Topics in Language Disorders:
Oral and Written Language Connections within Children and across Disciplines
Cross-Disciplinary Dialogue about the Nature of Oral and Written Language Problems in the Context of Developmental, Academic, and Phenotypic Profiles
Silliman, Elaine R. PhD; Berninger, Virginia W. PhD
Author Affiliations: University of South Florida, Tampa (Dr Silliman); and University of Washington, Seattle (Dr Berninger). Dr Silliman is a speech-language pathologist and Dr Berninger is a licensed psychologist.
Elaine R. Silliman, PhD, University of South Florida, 4202 E Fowler Ave, PCD 1017, Tampa, FL 33260 (email@example.com).
Grant P50 33812 from the National Institute of Child Health and Human Development (NICHD) to the University of Washington supported the research on diagnosing specific learning disabilities affecting written language.
Professionals across disciplines who assess and teach students with language problems should develop their own standards for best professional practices to improve the diagnostic and treatment (instructional) services in schools and nonschool settings rather than assessing only for eligibility for categories of special education services according to federal and state special education laws. Participation of professionals from multiple disciplines on teams is necessary but not sufficient unless cross-disciplinary conceptual frameworks are developed and used. Best practices for assessment and intervention for language problems should take into account the patterning of test and other assessment data within 3 kinds of profiles: (1) domains of development—cognition/memory, oral language, sensory and motor, attention and executive function, and social emotional; (2) academic skills—reading, writing, and math; and (3) phenotypes specific to neurogenetic or neurodevelopmental conditions that may apply to the case at hand.
Well I’ve often seen a cat without a grin, but a grin without a cat, thought Alice. It's the most curious thing I ever saw in all my life!
Alice's Adventures in Wonderland
(Lewis Carroll, 1866)
MANY DISCIPLINES (e.g., linguistics, psycholinguistics, sociolinguistics, neurolinguistics, child language development, speech–language pathology, and reading and writing assessment and instruction) generate knowledge of language through research. Professionals in multiple disciplines, each with relevant knowledge for serving students with language problems, lack conceptual models for integrating their knowledge across their disciplines for purposes of applying it to educational practice for these students. A consequence is that taking into account the cat with the grin (the context of assessment) does not happen; instead, the grin without the cat (no context of assessment) is& the rule. Of great concern, current federal and state eligibility criteria tend to be based on a variety of measures without considering (a) patterning of scores across relevant profiles for diagnosing nature of disability, (b) explaining etiology (possible or probable causal paths), and (c) predicting prognosis or reasonable expected outcome.
Authentic and valid evidence comes not only from research to practice in top down fashion but also from practice (what worked for whom and under what conditions or description and explanation of an individual case; Rosenfield & Berninger, 2009). The following cases from the second author's clinical experience illustrate the consequences of not having conceptual frameworks that take into account the context of assessment data.
THREE CASE EXAMPLES
An adolescent was diagnosed with Asperger syndrome due to language and social interaction problems noted during an interview by a private practice psychiatrist. Parents were concerned why phonological awareness training had not helped the child move beyond a beginning reading level. Only when the multidisciplinary team asked to review all assessments available from preschool to present was it noted that the child's cognitive functioning consistently fell 3 SDs below the mean; and all other domains of development were more than 2SDs below the mean and outside the normal range. Ironically, the areas of relatively higher but not normal functioning were in language and social development. The mental age for language and cognition had not reached the 6-year level, when children typically begin to read, even though the student was an adolescent. Nor did the student show evidence of emerging, prereading skills typically observed in the preschool years. Would the instructional program have been more developmentally appropriate for this child if the whole developmental profile across domains had been taken into account instead of skills in isolation? Had that happened, the school might have provided instruction relevant to emerging literacy at the student's cognitive, language, and other developmental levels and the educational outcomes would probably had been better—even if not at grade level, at least developmentally appropriate.
A speech–language pathologist (SLP) found that a third grader referred for significant reading comprehension problems did not meet state criteria of 2 SD below the mean in oral comprehension and production for special education services under the speech and language impairment category. The SLP also noted that the student's informal conversation appeared to be age appropriate. Subsequently, a psychologist found that the child had significant morphological and syntactic awareness problems (range, 3–4 SDs below the mean). Research has shown that linguistic awareness of morphemes in words and words in syntax, which is not the same as producing morphemes and syntax during informal conversation, is related to reading comprehension (e.g., Foorman, Arndt, & Crawford, 2011). What might the outcome have been if the SLP did diagnostic language assessment, as discussed by Scott (2011), Apel and Apel (2011), and Troia (2011) in this issue? Such assessment activities could have identified morphological and syntactic awareness as targets for treatment within a reading program that taught reading comprehension strategies (see Foorman et al., 2011).
A child who was not responding to timed repeated oral readings was referred for reading fluency problems. Diagnostic assessment showed a reading rate 1.33 SDs below the mean, but the only impaired oral language skill of the many assessed was verbal fluency (i.e., the ability to find, retrieve, and produce words from long-term memory in a time-efficient way). If this problem had been identified earlier would the child now have oral reading fluency problems? If the word finding problem had been documented earlier, relevant treatment would likely have been provided for both oral verbal fluency and reading fluency.
An important question is why the contexts of assessment have not been considered in reaching toward treatment-relevant diagnostic practices across disciplines. Our aim in this issue is to provide a wake-up call for professionals from different disciplines and professions that ignoring oral language problems—whether at the level of comprehension and/or production—is no longer acceptable because of the relationship of oral language issues to the more visible reading and writing problems. An initiative to develop cross-disciplinary models spearheaded by professionals can also transform best practices of professional disciplines and delivery of services to individuals with oral language problems. To begin this initiative for cross-disciplinary dialogue, we sketch some reasons why oral language impairment has remained largely invisible to the public and to many professionals. Next, we advocate for the use of case studies with profiles to illustrate diagnostic principles. Finally, we offer a possible starting point for a cross-disciplinary model by presenting developmental, academic, and phenotypic profiles for dysgraphia, dyslexia, and oral written language disability.
PERSPECTIVES OF A CHILD LANGUAGE SPECIALIST
The public invisibility of oral language impairment
Unlike the parent advocacy that engineered the movement for the learning disabilities concept, the language disabilities concept originated within the professional field of academic speech–language pathology. Master clinicians, such as Berry (1969) and Eisenson (1984), who recognized oral language impairment and provided treatment services to these children, spearheaded the effort. Both illustrated how best professional practices couldemanate from practice as well as from research. The difference in origin—parental political power versus professional initiative—is likely one reason why learning disabilities gained greater public visibility than language disabilities. As Bishop (2009) observed, language disabilities have “a public image problem” (p. 163).
A second reason for the lesser public prominence of language disabilities is that listening and speaking problems were not as obvious in school settings (except if one stuttered or had unintelligible speech) as was the struggle to learn to read. Reading problems are more noticeable because reading is necessary to complete class assignments, pass the grade, and indeed graduate from high school in an era of high stakes testing. Unless a student had severe problems in the comprehension or production of oral language, the student's problems in learning language were more likely to be ignored, undiagnosed, and untreated, or misdiagnosed as a behavior problem. By Grade 3, the student's classification might be learning disability (Mashburn & Myers, 2010) without taking into account the nature or severity of both oral and written language disabilities and other comorbid conditions.
A third reason for the relative invisibility of oral language impairment compared with learning disabilities was the widespread lack of attention to the well-established fact that learning to read and write draws on language just as learning to listen and speak do. For example, referring to “language, reading, and writing” mistakenly implies that reading and writing are not language, but both oral and written language are language (as discussed also by Apel & Apel, 2011). Recent evidence (Berninger & Abbott, 2010) shows there is a common language factor underlying language by ear (listening comprehension), language by mouth (oral expression), language by eye (reading comprehension), and language by hand (written expression). There is also unique variance associated with each language subsystem in which oral language or written language is linked to a sensory input or motor output unit.
The use of a case study profile to illustrate diagnostic principles
To begin with, a large body of research now links oral language learning with written language learning, including emergent literacy (e.g., Bishop & Snowling, 2004; Cabell, Justice, Zucker, & McGinty, 2009; Catts, Bridges, Little, & Tomblin, 2008; Pennington & Bishop, 2009; Scarborough, 2005; Silliman & Mody, 2008; Silliman & Scott, 2009; Skibbe et al., 2008). Yet, there is still insufficient attention to the preschool developmental origins of oral language problems, which may interfere in many ways with written language acquisition during the school age years. Using case studies may enhance professional awareness of the roles of developmental and school contexts in treatment-relevant diagnostic practices (see Mather & Fuchs, 2010). For example, consider the case of 9-year-old Kelly (a fictitious name for a child based on a composite of clinic cases).
* Kelly is currently 9 years old and in Grade 4. Her family consists of English-only speakers; both parents had some college. She has 2 younger sisters, ages 7 years and 6 years in Grades 2 and 1, respectively. The 7-year-old sister is also receiving modified instructional support for reading and writing.
* Kelly was a full-term baby, weighing 7 pounds, 1 ounce at birth. There were no problems with the pregnancy. Kelly sat independently at 6 months, stood up at 8 months, and began walking at 13 months. Her mother reported that Kelly used a few single words at 12 months and began to combine words into complete sentences at 36 months; the latter is the outer boundary of normal variation.
* Kelly attended preschool; she has not yet repeated a grade. By Grade 3, Kelly met benchmarks in phonemic awareness and fluency. On the Grade 3 state assessment in reading, she scored on grade-level for reading comprehension (65th national percentile rank) and mathematical problem solving (81st national percentile rank). Her lowest scores were on determining the main idea or purpose of a message and using information from multiple sources to reach conclusions.
* The following is based on mother's report about Kelly: She was an undemanding, easy to manage child. Her favorite activity is bowling and her favorite Grade 4 subject is math because “she's good at it.” She dislikes reading because she “struggles so hard with it.” She becomes easily frustrated when she has to write “longer sentences” based on her reading and writing assignments. The mother expressed concern that she will not do well on the state achievement test in writing, which she will take for the first time. Furthermore, she is a child who “works harder than normal to maintain a decent grade,” but one who has continuing difficulties with time concepts, word choices (e.g., thinking of words to say both at home and school), and inferencing. She is attentive when watching television, listening to a story, and playing with toys, but less attentive when she has to read.
* An excerpt of Kelly's practice writing of an expository text for the state writing assessment at grade 4 follows (original punctuation and spelling are retained). The prompt was: “Most of us have a favorite day of the week. Before you begin writing, think about a day of the week and why it is your favorite. Now explain why this day of the week is your favorite.”
My favorite day of the week is Saturday. Satuerday is favorite day of the week because at 9:30 am I have bolwing. It is fun because only friends are there… .The last day of bolwing we bolw with the lights off, song’s, disco and we get to eat…If you do realy well you will get trovey’s. I got three of them. So I move up a step. Alice and Molly did not move up a step.
* Kelly's fourth-grade teacher wrote on her practice paper that she had good ideas and good organization, but needed to work on adding some “wow” words, her spelling, and sentence structure.
Does Kelly have developmental oral language impairment or a specific reading impairment, such as dyslexia, or a specific writing impairment, such as dysgraphia? What kinds of assessments are needed to figure that out? It is a purpose of this article to provide a framework for answering such questions in a systematic way.
Defining late talking and interpreting its significance
We still face a puzzle with children like Kelly. Given the wide variability in the development of single word and syntactic constructions among individual children, at what point should professionals be concerned that oral language development is delayed? Do individual differences in these early oral language skills, such as late talking in sentences, predict later outcomes in oral language and written language disabilities after ages 4–5 years? Another complicating factor not yet answerable concerns whether or not there is a single cause or multiple causes of late talking (Thal & Katich, 1996). For example, prelinguistic communicative acts, gesture development, and synchronization of gesture with eye gaze and vocalization all play a role in assessing late talker profiles (Capone & McGregor, 2004; Crais, Douglas, & Campbell, 2004) and may be clinically significant factors that exert differential effects on subsequent language learning in the school years. We now consider research findings that are relevant to answering these questions.
Prelinguistic communicative acts
Early gestures serve to gain and sustain adult attention and convey communicative functions that then create multiple opportunities for the child's learning of language (Capone & McGregor, 2004). Assessing prelinguistic communicative acts has been shown to be a valuable diagnostic tool for nonverbal children with autistic spectrum disorder (Luyster, Kadlec, Carter, & Tager-Flusberg, 2008; Shumway & Wetherby, 2009; Wetherby, Watt, Morgan, & Shumway, 2007), but the evidence has not yet been reported for individual children who are late talkers with otherwise normal development. (For reviews of gestural development in detail from infancy to word combinations, see Capone & McGregor, 2004; Crais, Watson, & Baranek, 2009.)
Figure 1 depicts the relationships among intentionality, the two major categories of gestures (deictic and representational), and their respective subcategories that support three prelinguistic communicative intents that these gestures convey:
* Behavior regulation (such as protesting and the requesting of objects and actions).
* Social interaction (e.g., seeking the attention of another person, and the use of conventional representational gestures, such as quasi-participation in play routines like peek-a-boo).
* Joint attention (commenting as in pointing to a picture of mommy or daddy and vocalizing or showing or giving).
By approximately 15 months, which is a critical point for determining late talker status, the three functions should be used regularly with a variety of gestural intentions; thereafter, the use of gesture alone or vocalization alone begins to decrease as children become capable of coordinating the three types of gestures (Crais et al., 2009).
Late talker status
Most late talker data come from small longitudinal samples using parent report, which is often gathered with The MacArthur-Bates Communication Development Inventory (CDI; Fenson, Marchman, Thal, Dale, & Bates, 2007) combined with event sequence tasks in which children imitate representational gestures, such as feeding a teddy bear (Thal, Tobias, & Morrison, 1991). Also, these samples typically reflect middle class socialization practices. Nonetheless, Thal, Bates, Goodman, and Jahn-Samilo (1997) found considerable variability but that only about 10% of all youngsters met late talker status. For example, some children who scored at the 10th percentile for vocabulary production at 16 months (an age criterion for late talker status) scored above the 90th percentile at 30 months of age. However, there was stability in group patterns to a great extent from ages 13 to 32 months. In general, longitudinal data indicate that young children who start out as late talkers at 16 months tend to still meet late talker criteria at 32 months (the same stability holds true for precocious talkers; Thal & Bates, 1988; Thal et al., 1997; Thal & Tobias, 1992; Thal et al., 1991).
Types of late talkers
Two types of late talker profiles have been identified. They are characterized as follows:
1. Late comprehenders can first be identified at 16–18 months because they use fewer prelinguistic communicative gestures over the 16- to 30-month span compared to peers (Thal et al., 1991). Further research showed that this group understood fewer word meanings and produced fewer representational gestures than expected in familiar situations. Both variables were uniquely predictive of continued delay (Thal et al., 1997), consistent with previous findings that representational schemes, such as pretend play schemes where the infant brushes her hair with a banana, share common conceptual content with word meanings (Capone & McGregor, 2004).
2. Late producers exhibit normal prelinguistic communicative acts but delayed oral vocabulary production. Their use of gestures appeared to counterbalance the delay in the emergence of words suggesting “a positive prognostic sign” (Thal & Tobias, 1992, p. 1287). Resolution of the delay by age 3 years appeared to bode well for subsequent language and academic achievement (Thal & Katich, 1996), although the extent of success for individual children still remains to be verified. For example, it is unknown what proportion of late bloomers may actually present with a false recovery (Scarborough, 2005). Late bloomers may have renewed difficulty in Grades 3–4 when learning to read and write shifts to reading and writing as tools of learning.
Other longitudinal studies followed late talkers from age 2 years through the early school-age years (e.g., Paul, Murray, Clancy, & Andrews, 1997) or high school (e.g., Rescorla, 2009), but did not examine prelinguistic communicative acts or necessarily distinguish at early ages between late comprehenders and late producers.
Significance of late talking
Why might “late talking” occur in the presence of normal intellectual potential? Thal and Bates (1988) speculated as to the possible reasons: (a) temperamental or motivational factors to “produce fewer items on demand” (p. 121); (b) retrieval difficulties or low levels of access to representations in both the gestural and oral domains; or (c) information processing difficulties in both oral language and facets of cognitive functioning or less efficient synchrony between the components of the language and cognitive systems.
Relevance of case study for diagnostic profiles in learning disabilities
Kelly's mother did not perceive her to be a late talker, even though Kelly did not begin to combine words into sentences until 36months, the borderline between the normal and delayed ranges. Normative data (Fenson et al., 2007) indicate that by 30 months of age, about93% of toddlers are frequently combining words; hence, Kelly may have been a late producer, but one who did not fully “catch up” as a late bloomer (Thal & Tobias, 1992). Ellis and Thal (2008) noted that the majority of late producers had normal vocabulary development by age 3 years and normal discourse and syntactic abilities by school entry; however, about 3.5% of late producers subsequently developed a clinical profile of oral language impairment. Kelly may fit best in the 3.5% with a clinical profile, but one who, nevertheless, remained undiagnosed and underserved. For example, an analysis of a fictional oral narrative retelling,Stellaluna (Cannon, 1997), a story Kelly chose to retell, yielded minimal grammatical complexity for a child her age. Keeping in mind Scott's (2010) admonition that narrative discourse, unlike expository discourse, does not necessarily lead to complex grammatical productions, results indicated 32 T-units, 37 clauses (she produced only 5 subordinated clauses), and 266 words. Mean lengthT-unit was 7.18 and mean number of clauses per T-unit was 1.15, consistent with the low number of subordinated clauses. Her partial capability of formulating more complex dependent clauses was evident in her not so successful attempt at coordinating the elements of a conditional clause (in italics), which also contained two embedded infinitival clauses (in bold italics), “So then the mom stopped Stellaluna and–um—told her if she has/ to promise// to never ever do that again/.” There also were few instances of elaborated noun phrases, which would also add complexity. Combined with the obvious difficulty Kelly was having with inferring what her listener needed to know, the outcome was a narrative with minimal coherence.
As Kelly went through the lower elementary grades, she developed an aversion to reading and writing because both were a real effort for her. Furthermore, she showed some difficulty in making inferences, as the effort in taking the listener's perspective during the retelling also suggests, and with rapid word retrieval. Clinical assessment of word finding or verbal fluency (that is, executive functions for search-and-find in long-term memory) was not available for her, but if an SLP or psychologist could have tested this hypothesis (see Scott, 2011, on hypothesis testing) of slowed or less efficient word retrieval, a possible cause of her effortful reading may have been identified and then treated.
At the text level, Kelly struggled with spelling and the writing of more complex sentences related to school assignments, as also might be expected from her oral narrative. Her teacher's feedback on a practice expository composition (reported previously) conveyed that Kelly had good ideas and good organization, but needed to improve her lexical choices, spelling, and sentence structure. Such feedback does not provide Kelly with specific strategies she can use to make progress at any of these linguistic levels. At the time, neither a psychologist nor an SLP was consulting with the teacher. As suggested by her oral narrative and writing limitations, further assessment would be needed to know with greater clarity if Kelly may have morphological and syntactic awareness problems contributing to her spelling and written expression problems.
Morphological awareness represents sensitivity to the combination of form and meaning. It encompasses (a) an understanding of the internal structure of words, including word roots, prefixes, and suffixes (both inflectional and derivational), (b) is instrumental in both word formation and new vocabulary learning (Berninger, Abbott, Nagy, & Carlisle, 2010), and (c) is related to sentence (clausal) comprehension through functioning as a bridge between words and syntactic units. Even if Kelly had been referred to determine special education eligibility, these metalinguistic areas may not have been assessed because they typically are not required to be evaluated and practitioners vary widely in whether they assess any skills not mandated.
Of interest, Kelly's patterns fit the profile of oral and written language learning disability (OWL LD) in Table 1 observed in children whose oral language problems transcend the phonological processing of children with dyslexia; they included significant problems with morphological and syntactic awareness—in both its oral and written modes. Although children with dyslexia have their primary difficulty in learning to read words orally and spell words in writing, those with OWL LD also have reading comprehension and written expression problems.
PERSPECTIVES OF A PSYCHOLOGIST
Developmental profiles in assessment and instruction
Also instructive are cases that are assessed by professionals from multiple disciplines on a team to describe a developmental profile across the five domains of development—cognitive and memory, oral language, sensory and motor, social emotional, and attention and executive function (see Figure 2). These five domains are supported by separate functional systems in the brain (e.g., Eliot, 1999), all of which need to function in concert, but any one of which may dissociate (develop unevenly and not be in synchrony) with the others and interfere with development or learning. As illustrated with Figure 2, such developmental profiles contextualize learning profiles. For example, assessing and treating reading-related phonological problems are very different for a child who is outside the normal range in each of the five developmental domains in Figure 2, as was the case for the child misdiagnosed as having Asperger syndrome (Case 1 introduction), and for a child whose developmental profile is completely normal except for a specific learning disability in dyslexia.
According to this perspective, what is often referred to as mental retardation or intellectual disabilities might be more appropriately referred to as developmental disabilities across all developmental domains—all five domains of development are outside the normal range. In other cases, one, two, three, or four domains may be outside the normal range and the nature of the specific developmental disability should be noted. Whether all or selected domains are outside the normal range and so noted, the possibility of other comorbid neurogenetic disorder, disease, or injury, or substance abuse should be explored and documented if present. (See Figure 2 and Table 1, based on Berninger, 2007, 2010; Berninger & Miller, 2010.)
Although the commonly used term pervasive developmental disability (PDD) is currently used to refer to two or more developmental domains outside the normal range, PDD more appropriately captures a profile of developmental disability outside the normal range across all domains of development. In contrast, specific developmental disability (SDD) more appropriately refers to another context in which one or more but not all developmental domains are outside the normal range in a child's developmental profile. Whether assessment results point to PDD or SDD, best professional practices are to monitor the developmental profile across development and not give parents reasons for false hope in the future based on current assessment results if even one domain is outside the normal range. It is more appropriate to use current assessment results only to discuss the present functioning of the child until multiple assessments across the preschool and elementary school years are available to address prognosis. Development is not always linear and may depend on patterning within and across domains.
Learning (academic) profiles
Research inclusion criteria for dyslexia and dysgraphia in a family genetics study conducted at the University of Washington Multidisciplinary Learning Disabilities Center (UW LDC; funded by the National Institute of Child Health and Human Development [NICHD]) were designed to ensure that development was in the normal range across the five domains of development. To identify the nature of specific learning disabilities in children (probands who qualified the family for participation), cut-off criteria were set for verbal intelligence to maximize inclusion of children with specific learning problems in the context of otherwise normal development whose specific learning disabilities were unlikely to be due to neurogenetic disorders other than dyslexia or dysgraphia. Rarely did the participating children have histories of oral language learning problems during the preschool years or speech disorders. Their problems in learning to read and write were initially observed in kindergarten and first grade when they struggled in learning to name and write letters and associate sounds with them.
Three important multidisciplinary findings emerged from the UW LDC research:
* Two definable specific learning disabilities (SLDs) were identified: dyslexia and dysgraphia. See Table 1 for the associated learning profiles related to specific impaired academic skills for these SLDs.
* On the basis of brain imaging, phenotyping (behavioral expression of underlying genotypes), and genotyping studies (molecular biology methods used to identify specific alleles; that is, variations in the sequence of the four base chemicals in genes that are associated with phenotypes), the phenotype profile could be characterized. This profile consisted of a working-memory architecture with three word-form storage and processing units (phonological, orthographic, and morphological), two loops between internal language codes and motor output codes for mouth or hand, and executive functions for supervisory attention (inhibiting, rapid automatic switching, sustaining over time, and self-monitoring and updating over time; Berninger, 2007; Berninger et al., 2006; Berninger, Raskind, Richards, Abbott, and Stock, 2008; Richards et al., 2006). (See Table 1 for the associated phenotyping profiles related to specific academic skills that are impaired in these SLDs.)
* Follow-up studies with children who did not meet research inclusion criteria for studies of dyslexia and dysgraphia identified a learning disability characterized by history of significant oral language problems during the preschool years as well as reading and writing problems during the school years. Children who were often delayed in producing word combinations had significant problems in syntax and morphological skills and listening and reading comprehension in addition to the phonological and orthographic problems they shared with children with dyslexia or dysgraphia (Berninger, 2007; Berninger, 2008; Berninger, O’Donnell, & Holdnack, 2008; Berninger &O’Malley, in press). See Table 1 for associated academic learning and phenotyping profiles for these children with oral and written language learning disability (OWL LD). Diagnosis of this specific learning disability called to the attention of psychologists who are trained mainly to assess reading and writing and not oral language that a student may also have significant problems in oral language in any of multiple levels of language (syntax and text as well as word) that transcend oral language and reading and writing. In other words, reading and writing problems may involve not only impaired phonology but also other impaired language skills in some children. Whether these children with OWL LD are the same as those who are variously referred to as having language impairment (LI),specific language impairment (SLI), or language learning disability (LLD) in the field of speech–language pathology awaits further investigation and resolution within that field and also across disciplines regarding how each of these terms should be used appropriately.
External validity (generalizing research findings)
Many students’ very real problems related to language learning are not always identified and addressed by educational professionals, but psychologists working collaboratively with SLPs can change professional practices related to defining and diagnosing language problems so that these students’ needs are served. For example, they can identify the specific language impairment/s in SLI whether or not a student qualifies for special education services. In other words, sometimes diagnosis is needed to pinpoint language problems of instructional relevance even if the child's language problems are not so severe across the board to meet eligibility criteria for special education services. (See Berninger & Holdnack, 2008, for further discussion of the difference between diagnosis and eligibility decisions.) Specific concerns to address include the following:
* If a student falls significantly below the normal range (e.g., –2 SD) in receptive (processing) and/or expressive (producing) language, the student has language impairment (LI), a specific developmental disability. However, even if a student does not meet criteria for LI, the student's word retrieval fluency, morphological and syntactic awareness, listening comprehension, and discourse memory should be assessed to determine if the student has specific language impairment (SLI) because any one or a combination of these language problems may affect both their oral language and written language learning across the academic curriculum during the school years (see Silliman & Scott, 2009). Cases 2 and 3 in the introduction and the case of Kelly illustrate this lack of attention to the nature of the specific language impairment in children whose development is otherwise normal.
* Documenting preschool language developmental history is critical to diagnosis of LI or SLI, LLD, or OWL LD (depending on the term of choice). Of the members of the multidisciplinary team, in general SLPs are most likely to be trained in obtaining preschool language histories, whereas psychologists are most likely to be trained in obtaining family and developmental histories. By pooling this information the nature of the specific language impairment in SLI is better understood in its developmental and family contexts.
* Because multidisciplinary teams are not assessing both developmental profiles and learning profiles, much diagnostic confusion is interfering with delivery of appropriate educational services. Children experience difficulty in learning to read and write for many reasons and reading and writing problems have different etiologies, instructional needs, and prognoses, depending on the developmental profiles in which they occur and what is specific in SLI. For example, autism (which occurs in the context of developmental profiles in which all or selected developmental domains are outside the normal range) and dyslexia or dysgraphia (which are appropriately diagnosed only in the context of a profile in which all developmental domains are in the normal range) are mutually exclusive diagnoses. Thus, the research on effective instruction for dyslexia, both its associated spelling (Berninger, Nielsen, Abbott, Raskind, & Wijsman, 2008) as well as reading problems generalize only to other individuals diagnosed on the basis of evidence-based definitions of what dyslexia is. Indeed many of the individuals with dyslexia have developmental profiles characterized by talents in the cognitive domain (advanced development for age; e.g., Berninger et al., 2006).
* Moreover, not all reading disabilities are dyslexia. Many disabilities can only be understood in the context of the overall developmental profile and co-occurrence of other neurogenetic and medical issues (see Figure 2). Of course, children with autism may have difficulty learning to read or write, but for different reasons than those with dyslexia or dysgraphia, and they require different approaches to instructional treatment.
* Because of differences in training and characteristics of the referred populations, SLPs are working with individuals who have a relatively high incidence of oral language and/or speech problems with and without developmental profiles that are completely or partially outside the normal range and a relatively low, if at all, incidence of dysgraphia or dyslexia defined as just explained. Psychologists, in contrast, often receive referrals in which the learning problems occur in the context of otherwise normal language and development across the five domains, but due to lack of adequate training, psychologists may not recognize specific oral language impairments when they do occur with or without developmental disabilities.
* Likewise, reading disabilities with varying etiologies are confounded in research samples. For example, in the Finnish longitudinal study of reading disability (Torppa et al., 2007; Torppa, Lyytinen, Erskine, Eklund, & Lyytinen, 2010), the affected children differed from controls in families with and without reading disabilities in expressive and receptive language and morphological sensitivity, as is typical in children with early emerging oral language disabilities, but also in later emerging phonological awareness, as is typical of dyslexia. Is the Finnish sample comparable to that of Berninger et al. (2006), who studied children who had phonological problems but did not for the most part have expressive (producing) and receptive (processing) oral language or morphological or syntax problems? Moreover, growth mixture modeling of children in the Finnish longitudinal study showed that some children had a profile with impairments only in word reading, only in reading comprehension, both, or neither and varied in whether accuracy or only rate was impaired in any of these skills. These differences in learning profiles show more heterogeneity in preschool language development than did the phenotyping sample for dyslexia and dsygraphia described earlier. These differences in sample characteristics have implications for effective instruction, which may be missed if the nature of the reading disability within developmental and learning profiles is not identified and defined.
* Phonological processing problems may occur in children with early emerging language learning problems and those whose problems are first apparent when exposed to formal reading or writing instruction, but the nature of the phonological processing problems may differ across these groups (e.g., Cabell et al., 2009; Catts, Adlof, Hogan, & Weismer, 2005). For example, children with language learning problems that include phonological processing problems, but also other aspects of language, are often faster responders to phonics instruction than those with dyslexia, but slower in responding to reading comprehension instruction (Berninger, O’Donnett et al.,2008; Berninger & O’Malley, in press). Once children with dyslexia learn phonological decoding, their reading comprehension problems often resolve relatively quickly, unlike those with more pervasive language learning problems that transcend phonology alone (e.g.,Berninger, 2008; Berninger, O’Donnell et al., 2008).
* Overlooking the developmental domain context, including comorbid biological conditions, in interpreting academic-learning profiles is likely to result in not providing the most appropriate instruction geared to a student's developmental level and may, as a result, contribute to adversarial parent–school relationships that sometimes result in law suits. At present, little is known about the learning profiles or effective academic instruction for students with PDD or SDD. The research on effective reading and writing instruction in which the participants were all well within the normal range across the five developmental domains (Figure 2) does not generalize to them.
CONCLUSION: COAUTHORS’ CALL FOR ACTION
More children with developmental and learning disabilities might be identified and served if professionals across disciplines that serve individuals with educationally handicapping conditions addressed each of the following issues on the basis of best professional practice. Although the sanction of authorities in the community, state, and federal governments and the law is desirable, only professionals can define best professional practices for proactively serving individuals with language problems in the context of developmental or learning disabilities. As such, this article is a call for action for evidence-based definitions, diagnoses, and treatments linked, with consensus, to a cross-disciplinary conceptual framework with well-defined and diagnosed language problems in the context of developmental and learning profiles. SLPs, psychologists, and educators are encouraged to contribute to and support the effort by addressing jointly the following questions:
1. What are the critical skills to assess for each of the five developmental domains (especially language) and the academic learning profiles?
2. What kinds of clinical thinking skills are needed to integrate the information across developmental and learning profiles for purposes of evidence-based definitions and diagnoses and appropriate treatment in schools and other settings?
3. How might a specific language skill vary in diagnostic or treatment significance as a function of not only the developmental profile but also the learning or phenotype profile (see Table 1) in which it occurs (context)?
To begin with, both a certified SLP and a certified psychologist with appropriate training and experience should participate in the assessment of any child referred for developmental, behavior, and learning problems. SLPs have valuable assessment expertise related to profiles of oral and written language skills relevant to determining whether (a) the oral language domain is within the normal range, (b) either oral or written language or both are impaired in some way that affects learning to read and write, and (c) significant deficits exist in social cognition (pragmatics; see Troia, 2011). Psychologists have assessment expertise related to not only written language (and increasingly oral language) but also attention, executive functions, and self-regulation, which are often weaknesses or impaired in students with language problems. SLPs and psychologists can improve the reliability of the assessed learning profiles and related phenotypes (including common core of attention and executive functions for self-regulation, see Table 1) if they both give measures of oral and written language and then evaluate whether results are comparable across different measures of the same construct and across different assessment contexts (clinicians). Moreover, both SLPs and psychologists have much to learn from the expertise of educators who teach reading and writing and use classroom assessments to make instructional decisions (see the article by Foorman et al., 2011).
In this issue, we focused on language problems. These language problems may affect listening, oral expression, reading, and writing in the context of a profile in which each of the five domains of development may fall within or outside the normal range and other neurogenetic or medical conditions may also occur. When language impairment occurs in the context of developmental disabilities, professionals providing early intervention services should avoid communicating false hope that reading and writing will necessarily be grade appropriate to parents of children for whom one, some, or all developmental domains are outside the normal range. Raising scores during the preschool years on IQ tests that do not have predictive validity until age 6 years does not guarantee that the child will have completely normal development. That is especially so if cognitive function does not fall well within the normal range during the school years. However, even if some or all developmental domains fall outside the normal range, the multidisciplinary team can work collaboratively with each other and the parents to nurture each developmental domain of the current developmental profile. However, it is always best practices to avoid giving false hope that development will become fully normal based on isolated gains. If one or more domains of development fall below the normal range, that may interfere with all developmental domains working together in concert to support grade-level achievement. Children with PDD or SDDs are most likely to respond to literacy instruction at their developmental level (mental age) rather than chronological age or grade level (Berninger & Miller, 2010; Silliman & Mody, 2008).
Academic learning problems have different diagnostic features and instructional needs according to the kinds of developmental profiles in which they occur. For example, academic profiles specific to autism are under investigation (see Jones et al., 2009), but the full developmental profile needs to be fully characterized for purposes of external validity (the generalization of research findings). The reading and writing instructional needs of children with dyslexia and those with autism are not the same. One size does not fit all in the quest for Free and Appropriate Education for ALL.
Monitoring developmental profiles across time may help reduce adversarial home–school relationships because parents are less likely to become frustrated when they understand that schools cannot realistically eliminate all developmental disabilities, but can nevertheless teach their child in a compassionate way tailored to the child's developmental and learning profiles to optimize development and learning within those realistic constraints, and celebrate each accomplishment. Developmental profilesare also relevant to decision making for the transition from schooling to vocational training and job placement and independent or assisted living.
Achieving this kind of cross-disciplinary conceptual model will improve services for students with language problems. Professionals across disciplines in English-speaking countries need to create precise definitions that capture the defining features of developmental, academic, phenotypic, neurogenetic, and other profiles—that is, the various contexts in which oral and written language problems occur—and then use these definitions with cross-disciplinary consensus in practice. For an exemplary model resulting from such cross-disciplinary dialogue across domains of psychology (cognitive and motor domains) and speech and language in the United Kingdom, please see Connelly, Dockrell, and Barnett (in press). Cross-disciplinary communication and collaboration may result in more grinning and less hissing if we pay more attention to the cat, that is, the developmental and learning context of the individual profiles and, when relevant, related and comorbid disorders.
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academic learning profiles; cross-disciplinary models for language in varying contexts; developmental profiles; late talkers; phenotype profiles; oral and written language
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