. 12
• Focus on what is wrong with the child; may
ignore aspects of environment
• Can be excuse for what is really
consequence of bad
teaching
• Parents/teachers take no responsibility
• Child feels failure inevitable, stops trying
• Labelling leads to stigmatisation, social
disadvantage and exclusion
Arguments against labelling as disorder

12. Sternberg & Grigorenko
Our Labeled Children (1999)
 Schools have financial interest in identifying
specific learning disabilities
 Teachers “let off the hook”
 “.. diagnosis as it now exists has provided some
children who seem to be underachieving, based on
their socioeconomic status, a way out"
 Notion that resources are denied to children whose
parents don’t push for a label
• Implication seems to be that life will be fairer if we do away
with labels
• Runs risk that no children will get adequate services!
• May be better to retain labels but ensure they are used fairly

13. • “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.” (p. 117).
14
Sonuga-Barke (1998) Categorical models of childhood disorder:
a conceptual and empirical analysis. Journal of Child Psychology
and Psychiatry, 39, 115-133.

14. Two things we can all agree on?
• There are children who have difficulties
with oral or written language that are
serious enough to affect everyday life and
academic outcomes and are not just a
consequence of poor schooling/parenting
• We should do our best to help these
children overcome these difficulties: doing
nothing is not an option
Bishop, D. V. M. (2014). Ten questions about terminology for children with unexplained
language problems. International Journal of Language & Communication Disorders,
49(4), 381-415. doi:10.1111/1460-6984.12101.

15. Adult outcomes for school-aged children
with language impairments
16
Academic
failure
Psychiatric
problems
Unemployment
Social
impairment
Increased risk
Clegg J, Hollis C, Mawhood L, Rutter M (2005). "Developmental language disorders—a follow-up in
later adult life. Cognitive, language and psychosocial outcomes". J Child Psychol Psychiatry 46 (2):
128–49.
N.B. Outcomes very varied; may depend on severity and language profile.
Comprehension problems seem to have worst prognosis:

16. Questions we need to be able to answer
• Which children should get extra
help?
• Audit: how many SALTs do we
need?
• Is rate of language problems
increasing/decreasing over time?
• How do different countries/region
compare?
• What causes children’s language
problems?
Can only
answer these
if we have
common
criteria for
identifying
problems and
common
language for
referring to
them

17. No perfect answer!
GOAL: Find an agreed way of identifying
and talking about children who need
services
WHILE
Minimising negative impact of labels:
 Misunderstanding
 Denial of services
 Stigmatisation

18. 19
Maggie
Natalie
(Team
Spirit)
Gina Courtenay Becky
Beth
(Team
Spirit)
Raising Awareness of Language Learning Impairments: 2012

19. 20
https://www.youtube.com/RALLIcampaign
Goals of RALLI campaign
• Raise awareness of language impairments through YouTube
• Sort out the mess in definitions and terminology

20. 21
https://www.youtube.com/RALLIcampaign
Goals of RALLI campaign
• Raise awareness of language impairments through YouTube
• Sort out the mess in definitions and terminology

21. CATALISE
Criteria and Terminology Applied to Language
Impairments: Synthesising the Evidence
Dorothy Bishop, Maggie Snowling,
Paul Thompson & Trisha Greenhalgh

22. 23
What is the focus?
Seek consensus on how to identify children in need of extra,
specialist help with language beyond what is usually available in the
classroom.

23. Delphi approach
Multidisciplinary panel of 57 experts from UK,Ireland, US,
Canada, Australia, New Zealand

24. What was the consensus?
25

25. 26
The Bottom Line:
Consensus on terminology

26. 27
1. Label misleading in implying a clearcut, homogenous
condition
Why is it so hard to agree on labels?

27. Cause
1
DLD
A model that is tidy but wrong!
Dyslexia
Cause
2
NB. Brain diagram
is schematic:
location of regions
not realistic!

28. Gene 1
Gene 2
Gene 3
Gene 4
Gene 5
Gene 6
Env 1 Env 2
Grammar
Semantics
Pragmatics
Literacy
DLD Dyslexia ASD ADHD
Closer to the truth…….
Social
cognition
Social
drive
Attention
focus
Inhibition
• Many-to-one mappings
• Same cause, different effect
• Same disorder, different cause
• Gene x environment interactions
• Gene x gene interactions

29. Implications for DLD
• It is NOT a coherent syndrome and there are no neat subtypes
• Many overlaps with other neurodevelopmental disorders
• Can seldom attribute the language disorder to a single cause
30

30. But, we still need a label!
• We need a term to indicate the child has problems that might
benefit from involvement of a speech-language therapist
• We need a way to group children for research purposes
• We also need a label that can be used by the general public
31
“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.”
Panel member

31. Diagnosing DLD
32

32. Associated with
biomedical condition, X*
Language
disorder
Child with language difficulties that:
• impair social and/or educational
functioning
• with indicators of poor prognosis
Developmental
language
disorder (DLD)
Language
disorder
associated with X*
*includes genetic syndromes, a sensorineural hearing loss,
neurological disease, ASD or Intellectual Disability
Important!
Not exclusionary
factors.
Child eligible for
assessment/
intervention
Starting point

33. Associated with
biomedical condition, X*
Language
disorder
Child with language difficulties that:
• impair social and/or educational
functioning
• with indicators of poor prognosis
Developmental
language
disorder (DLD)
Language
disorder
associated with X*
*includes genetic syndromes, a sensorineural hearing loss,
neurological disease, ASD or Intellectual Disability
Important!
Not exclusionary
factors.
Child eligible for
assessment/
intervention

34. Language Disorder
Speech,
Language and
Communication
Needs
Language Disorder is a subset of broader category of SLCN

35. Language Disorder
Developmental
Language
Disorder
Language Disorder
Speech,
Language and
Communication
Needs
DLD is a subset of Language Disorder

36. 37
This definition very broad: need additional information
Nature of language impairments
• Phonology
• Syntax
• Semantics
• Word finding
• Pragmatics/language use
• Verbal learning & memory
Decided against subtypes –
too many children don’t fit
neatly!
Risk factors
• Family history
• Poverty
• Low level of parental education
• Neglect or abuse
• Prenatal/perinatal problems
• Male
Co-occurring disorders
• Attention
• Motor skills
• Literacy
• Speech
• Executive function
• Adaptive behaviour
• Behaviour

37. Common questions
1. What about children with ‘language delay’?
• The term ‘language delay’ was rejected by the CATALISE panel:
The ‘delay’ vs ’disorder’ distinction has been around for a very long
time but there is remarkably little evidence to support it
• Back in 1987 I found that children with a ‘spikey’ profile had milder
problems and better prognosis than those with a ‘flat’ profile – yet
the former group often get better access to therapy
• In addition, it is sometimes argued that a distinctive profile of
‘language delay’ is caused by poor environment, but comparisons of
children from deprived/non-deprived backgrounds don’t support this
Bishop, D. V. M., & Edmundson, A. (1987). Language-impaired four-year-olds:
distinguishing transient from persistent impairment. Journal of Speech and Hearing
Disorders, 52, 156-173. 38

38. Common questions
2. What about younger children who would not meet criteria for
‘disorder’?
39
They weren’t the focus of
CATALISE, as we were
concerned with those
requiring Tier 3 specialist
provision
We don’t recommend using
‘disorder’ except for more
persistent problems
This group would come
under the umbrella of
SLCN; they could be
referred to as having
‘language difficulties’ or
‘needs’

39. Common questions
3. Will services get flooded with low IQ children who were previously
excluded because their problems were not ‘specific’?
Population survey of children in Surrey by Norbury:
4.8% with DLD and average range IQ (85 upwards)
2.8% with DLD and low average IQ (70-84)
2.34% with language disorder + associated condition
• No differences between those with average and low-average NVIQ
scores in severity of language deficit, social, emotional, and
behavioural problems or educational attainment.
• In contrast, children with language impairments associated with
known medical diagnosis and/or intellectual disability displayed
more severe deficits on multiple measures.
40

40. Access to services: a key issue
41
• Rational response requires speech-language therapy (SLT) profession
to examine what it has to offer by way of effective intervention
• Evidence base is still very weak, so decisions often based on habitual
practice, assumption that intervention works, or local pressures
• Urgent need for more multicentre intervention research: won’t get
funding unless can demonstrate impact of SLT
• Need outcome measures that assess impact on child and family social
and educational functioning: many language disorders won’t be ‘cured’
but can be managed to make a big difference (cf. autism, hearing
impairment)

41. Conclusion
42
Remember! Not a single, homogenous condition, and no
label is perfect.
Hope is that we can agree to go with the consensus and so
move forward to raise awareness, improve services to
children, and do much-needed research
http://www.slideshare.net/deevybishop/ijlcd-winter-lecture-20167-references