Language Disorder and Developmental Language Disorder
Language is the term used for the words, grammar and sentences that we understand and use to communicate. Language is both receptive; understanding what someone is saying, and expressive; being able to use words, phrases and sentences to communicate our thoughts and ideas. The term language disorder refers to children who have difficulties understanding and/or using language which significantly impact on their ability to communicate effectively and to make academic progress.
There has been ongoing debate about the most appropriate terminology to use for children that have difficulties with understanding and/or using language. Until recently, lots of different terms were used including Specific Language Impairment (SLI), language disorder and language impairment. In 2016, an international group of experts, called the CATALISE panel, reached a consensus on the terminology to be used for children with language difficulties, which is outlined below.
Language and Communication Needs (LCN)
SLCN is an umbrella term used when speaking about all children who have difficulties with speech, language and communication skills. Children with SLCN may have difficulty in one of these areas, or more than one. If a child doesn’t have difficulties with speech sound production, they may be described as having Language and Communication Needs (LCN). This diagnosis is given when a child has difficulties understanding and using language, but they do not meet the criteria for a diagnosis of language disorder.
The term language delay was previously used to describe children whose language skills appeared to be developing in the same way as typically developing children, but at a slower rate. This was previously contrasted with a language disorder profile where children had a spiky range of skills developing at different levels. There is a lack of research, however, to back up these traditional delay and disorder profiles, as many children with language disorder have a flat profile of skills, with all areas of language presenting as severely disordered. It is recommended that the term language delay is, therefore, no longer used and children who do not meet the criteria for a diagnosis of language disorder, would be described as having LCN.
If they meet the criteria for a diagnosis of language disorder, children can be given one of two diagnostic labels; Developmental Language Disorder (DLD) or Language Disorder in association with…
Developmental Language Disorder (DLD)
The term Developmental Language Disorder (DLD) is used when children have a language disorder that is not associated with another condition that would also result in language and communication difficulties, such as Autism Spectrum Disorder (ASD), Down’s syndrome or hearing impairment. Children can have a diagnosis of DLD and another condition that does not cause communication difficulties, such as ADHD or a motor disorder.
Children with DLD have significant difficulties with understanding and/or use of language which affect their spoken and written language skills. Their language abilities are substantially below those expected for their age, which results in difficulty functionally communicating, participating socially and accessing the curriculum. These difficulties are persistent; they start in early development and continue throughout childhood, the teenage years and into adulthood. This means that without support, these children have a poor prognosis.
A diagnosis of DLD is usually not given to children under 5 years of age, as part of the diagnostic criteria is that the language difficulties are persisting, which can be difficult to determine before this age. If a child has significant language difficulties which are likely to persist, the diagnosis may be given earlier, but many children under five would receive a diagnosis of LCN.
Language Disorder in Association with…
This diagnosis is given to children who have a language disorder, but they also have a co-occurring condition that causes language and communication difficulties, such as ASD or Down’s syndrome. For example, if a child had a hearing impairment and a language disorder, the child’s diagnosis would be Language Disorder in association with hearing impairment. The diagnosis does not mean that all of the child’s language difficulties are due to their co-occurring condition, but they are likely to be due to a combination of the diagnoses.
Myth Busting
Is DLD caused by poor parenting?
The cause of DLD for most children is not known and it is a common misconception that it results from poor parenting and lack of language input during development. DLD is more common in areas of socio-economic disadvantage, but it is likely that there are several interacting genetic and environmental factors, rather than one single cause.
Will children with DLD just grow out of it?
Research strongly indicates that children starting school with limited language are very likely to have language difficulties throughout their school years and into adulthood. Children with DLD have been found to maintain a 2-3-year gap in language skills during the first three years of primary school, with little evidence of ‘catching up’. The language difficulties of children with DLD are thought to be stable, therefore, without support they will not ‘grow out of it’.
Does speaking two languages make DLD worse?
Bilingual parents often ask whether they should only speak one language, or just use English at home. Research clearly indicates that exposure to two languages does not cause or complicate DLD or language disorder. It is best for children to have a high-quality language model, so parents are recommended to speak to their child in their strongest language, which often will be their mother tongue. To diagnose DLD in children who are bilingual or EAL, their first or home language needs to be assessed, as DLD would span both or all languages the child has.
Do children with DLD have poor general learning ability?
Children with DLD have identified difficulties with language and communication skills, where there is no other known reason for their difficulties. This means that children with DLD can vary in terms of their general learning ability, but a child with DLD could not have a Learning Disability (IQ below 70). Children with DLD often have a good general learning ability in contrast to their significant language difficulties, which impact on their ability to learn. This is why many children with DLD have the intelligence to use good strategies for masking their difficulties. With the correct support in place for their underlying language difficulties, children with DLD are able to demonstrate good progress with their learning.
Prevalence of DLD and Language Disorder
The prevalence of DLD is estimated to be 7.58% of the population, equating to two children in every class, meaning that the condition is more common than ASD. The language difficulties for children with DLD are felt to be stable and persistent, so it is felt that this figure can be applied to the teenage and adult population. The prevalence of children with Language Disorder in association with another condition is 2.34% and, therefore, the total prevalence of children with Language Disorder is 9.92%, affecting nearly 1 in 10 children.
This graph shows the national picture for the prevalence of language difficulties in children.
Difficulties
DLD can affect different areas of language to varying degrees, resulting in each child presenting with a different profile of strengths and difficulties. Some or all of the following language domains may be affected and, in addition to the diagnosis of DLD being given, a SaLT should specify which domains of language are affected. Many of the general strategies for supporting children with SLCN will be applicable for children with DLD and specific strategies for supporting them would be identified by the SaLT following assessment.
Semantics (understanding meaning)
The ability to understand the meaning of words and how words are related to each another is called semantics. Children with DLD often have difficulty understanding and learning new words and may have a very limited vocabulary. For words that the child does know and use, their knowledge is likely to be very shallow with weak links to other words.
This significantly impacts on their ability to understand spoken information within the classroom, participate in class discussion and activities, follow instructions and make academic progress.
Top Tip
Pre- and post-teaching of curriculum topic vocabulary and concepts can support children to access classroom learning. It is important to also target easier words linked to topics to help children to fill in gaps in their knowledge, and high frequency words that are used throughout different lessons regardless of topic, e.g. explain, describe.
Phonology
Refers to the rules that govern how sounds are combined into words. Children with DLD who have difficulties with phonology may have difficulty distinguishing between different sounds. Difficulty identifying and manipulating speech sounds within words (phonological awareness) may affect the child’s speech sound skills and is likely to impact on development of their literacy skills. See the speech disorders section for further information about phonological disorders.
Top Tip
When teaching new vocabulary and concepts, focus on the sound structure of the word (e.g. syllables, first and last sounds, rhyming words), as well as the meaning of the word, to build up a strong knowledge of word sound structures.
Grammar
The area of grammar includes syntax (rules for how to combine words into sentence structures) and morphology (adding grammatical parts to words, e.g. past tense -ed). This is usually a key area of deficit for children with DLD and their expressive language is often characterised by the use of short simple sentences, with difficulty maintaining the correct word order. This impacts on their ability to successfully convey who, when and what they are speaking about.
Children’s understanding of grammar can be affected as well, for example difficulty understanding complex sentence structures. ‘The girl was pushed by the boy’, may be understood as the girl is doing the pushing. This means that they have significant difficulty understanding complex spoken information.
Top Tip
Use a structured visual approach to support children to identify types of words (e.g. noun, verb, adjective), and to understand which elements are needed to create spoken and written sentences. Sentence planners and colourful semantics are useful for this.
Word Finding
Vocabulary is thought of as the building block of language and the foundation for development of other language skills. In addition to weaker systems for learning vocabulary, children with DLD often experience word finding difficulties, where they know the word they want to say, but retrieving it is very challenging.
This significantly affects the child’s ability to express their thoughts and ideas successfully. Their spoken language can often be characterised by over-use of non-specific words, e.g. “He’s doing that”.
Top Tip
Encourage the child to talk around a word they are unable to remember, e.g. giving its category, function, location and description, which can help the listener to understand what they are trying to say. Play games to develop this skill, where the child needs to describe something for you to guess and vice versa.
Pragmatics
Pragmatics refers to the use of language in social contexts, including the skills for turn taking, maintaining a topic of conversation and being able to repair conversational breakdowns. It
looks beyond the literal meaning of language, so we can understand what people really mean when they are talking. This helps us to understand implied information, for example ‘What time do you call this?’ could be asking for a literal response of a specific time, but the implied meaning is that the person is late.
Children with DLD often struggle to use their language successfully for different functions, such as to tell a story/event in a logical sequence or to explain and reason. They have difficulty understanding non-literal language, such as idioms or metaphors and will have difficulty making inferences from spoken information. This means that they find it hard to change what and how they are saying something depending on different contexts and listeners.
Top Tip
Don’t completely avoid using non-literal language (e.g. idioms, metaphors), as this is used frequently in the child’s other communication contexts, but ensure that you explicitly explain the meaning of what you are saying, using the context and visuals you are working with others and not get into so many arguments.
Verbal learning and memory
Weaker memory for spoken information results in significant difficulty remembering and understanding information that is presented verbally, which within lessons refers to a significant amount of the information presented. Spoken language is only available for a limited amount of time before it is gone, meaning that children with poor verbal memory are unable to process, remember and make sense of the information quickly enough.
This significantly impacts on their ability to follow instructions, learn new vocabulary and concepts, access classroom input and to problem solve as they will have difficulty holding all of the information in their head.
Top Tip
Support verbal information with visuals, e.g. pictures, symbols, gestures and written word, and allow time for processing before expecting a response, e.g. 10 second rule.
Impact of DLD
Language and communication skills underpin everything that we do and are skills that we can take for granted. DLD is often described as a ‘hidden’ difficulty as you cannot always easily tell if a child is having difficulty understanding and/or using language. Some children are very adept at developing strategies to mask or compensate for their difficulties, such as copying other children or using gestures and visual prompts to follow instructions, without actually understanding all of the language. This means that many children’s language needs are not identified until their difficulties accessing learning, paying attention in class, making friends and/or challenging behaviour do get them noticed.
Myth Busting
Can you observe if a child has difficulty understanding language?
If a child fails to complete a classroom instruction, it might be because they did not understand. However, if they do complete the instruction correctly, you cannot be sure that they understood the words. They may have understood the context, they may have followed any visual clues, such as hand gestures, that you used, or they may simply be copying the other children. Unless you test understanding, you cannot be sure a child has understood all of the words you have used, and observation alone will not pick up difficulties understanding language.
If children with DLD are not identified and supported, they are at risk of long-term difficulties in the following areas:
| Impact of DLD: | Research: |
| Low attainment: Difficulty accessing education and making progress | • Just 26% of young children with SLCN made expected academic progress in the Early Years Foundation Stage compared with 69% of all children.
• Just 15% of pupils with identified SLCN achieved the expected standard in reading, writing and mathematics at the end of their primary school years compared with 61% of all pupils. • Only 20.3% of pupils with SLCN gained grade 4/C or above in English and maths at GCSE, compared with 63.9% of all pupils. (DfE 2017) • Language was found to be stable at an individual level over the first three years of school and there is little evidence that children with language disorders are narrowing the gap with peers. (Norbury et al 2017) |
| Literacy difficulties: Poor development of literacy skills, as understanding and use of language underpin reading and writing | • Early speech, language and communication difficulties are a very significant predictor of later literacy difficulties. (Snowling 2006)
• Children with language difficulties at age five were four times more likely to have reading difficulties in adulthood. (Law, Charlton & Asmussen 2017) |
| Mental health difficulties: Difficulty successfully socialising with others and making friends, often leading to low self-esteem and anxiety | • Children with language difficulties at age five were three times as likely to have mental health problems, and twice as likely to be unemployed when they reached adulthood. (Law, Charlton & Asmussen, 2017)
• Adolescents with DLD report more social stress and are more likely to be bullied and victimised by peers (Durkin and Conti-Ramsden 2010, Wadman et al 2011) • Anxiety was higher in young people with language impairment than age matched peers and remained so from adolescence to adulthood. (Botting et al 2016) |
| Behaviour difficulties: Social, emotional and mental health difficulties, and challenging behaviour increasing as children move up the school | • Estimates of the proportion of children who have co-existing language difficulties and Emotional and Behavioural Difficulties (EBD) vary between approximately 40% to over 90%. (Benner, Nelson and Epstein, 2002)
• Three quarters of young people in the UK youth offending system have below average communication skills, and just under a third have diagnosed speech, language and communication needs. (Early Intervention Foundation 2017) |
| Reduced employment opportunities: Poor employment prospects and socio-economic disadvantage | • 88% of long-term unemployed young men have been found to have SLCN. (Elliot, 2011)
• Compared to typically developing peers, a higher proportion of young people with DLD draw on support, primarily from parents, in various financial tasks, including paying bills, choosing financial products and taking loans from family or friends. (Winstanley et al 2018) |
It is important to remember that if a child is having difficulty accessing learning, struggling to concentrate in class or displaying difficult behaviour, they may have an underlying SLCN which needs to be identified so that the correct support can be put in place. Putting strategies in place to solely support the child’s learning, attention, social skills or behaviour will not be effective, as this does not work on their underlying areas of need.
When to refer
Children with DLD need to be identified as early as possible, so that support can be put in place to enable them to access learning and make progress. It is recommended that all children entering school are screened to determine whether they have any language difficulties, which may indicate DLD or language disorder. Completing the Language Link assessment with all children in Year R will determine which children have age appropriate language, which children have LCN and need to be supported by an intervention programme in school, and which children are at a risk of having DLD and need to be discussed with SaLT.
Early identification doesn’t just mean identifying children in pre-school and Year R. Some children will manage well in school during the first few years and then start to struggle as the language demands of the classroom increase, for example when they have to use higher level language skills such as making inferences or using their language to explain and reason. As soon as a child starts to have difficulties with accessing learning and communicating, it is important that they are screened to determine whether they have an underlying SLCN that needs support.
Top Tip
If a child in your care has behaviour difficulties, always check their understanding of language has been assessed.
Role of SaLT
Children that are referred to SaLT and accepted will have an assessment to determine their diagnosis, including the areas of language that they are struggling with and the impact of these for them. Support from SaLT may include devising a programme of targets to be worked on with the pupil in school, advice and training to support schools to integrate strategies into the classroom to support the pupil to access learning and/or direct therapy support, as appropriate. Direct therapy will include work to develop the child’s language abilities to their full potential and to teach them to use strategies to reduce the impact of their difficulties within the classroom and other communication environments.
Further Information
Raising Awareness of Developmental Language Disorder (RADLD) – www.radld.org
NAPLIC DLD Resources – www.naplic.org.uk/dld
Afasic – www.afasic.org.uk
The Communication Trust – www.thecommunicationtrust.org.uk
RCSLT DLD Overview – www.rcslt.org/speech-and-language-therapy/clinical-information/developmental-language-disorder
Read more about DLD in The Link magazine, issues 16, 15, 14, 13 & 10.
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