By Nikolaos Damaskos, Speech Language Therapist and
student of the Master in Speech-Language Pathology and Lerning Difficulties
Screening is an essential part of assessment methods for speech and language therapists. Suspecting a Language Disorder (LD), or examining a child with Speech Delay (SD), leads to formal or informal methods of screening of spoken language skills. It should be noted that terminology provided across references throughout this thesis is characterized by a plethora of terms alongside LD, such as Language Impairment (LI), Developmental Language Disorder (DLD), and Specific Language Impairment (SLI). Developmental Language Disorder is a neuro-developmental condition that emerges in early childhood and in many cases persists into adulthood. Screening will be implemented to explore the need for further future assessment (American Speech-Language-Hearing Association, n.d.). Prevalence of DLD in a UK population study has been estimated about 7.58% (Norbury et al., 2016). Phonology, morphology, syntax, semantics, and pragmatics are all language areas that can be affected. The consequences for children facing developmental language disorders have been reported to result in academic difficulties (Tomblin et al., 2000), emotional or behavioural difficulties (Yew and O’Kearney, 2013), and longitudinal effects in social life (Mok et al., 2014). Warning signs of LD can be evident through different ages between preschool and school aged children. Therefore, it is important to identify such difficulties as early as possible and plan adequate intervention strategies.
Screening has also proven helpful to acknowledge the impact of global public health restrictions introduced after the outbreak of the COVID 19 pandemic. Unrestricted development of communication skills and insufficient opportunities for communication, due to a larger than usual exposure of young children to screen time, have led many teachers to express their concerns in a report published by I CAN (2021). Catching up the potential of peers in communication is yet to be proven, but screening tools can prove advantageous, in order to identify potential difficulties or persistent problems.
Nonetheless, there is also an ongoing discussion on the efficacy of screening tools and as a result on early intervention strategies, regarding children with language disorders or speech delay. The time period that falls under the spotlight is under the age of five years old. Interestingly, the 2006 report of the US Preventive Services Task Force on Screening for speech and language delay in preschool children concluded that data on what it was claimed as key issues were not available. The study of screening aspects was also reported as inadequate, and subsequent trials of intervention were deemed as limited in terms of generalizability (Nelson et al., 2006). Updating evidence from the previous study, there was another review (Wallace et al., 2015), which in turn reported the ability of some screening tools to identify accurately children in need of diagnosis, and additionally the possibility that some of the intervention strategies applied may have been successful to a certain extent. By assessing the efficacy of universal screening for language and speech delay in children under 5, Jullien (2021), concludes in her study that there is not sufficient evidence, supporting the effects of early screening (primary care setting). No short-term or long-term effects were suggested on the speech or language outcomes, even though no harm was either reported as a result of early screening. Findings in general seem to be inconclusive regarding such a delicate matter.
There is a tendency to acknowledge the efficacy of formal screening tests in distinguishing children that may be in need of further diagnosis, but lack of data, or studies that may be limited in design, or even perhaps have weaknesses in planning and execution have not yet led to solid findings.
For many professionals in the field DLD is by nature compelling because of the many and different systems involved (Phonology – the speech sounds and rules for combining that make up words, Morphology – the rules for forming words or parts of words, Syntax – the rules for combining words into sentences, Semantics – the meaning of words and sentences, and Pragmatics – the rules for using language in social situations such as conversation). The overlapping nature of these systems also results in many and different language patterns in children with DLD. It would be a logical assumption that the plethora of language patterns manifested in DLD, make it difficult for non-professionals to recognize the symptoms. And yet the ability to recognize symptoms could lead to screening and possible intervention and in the long term more data available for future research.
It has long been described as an invisible disability (Patchell, and Hand, 1993), but since then not many things have changed on the way DLD is being perceived. Besides the numerous terms used to describe it in the past, recorded as many as 32 different terms in relevant literature by Bishop (2014), there are also other factors that still render DLD an invisible disorder. The absence of physical signs in children with DLD, does not allow for anyone to speculate on the possibility of such a disorder. Daily communication and coping with familiar situations are going to be based on language skills that almost the majority of children with DLD will be able to develop. Only in cases of complex language demands will children with DLD start to show weaknesses and are required to put much effort. In a sample taken from children in Australia, who exhibited speech and language difficulties, the children with speech disorders were more likely to be diagnosed and be provided with treatment Skeat et al., 2010). Moreover, parents, the second group of adults beyond teachers, who are in a constant state of observing and comparing their children and their abilities to others, even they are not able to compare successfully the abilities of their children when it comes to language development or language abilities in general (Hendricks et al., 2019). But even in teachers it is interesting that even in older ages of elementary schools; they still remain without confidence, but most importantly without specific knowledge, on how to cope with DLD (Marshall et al., 2002).
In addition to the reasons on why DLD remains “unseen” the sense of professionals in the field that popular knowledge on that matter is low has to be validated again by facts. In reality many people might be able to provide information on autism, ADHD and dyslexia, but they do not succeed when faced with the term DLD. And even in some cases the information portrayed by people on DLD could be mistaken, as has been proven with the help of an online small scale survey in Australia (Kim et al., 2022). This particular lack of popularity, and especially knowledge on DLD, could be attributed to the high rates of comorbidity prevalent in DLD with other disorders. Based on the idea that reading comprehension as a procedure requires children to exhibit sufficient abilities in both decoding and linguistic comprehension. Snowling et al. (2020), have found that indeed reading difficulties are present in children with dyslexia or DLD. High rates of co-occurrence have been also reported between DLD and ADHD, both very common developmental disorders (Mueller & Tomblin, 2012). And continuing with the relationship between DLD and autism, many commonalities have been discussed based on deficits exhibited in language and communication, but there have also been suggested possible links between them, perhaps the existence of a subgroup of children in the autism spectrum disorder that manifest language disorder (Georgiou & Spanoudis, 2021). It is not unusual for children being diagnosed with dyslexia, ADHD, and sometimes being diagnosed with DLD and after some years the initial diagnosis is changed to learning impairment. For Speech and Language Pathologists in school settings there have been reported limited diagnostic labelling or the use of terms descriptive to the situation, avoiding the term DLD (Ash et al., 2020). Educational constraints are common in that matter and further enhance the problem of public awareness on the topic of DLD.
The general attitude prevalent in the United States for example, treating DLD inside the educational procedure is at odds with how other “famous” developmental disorders are handled (e.g., ADHD, autism), which in turn will be diagnosed easily by a medical staff and treated alongside the educational procedure and not exclusively through education alone (McGregor, 2020). As a result, it further undermines the assessment efforts and the communication of the need why more research is required in general around DLD.
For Speech and Language Therapists it is common practice to inform people on early identification signs, regarding the development of speech and language in children, and it is focused mainly in the time period 0 to 3 years old, or extending to the age of 5 years old, in order to achieve early identification and intervention, if needed (ASHA). Such a process, called screening can be performed either formally, or informally, and it will lead children identified as having difficulties to diagnostic procedures. But most notably, as shown by the 2006 report of the US Preventive Services Task Force, it remains to be proven:
– The convergence between language screening tools for preschool ages and current developments in the study of preschool language development. Reliability and content.
– Whether they can be administered in certain age groups.
– Whether screening tool administration to children can be effective following certain rules.