In Class Language Impairment

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Specific Language Impairment

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1. Children with language difficulties.
- normal in other areas of development
- no neurological cause known
2. prevalence: 5-10%
3. need SLP

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Goal setting

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baseline:
1. Most impaired first
- Highest level of functioning first with in that area
- work to goal

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ASHA Language disorder

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An impairment in comprehension and/or use of spoken, written, and/or symbol system. The disorder may involve:
1. Form
2. Content
3. Function of language in communication
In any combination

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Frey's language disorder

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A significant deficit in the child's level of development of the form, content, or use of language

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Paul's language disorder

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A significant deficit in learning to talk, understand, or use any aspect of language appropriately, relative to both environmental and norm-referenced expectations for children of similar developmental level

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Paul's deficit expectations

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Normative- everyday life and functioning
Neutralist- standardized or norm-referenced tests

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When would it be bad to use only the neutralist view

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Autism because they may do very well on tests.

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Do you use standardized tests for stuttering?

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No- too variable

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Systems model

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Communication problems exist in the relationships between communication partners.
interaction between child and enviornments.
Target is not normal language. Change the enviornment.

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Systems model includes

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1.Preventative approach
2.Acceptance
3.No labels
4.Life long
5.Inform others and make a difference IFSP
6.Overcome barriers

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categorical model

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Organized based on similarities and a collection of behaviors. ID, HI, ASD, neurological damage.....

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specific disabilities model

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Within child variations.
1. Create a strengths profile and weaknesses
2. Teach to the strengths and remediate the weaknesses

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Bottom up

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Start with smaller skills and build up in little steps. Higher level skills are supported by lower level. "Fast Forward"

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Specific disabilities model includes

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1. Bottom up
2. Auditory perceptual deficits approach
3. Limited processing capacity approach

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Auditory perceptual deficits approach

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Spoken language relies primarily on the processing of auditory information

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Limited processing capacity approach

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Successful comprehension depends on the ability to hold new information in temporary storage while integrating new, incoming linguistic material

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Auditory perceptual deficits and SLI

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Not all have Auditory deficits

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Descriptive- Developmental model

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Describes present level of form, content, and use
Use normal language development as the basis for treatment targets.

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Descriptive- Developmental Model subtypes

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Expressive disorder
Receptive disorder

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Language disorders pyramid

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Bottom= categorical etiology, does not help with tx
Specific abilities
Descriptive manifestation
Systems- context

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How do you assess a three-year-old that is not talking or interacting?

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1. Talk to parents
2. Auditory processing check
3. Discourse, linguistic unit or morphemes
4. How child interacts in society

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SLI via the different models
Specific disabilities model
Categorical model
Descriptive developmental model

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Specific disabilities model: Oral language is impaired due to underlying auditory processing disorder
Categorical model: rule out other categories
Descriptive developmental model: language sample would show an expressive disorder manifested by poor use of syntax 3 word utterances at age 4. Produces nouns, verbs, ing, and plurals. Produces no later morphemes and MLU poor with only nouns and verbs

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Performance

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1. Use of a skill
2. Specific
3. Progression
4. Support needed
5. Don’t know why

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Knowledge

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1. Mastery
2. Ask questions
3. Consistency
4. Little support
5. Point out errors and how to apply rules
6. Implicit knowledge
7. Can apply rules and strategies to new situations (novel)
8. Can explain how to produce

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performance goal

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1. To say /Ø/ in the final position in three words in the presence of the speech clinician who shows three pictures (bath, both, path) in ten seconds with 100% accuracy.

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Knowledge goal

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When talking on the phone John will use strategies to reduce stuttering

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SLI profile

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1. Slower onset and development of all language domains
2. Low performance in grammatical morphology and phonological processing
3. 75-80% catch up by age 5 (illusory recovery)
4. 60% have later reading difficulty

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Predictors of later risk with SLI

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Expression + comprehension = most risk
Expression= more risk
Phonology only= some risk
- More severe = less favorable outcome
- Phonological processing deficits

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SLI Predispositions

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1. Perception of short duration, sequenced acoustic events
2. Attentional response mechanisms
- Ability to use symbols
- Invent syntax
- Energy to do the above al at once
(Failure to attend to stimuli and manipulate speech at the same time)

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SLI means?

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You have a weakness in verbal skills. there are variations within and accross individuals

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Slow Expressive Language Development (SLED)

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- Toddlers who are late in talking
- SLED at 2-years-old: fewer than 50 words, failure to combine words, little productive language

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Late talker can also be called?

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SLED

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Predictors of SLI

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1. Family history
2. Low caregiver (mother) education
3. fewer gestures
4. Less joint attention and comments
5. less thematic play
6. simpiler phonetic inventory
7. Passive communicators
8. Few verbs in early vocabulary and heavy use of general verbs

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AGES of SLED, SLI and RD

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SELD: 2-3 years
SLI: 4-8 years
RD: 7+

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Why look at etiology?

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1. Eligibility for services
2. Hints for areas to assess
3. Hints for treatment priorities
4. Reports

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Intellectual disabilities

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1. Nonspecific
2. common syndroms
- Down syndrome
-Fragile X syndrome

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Intellectual disabilities

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- American association on Mental Retardation definition:
- 1. Mental retardation is a disability characterized by significant limitations both intellectual functioning and in adaptive behavior as expressed in conceptual, social, and practical adaptive skills. Before age 18.
- 2. Limitations in present function must be considered within the context of community environment typical of the individual’s age peers and culture.
- Profile of needed supports
- Personalized supports to improve functioning of individual (adaptive skills)
- Significant limitations in intellectual function= IQ of 70-75 or less. 2SD below or less than 2% of individuals.
- Must show significant deficits in behavior when compared to culture
-Rule out linguistic or cultural differences

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Standardized test for ID

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Vineland Adaptive Behavior Scales-II

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levels of ID- before 1992

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- mild 89% at 55-69 IQ
- Moderate 6% 40-54 IQ
- severe 3.5% 25-39 IQ
- profound 1.5% below 25

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ID Now

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1. Eligibility for services based on ID diagnosis
2. Identify strengths and weaknesses. Psychological, health, and etiology
3. Level and type of supports needed.
a. Intermittent-= as needed- episodic or short
b. Limited= consistent over time or limited
c. Extensive= regular, involvement in living environment and maybe work
d. Pervasive= high intensity in all environments- life may depend on it
Support Intensity Scale can help identify
Page 116 Evaluation: based on functional use of communication and informed clinical opinion.
Assessment: developmental-descriptive model= in-depth assessment- all children
Intervention: 1. Clinic directed behavioral methods. 2. Hybrid and naturalistic approaches.
- Indirect language stimulation with children who have MLUs above 2
- Clinician-directed when below 2 MLU
- Milieu teaching is associated with receptive language

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ID level and type of supports needed?

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a. Intermittent-= as needed- episodic or short
b. Limited= consistent over time or limited
c. Extensive= regular, involvement in living environment and maybe work
d. Pervasive= high intensity in all environments- life may depend on it

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Langauge features of ID

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Low level: Non-intonational and reflexive acts, interpreted by caregivers.
Middle level: may be intentional, prelinguistic, communication and contextualized (scaffold)
High level: possible comprehension, language production: 30-50 word vocabulary, 1-2 word utterances

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Language of Down Syndrome

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Strength: Pragmatics, some semantics
Weakness: Morphosyntax
A basic level of reading may be attainable

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Down syndrome Pragmatics

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-Good early and later social interaction
- Poor on object attention and joint attention to objects
- More gestures than gestures + vocalizations

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Down syndrome Semantics

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- Good vocabulary and comprehension
- Poor expressive vocabulary

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Phonology in Down Syndrome

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- Poor and distorted
- Poor intelligibility
- Not passive

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Morphosyntax DS

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-Poor Comprehension and expression
- With co-occurring ID complex syntax may not develop
- IQ below 50 may never develop beyond early grammatical stage

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PDD-NOS

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pervasive Developmental Disorder - Not Otherwise Specified
1.Pragmatic Language Impairment (PLI)
2. Nonverbal Learning Disability (NLD)
4. Asperger Syndrome (AS) (Hans Asperger 1944 first wrote about)

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Asperger's disorder

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Social and behavioral symptoms, but normal cognition and language development

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Prevalence and prognosis

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- Addition of Aslperger’s and increased prevalence
- 75% develop useable speech by 6-years
- Acceleration of developmental rate
- Language and IQ gains
- Improved social behavioral and decreased autistic behaviors

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TBI VS SLI

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- Intact syntax and morphology
- Social and pragmatic impulsivity

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Acquired disorders

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- Focal lesions
- Seizure disorders
- Tumors, infection, or radiation
- Traumatic brain injury

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ASD:Describe:
Social interactions:
Communication:
Behaviors:

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Social interactions: eye gaze, turn-taking, isolation, no seeking of comfort
Communication: Gestures, no symbolic play, or play with toys in odd repetitive ways
Behaviors: Do not like change
Difficulty prior to age 3 can be noted

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ASD strenghts

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- Short-term memory
- Discrimination
- Identification of small differences between stimuli

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ASD difficulties

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- Overly responsive to specific stimuli
- Under sensitive to stimuli
- Transfer of information across sensory modalities
- Recognizing facial expressions
- Theory of mind. Can’t understand how others think and feel
Look at 4-10 in book

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ASD Hallmarks

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- Social impairment
- Preoccupation with objects
- Humor impairment
- Theory of mind

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ASD communication

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1. Intentional communication: lack of joint attention and abnormal response to human faces
2. Speech: Late onset, Slower rate of acquisition, and impacted suprasegmentals (sarcasm)
3. Language: form and vocabulary usually equal mental age, but meaning and pragmatics are impaired

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Nonverbal Learning Disability (NLD)

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- Children with nonverbal learning disabilities (NLD) have normal verbal IQ’s, but nonverbal IQ’s that are significantly lower

- They show preserved single word reading and talk fluency, but have difficulty with non-verbal problem solving, visual-spatial skills, tactical perception, psychomotor coordination and, despite superficially normal language form, show deficits in pragmatic use of language.
- Language may be verbose, rambling, disorganized, incoherent, tangential, repetitive, monotone, and lose (Volden 2002)
- Assessment: CCC-2 can help with establishing eligibility – assessment based on observation, parent and teacher report, and testing that describes pragmatic abilities. Qualification can be difficult due to high level of abilities

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Asperger Syndrome (AS)

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(Hans Asperger 1944 first wrote about)
- Children with marked social deficits in the presence of normal intelligence
Assessment: Children’s Communication Checklist-2 (CCC-2) Bishop 2003
TX: visual cueing, social skills training, script-based and meta-cognitive strategies. Peer-mediated intervention, working with teachers to provide support within the class, and transition planning to post school settings
Possibly encouraging students to observe others and learn how others express feelings with their faces

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Pragmatic Language Impairment (PLI)

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3. Pragmatic Language Impairment (PLI)
- Type one semantic-pragmatic disorder ( Rapin and Allen 1983)
• Children with developmental language disorder whose primary deficits were not in language form, but in semantic and pragmatic aspects of communication

-Type two (Bishop and Rosenbloom 1987)
• Lack of difficulty with peer relations, but have symptoms of SLI and ASD
TX and assessment:
- CCC-2, narrative, and conversation assessments. Produce less information in retelling task than children with SLI
- Conversational analysis focusing on initiation and responsiveness to topic may also be helpful.
- ADAM 2005 provided elements of a social communication intervention program (SCI) some documentation of the effectiveness of this intervention is available- replication with case studies- page 147

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Considerations for identification of language disorder

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1. Operational definition of language disorder may vary based on model used.
2. Differences in operational definition provide the potential for disagreement
3. Other considerations
- SLP focus= morphosyntax versus pragmatics
- Real child= strengths and weaknesses
- Real measures= different tests used measure different items
- Social and economic situations= funding in school

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What disorders hallmark is poor pragmatics?

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Autism

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Passiveness is a hallmark of what disorder?

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SLI (pragmatics)

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Syntax is best

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Autism, but may have dificulties

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Syntax stands out with?

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ID and SLI

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When working with adults we need to look at what?

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Morphemes and relative clauses
Abstract or figurative

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Considerations when identifying SLI

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1. Exclusionary criteria
2. Discrepancy criteria
- Variations in identification standards: clinical vs standardized operational criteria (research)

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SLI exclusionary criteria

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- A disorder defined mainly by its exclusion of organic pathology and etiology
- Identification by agreed upon standards
- Don’t do X well and don’t know why

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What criteria do we need to exclude

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1. Hearing impairment
2. Oral motor
3. Genetic
4. ID
5. Trauma- neurological
6. Emotional disturbance

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SLI discrepancy criteria

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- A disorder defined mainly by it’s disparity between an impaired function with a non-impaired function
- There’s a difference between morphosyntax and nonverbal IQ

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Considerations for conceptual to operational definition of disorder

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1. Normative or adaptive dysfunction
2. Neutralist or normative referenced score deficits
3. Qualitative or quantitative distinction (do before you test)
- How low is discrepancy?
- Which aspects
- Which modalities
- Which contexts
- Which tests
- How to reference age?
- Cognitive level

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What is the best test for SLI?

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MLU- matched with clinical judgment

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Exclusionary criteria: Aram et al.

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- Hearing 20 dB for 1000 and 2000 and 25 dB for 500 and 4000 Hz
- Bilingualism- is English 1st or 2nd language
- Major neurological or orofacial abnormalities: history and exam
- Generalized deficient intelligence: abstract/visual reasoning – Stanford-Binet
- Abnormal social behavior: autistic disorders checklist

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SLI identification results:

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1. Nonverbal IQ – language discrepancy (59)
2. Chronological age-language age
3. Language performance cut-off< 1SD
4. Nonverbal IQ and TELD (79)
5. Other language measures and S-B
6. Other language areas cut off<1SD
MLU and clinical judgment of expressive is the best way!

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Factors leading to lack of congruence

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1. Different clinic perspective
2. Training issues
3. Professional judgment limitations (training)
4. Assessment tool limitations

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ID and language impaired

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1. Disorder definition
2. Cognition-language link (language facilitates cognition)
3. Compensation

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Should we ever use cognition referencing?

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NO!!!!

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Nonverbal cognition

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1. Prelinguistic abilities
- Sensorimotor schema
- Perceptual abilities
-
2. Older abilities
- Pattern recognition
- Spatial organization
- Puzzle construction
- Numbers
- Math
- Mental rotation
- Mechanical aptitude

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Can language improve cognition?

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- YES, Jack Fletcher showed that it can improve reading skills

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Nonverbal cognition and language relationship

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- Ceiling- does not predict a ceiling for language abilities
- Predictor- no
- Related-no
- Enhanced?
- Reciprocal- lose, but not causual
- Separate and unrelated- yes

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IQ and cognitive relationships

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1. Vocabulary- schema
2. Pragmatics- means end
3. Morphosyntax- hallmark of SLI and separate from cognition (somewhat)
4. Phonologic processing

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Arguments for language treatment for ID

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1. People with ID can learn there is not a ceiling
2. Morphosyntax and phonological processing may get better results with tx
3. Language treatment can help cognitive and learning abilities: “helps you organize and think about organization of words.” Also teaches learning behaviors such as how to sit and listen
4. Does Down Syndrome involve any special language deficits- no language is overall impaired
5. We communicate to get things done so social communication is imperative
6. We can help people with behaviors, classroom modification, compensatory strategies- advocate!

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Nonverbal Language

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- Non-intentional
- Intentional

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Emerging language

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- 18 to 36 months
- Producing single words
- Combining two words followed by simple sentences

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Developing language

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- 2 to 5 years
- Expressive vocabulary larger than 50 words (SLI, SELD if not)
- Combining words into sentences
- Not yet acquired all the basic sentence structures

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Standardized tests

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- Standardized administration and scoring procedures
- Compared to a normative sample
- Often broad based
- Provides quantified relative scores
- Some empirical evidence of validity and reliability

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Overview of considerations

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- Length of time to administer and score
- Purpose and uses of tests
- Recognizable names and descriptions of subtests that make sense
- Items, directions, and scoring rules are clear and practical
- Score types are provided and match current practice/local regulations

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Diagnostic accuracy

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Specificity and sensitivity

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z score

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- Mean = 0, SD = 1

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t score

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- Mean = 50, SD = 10

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Floor effect

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- Too hard for youngest

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Ceiling effect

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- Too easy for the oldest

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-.5=
-1=
-1.5=
-2=
If mean=100 and 15sd

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30%= 93
16%=85
7%=78
2%=70

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Phonological processing tests

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- RAN = rapid naming

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Confidence intereval=

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SEM

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If a pretest measure is 78 and the confidence interval is +or- 7 what scores are needed to be reliable and what scores are needed to show improvement

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- 86 and from the 7th % to the 16%
Always need to be above the confidence interval