The language of language impairment. Roses by other names can still be thorny.

The recent issue of the International Journal of Language and Communication Disorders focussing on nomenclature for children with impaired language skills is both timely and thought-provoking. The open access papers are written by pre-eminent experts in child language research and provide an important melting pot of current ideas, tensions, conundrums and importantly, some suggestions as to sensible ways forward. I have only managed a “first pass” read of the papers so far and need to sit and re-read them to absorb them properly, but offer here some initial ideas and responses – which may change of course, as my re-reading helps the ideas percolate further.

Firstly, let me say I have been as guilty as the next person of being inconsistent in how I use terminology in relation to language difficulties / disorders / impairments / problems / deficits. Ironically though, the one term I have been able to comfortably avoid in recent years is Specific Language Impairment (SLI), because my research with young people in the youth justice and child protection systems tells me that their language difficulties, while both marked and common, are not at all “specific” in the sense in which this word has been used in the SLI literature over the past two decades.  In our 2011 paper describing the expressive  and receptive language skills of 100 young offenders completing custodial orders, in whom (using what was probably an overly conservative cut-off) we identified 48% as “language impaired”, and observed that:

“While it is possible that some may meet diagnostic criteria for Specific Language Impairment (SLI), it is more likely that the patterns of decrement evident in this group are of a generalized and non-specific nature - reflecting perhaps early disruptions in attachment, low parent–child attunement, and other socio-environmental factors that militate against the development of robust oral language skills” 

(Snow & Powell, 2011, pp. 486-87).

I agree with Reilly et al. when they state (p.423) that

 “…making a conceptual distinction between ‘real’ language impairment and children for whom the environment has caused their language impairment may be simplistic”. 

It follows, then, that I support the view that the descriptor “specific” is unhelpful, both nosologically and with respect to allocation of intervention services. Many children and adolescents have clinical profiles that reflect clear need with respect to their language skills, yet these are anything other than “specific” in the sense in which this term was intended to be applied. I am comfortable describing young offenders as having “language impairments” because their expressive and receptive language skills are not adequate to enable them to meet everyday social, academic, vocational communication demands. In reality of course, many of these young people are coming from a literal “deficit” position with respect to language exposure and experience, but the term deficit has unhelpful connotations and will be even less likely to gain traction than its more widely known and used counterpart “impairment”.  

When I think about the young people in our youth justice / child protection studies and their language profiles, this is the way I think about the complex developmental pathways that in many cases result in impaired language skills:

In reality, the diagram should be a lot busier, showing arrows from each point of intersection between different risk factors, but that would make it visually unworkable.

It is of course not possible in this line of research to partial out contributory mechanisms (or their interactions). The important take-home message for policy makers and schools in particular, is that language skills in already vulnerable young people are fragile. I fully support the arguments presented by both Dorothy Bishop and by Reilly et al. that discrepancy-based diagnostic criteria (i.e. excluding children with nonverbal IQs below certain arbitrary cut-offs) are not helpful in deciding who does or does not have a language impairment. A language impairment exists when you do not have sufficient expressive and /or receptive skills to verbally navigate your way through the business of everyday life at the expected developmental level. Low IQ may sometimes explain some of this difficulty, but is not an “opt-out” clause with respect to explaining poor language functioning, or determining who might benefit from intervention services.  

It is pleasing to see a focus in Dorothy Bishop’s paper on fostering children’s skills and interests that are not reliant on language/literacy achievement, and of course I fully agree with such a strengths-based approach. Improved self-esteem and a sense of achievement are important in their own right, and also for school attachment and retention. Sadly though, we need to recognise that in industrialised, first world countries, the job market is going to rely more, rather than less, on language and literacy skills. We only need to look to our local supermarkets for evidence that low-skill jobs (working as a cashier) are disappearing and are being replaced by high-skill jobs (designing, installing and maintaining self-checkout points). 

Children with language impairments grow into adolescents with language impairments, who of course emerge as adults with language impairments. Such impairments are sometimes superficially masked by behavioural and mental health issues, but they are not lost on employers. In 2011, the Industry Skills Council of Australia published a report stating (p. 1) that 

Literally millions of Australians have insufficient language, literacy and  numeracy skills to benefit fully from training or to participate effectively at work

Non-specific language impairment is likely to be what turns up in classrooms and on SLP caseloads – so I’d like to see the term “specific” dropped and would be happy to run with “language impairment” OR “language-learning impairment”. Both are closer to the reality of complex underlying causal pathways, and the latter has an important link to academic achievement. However both would need to be “sold” to policy makers and funding bodies with respect to the prevalence and life-span importance of the problems to which they refer.

A further reason to drop the descriptor "specific" is that this would remove the (false) two-tiered hierarchy between those children whose language impairment is "pure" and those in whom other developmental threats to language competence (as per my diagram above) are identifiable. We only need to look to the world of "dyslexia" Vs "reading difficulties" to see how unhelpful such hierarchies are in practice.  Researchers will of course continue to investigate children whose language impairments are ideopathic, and will need to convince funding bodies of the empirical and applied importance of doing so.  

Oral language competence is a complex output that requires complex inputs. The bottom line for me is that language experts, whether from psychology, speech language pathology, education, paediatrics, or public health need to make a lot of noise about oral language competence – what it is, why it matters, and how to strengthen its chances, right from birth. Deciding what we will call its inverse will be an important part of the way forward.

I’m looking forward to thinking and reading further and will be interested to see how others react to these important papers.

References

Bishop, D.V.M. (2014). Ten questions about terminology for children with unexplained language problems. International Journal of Language and Communication Disorders, 49(4), 381–415.

Reilly, S., Tomblin, B., Law, J., McKean, C., Mensah, F.K., Morgan, A., Goldfeld, S., Nicholson, J.M. & Wake, M. (2014). Specific language impairment: A convenient label for whom? International Journal of Language and Communication Disorders, 49(4), 416-451.

Tweet Snow, P.C. & Powell, M.B. (2011). Oral language competence in incarcerated young offenders: Links with offending severity. International Journal of Speech-Language Pathology 13(6), 480-489.

© Pamela Snow 2014