Posted in Assessment, Cognition & Executive Function, Special Populations

Special Populations: Navigating Diagnoses

I think one of the most interesting parts of finally practicing as an SLP will be having the opportunity to work with children who have speech and language concerns as just one part of a broader disorder or disability. Some of the disorders that we learned are commonly co-morbid with developmental language disorder (DLD) include:

Attention Deficit Hyperactivity Disorder (ADHD)
Primary symptoms of ADHD include inattention, hyperactivity, and distractibility.
• Although ADHD and DLD have similar prevalence rates, awareness of ADHD is much greater and only ADHD rates are being tracked in healthcare service data.
• Studies have shown that children with ADHD show increased maze behaviour during conversation.
• Executive function and continuous performance measures do not clearly differentiate DLD from ADHD due to concerns around their validity (i.e., some children with ADHD will not have executive function deficits).
• Informant ratings (i.e., from parents, teachers, etc.) of the child’s attention, impulsivity, and defiance appear to be more useful measures for differentiating ADHD from DLD (especially when language-loaded items are removed from analysis).

Auditory Processing Disorder (APD)
Children with APD tend to have difficulties processing information and speech in noise.
• When differentiating children with APD and DLD, Ferguson et al. (cited below in Additional Resources) found that the following measures did not differentiate the two disorders:
– Structural language
– Social/pragmatic
– Attention ratings (item analysis suggested possible qualitative differences)
– Speech intelligibility in quiet or noise (despite being the most commonly reported symptom of APD)
– Intelligence (verbal or nonverbal)
– Reading
• Thus, Ferguson et al. concluded that the child’s diagnosis of APD or DLD was determined based on the referral route (i.e., referred to an audiologist vs. a speech-language pathologist)

Autism Spectrum Disorder (ASD)
ASD is characterized by impairments in social communication and social reciprocity, and by the presence of restricted interests and repetitive behaviours.
• DLD can occur co-morbidly with ASD, but ASD cannot occur co-morbidly with social communication disorder (SCD).

Social (Pragmatic) Communication Disorder (SCD)
SCD is defined by a primary deficit in the social use of nonverbal and verbal communication.
• Individuals with SCD may be categorized as having difficulty in using language for social purposes, appropriately matching communication to the social context, following rules of the communication context (e.g., turn-taking), understanding non-literal language (e.g., jokes, idioms, metaphors), and integrating language with nonverbal communicative behaviours.
• Sufficient language skills must be developed before higher-order pragmatic deficits can be detected, so a diagnosis of SCD should not be made until children are 4–5 years of age.
• DLD can occur co-morbidly with SCD, but SCD and ASD are mutually exclusive disorders (the presence of one means the other cannot occur co-morbidly).
• SCD may be considered by some as the “middleman” on a continuum between DLD and ASD

This graphic created by Dr. Lisa Archibald demonstrates some of the shared characteristics between DLD and the above-mentioned disorders. Difficulties with pragmatic and social communication skills (i.e., identifying nonverbal communication markers, following conversational rules, etc.) are present in all of the disorders, which I think highlights how a very diverse variety of skills influences an individual’s ability to be socially competent (i.e., executive functions like attention, language, ability to process information, etc.).

disorders

For more information, check out these additional resources:
Ferguson, M. A., Hall, R. L., Riley, A., & Moore, D. R. (2011). Communication, listening, cognitive and speech perception skills in children with auditory processing disorder (APD) or specific language impairment (SLI). Journal of Speech, Language, and Hearing Research, 54(1), 211-227.

Redmond, S. M. (2016;2015;). Markers, models, and measurement error: Exploring the links between attention deficits and language impairments. Journal of Speech, Language, and Hearing Research, 59(1), 62.

Swineford, L. B., Thurm, A., Baird, G., Wetherby, A. M., & Swedo, S. (2014). Social (pragmatic) communication disorder: A research review of this new DSM-5 diagnostic category. Journal of Neurodevelopmental Disorders, 6(1), 41.

CanChild’s Autism Classification System of Functioning: Social Communication
https://www.canchild.ca/en/resources/254-autism-classification-system-of-functioning-social-communication-acsf-sc

The Communication Matrix
https://communicationmatrix.org/Matrix/About#forPractitioners
• An assessment tool for children who are not speaking or writing to communicate

Posted in Cognition & Executive Function

What’s in a Label?

ASD, ADHD, SLI, DLD…the list goes on! All of these acronyms represent a label which may be associated with a child receiving speech and language services (i.e., Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder, Specific Language Impairment, Developmental Language Disorder, etc.). It can seem overwhelming to navigate an abundance of diagnostic labels, and this is especially true in the domain of language. Currently, there is no agreed upon label used to universally describe children with unexplained language problems.

In a review of terminology used for this population, Professor Dorothy Bishop at the University of Oxford found that 132 different terms were being used to describe children with unexplained language problems. Consistency and consensus across professionals regarding which label to use to describe children with unexplained language disorders could allow the focus to shift to how to best serve and support this population, rather than how to label it.

Some may argue that a label isn’t needed in order to set goals and establish an intervention plan for a child with a significant language problem. However, establishing diagnostic criteria for what constitutes a significant language problem allows clinicians to determine who needs help and researchers to determine which children to study in interventions. Professor Bishop’s review also provided a table with some interesting pros and cons for diagnostic labels:

pros-and-cons-of-labels
Table taken from Bishop (2014), cited below.

It’s difficult for me to be vehemently for or against diagnostic labels, because there are valid points on both sides of the argument. In terms of labels being detrimental, I can certainly see how a label can be associated with stigma or negatively influence the construction of a child’s identity. However, when conducting a mental “risks vs. benefits” analysis, I think that if a label allows a child and his or her family to receive the supports they need it is worth the potential adjustment to the label. A label may actually serve as a source of relief for parents, since it may finally explain the difficulties encountered by their child! Our role as an SLP doesn’t stop at providing services for the child; in situations where children, parents, or other caregivers may find it difficult to accept a diagnostic label which is now part of the child’s identity, we must support families and provide them with the appropriate resources to move forward.

For more information, check out these additional resources:

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.

Categories of Exceptionalities for Special Education in Ontario:
http://www.peopleforeducation.ca/faq/what-are-the-categories-of-exceptionalities/

Posted in Cognition & Executive Function

The Neurocognitive Model of Language & Executive Function

The neurocognitive model of language and executive function (I know…it’s quite a mouthful!) allows us to create and store representations of the world around us. This provides us with language (a label system for our representations) and mental life (i.e., mental thoughts and actions, the ability to manipulate thoughts in novel and alternate ways, ability to set goals, etc.).

The featured image above (created by Dr . Lisa Archibald) illustrates the interaction between all of the elements involved in our representation system. Throughout our Development Language Disorders course we are learning how one of these elements (i.e., working memory) or a combination of these elements (i.e., experience-based knowledge network) can have huge implications on a child’s ability to learn and make progress. The Model also highlights the importance of differentiated instruction and a universal design for learning approach (i.e., providing multiple means of representation, action and expression, and engagement in activities) which allows all children to participate and achieve success.

Thus, it is important for SLPs to consider the neurocognitive model during both assessment and intervention for a variety of reasons:

  • The model allows us to consider a child’s cognitive competencies as a whole (i.e., experience-based knowledge network, language skills, time and space awareness, metacognitive skills, fluid intelligence, crystallized intelligence, etc.) and this may alter which tools we choose during assessment (i.e., informal vs. standardized assessment, dynamic assessment, etc.) and service delivery (i.e., structured drill vs. following the child’s lead).
  • Using materials which are salient and culturally appropriate to the client may allow better activation of the child’s experience-based knowledge network (i.e., pragmatic knowledge, semantic knowledge, and episodic memory) and thus increase participation.
  • To establish entrenchment of a particular grammatical form the child must be provided with frequent exposure to the target (i.e., via distributed practice).
  • A child’s affective qualities (i.e., personality traits, temperaments, self-regulation skills, etc.) can impact the “ease” of assessment (i.e., easy to test vs. more difficult to test) or influence the format which will be most effective during intervention (i.e., working in a small group, one-on-one intervention, etc.).
  • A child’s conative qualities (i.e., impulse, desire, volition, striving, coping, etc.) will also determine if they have the motivation to complete tasks and the self-regulation required to attend to tasks in various settings.
  • We must consider the child’s environment (i.e., exposure to experiential opportunities, social relationships, classroom practices, etc.) and whether it is conducive to the child’s individual needs and learning. If it is not, we must consider which elements of the environment can be altered (i.e., classroom environment vs. experiential opportunities at home).