When preschool children, before the age of five years, are referred to speech and language therapy due to atypical language development, it is important to determine whether they have a problem which may be serious and persistent, or one which will resolve by time (Emanuel, Chiat & Roy, 2007). This is because language fully develops at around the age of five years, so before this age it is still too early to diagnose a disorder. In order to plan the appropriate intervention for a child, it is important to determine the risk factors for a disorder. According to Emanuel, Chiat & Roy (2007) on first referral, different children who present with similar problems and results from assessment, thus similar diagnosis and prognosis, may still turn out having a different outcome. This shows how difficult it is to determine the risk for disorder at a very young age. We must therefore identify risk factors and clinical markers instead which determine whether or not the child is at risk for disorder later on in his life.
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As reported by Conti-Ramsden and Hesketh (2003), one of the first steps when assessing a young child who is still in the language-learning process is to establish the hearing status of the child usually with the help of other professionals together with their overall non-verbal abilities. By doing so, the SLP could discount any general learning difficulties or hearing problems as possible causal factors. We must then consider the child’s age and compare his language abilities to the ‘norm’ using standardized or non-standardized tools, language samples and systematic observations. Assuming the mother attends the initial interview, through case history taking we should find out when the child first started speaking and the ages he reached all his developmental milestones because delayed emergence of first words is often a marker of delay and possible disorder. Through this, we could exclude or consider global developmental delay. According to Sheridan (1997), at three years of age a child should typically exhibit a large vocabulary of words and be able to participate in simple conversation with others. Also, a child of 1; 6 years typically exhibits a small repertoire of single words so at his age, John appears to be at this level of language development rather than at that of a child his age. This indicates the possibility of language delay, with steps followed by typically developing children but at a later stage.
Due to the large differences between the rate of development of one typically developing child to another, it is difficult to distinguish between normal and abnormal variation, particularly in young children. As a result, the identification of risk markers for a disorder such as specific language impairment/(SLI) is all the more crucial (Conti-Ramsden & Hesketh, 2003). SLI is present when the native language is not acquired at the typical rate or pattern in comparison to the ‘norm’ for no apparent reason. Also the disorder must not be secondary to other impairments or be associated with any other cognitive, sensory or developmental issues. A child having SLI would have a difficulty specifically targeted towards language (Bishop,-2006). A child with language delay will either continue to have problems after the age of five or these will resolve. We would not know if a child with language delay will continue having language problems so he would be at risk for SLI.
By employing the same utterances for various purposes, John’s semantic representations may be limited and impoverished. Considering words needed to express meaning are found in the phonological output lexicon, this could be a manifestation of a problem in this area of language. A distinctive feature of SLI is difficulty with verbal memory and this also makes it difficult to store meanings for later use. Clinical markers for SLI include; non-word repetition; the repetition of non-sense words with increasing numbers of syllables, and sentence repetition. These should be looked out for when observing or assessing the child, as clinical markers are very important for prognosis. It is very important to assess both receptive and expressive language as this too can affect prognosis quality. Contextual understanding can easily be misinterpreted as verbal comprehension by parents, hence why we must assess comprehension even if the parent does not feel the need. In SLI, you may have strength in one area of language such as vocabulary but difficulties in others such as syntax, so we have a mismatch of language abilities. The same may occur in other non-language abilities so the child may be more advanced in one section of development than the other. Thus when assessing, we must be knowledgeable of the child’s developmental milestones. From the information provided by the mother, an SLP must also consider whether three months of preschool is enough time for the child’s language to enhance or whether he should be given more time (Webster & Shevell, 2003).
Children with a problem solely in expression despite having subtle comprehension problems are more likely to recover than children with prominent receptive difficulties. Considering John is compensating through the use of gestures when he cannot express himself using language, we know that communicative intent is present so there is a higher chance of improvement and the child would be less likely to develop SLI further on. These factors change the prognosis making it better and if both are present in the child, there is a further decrease in the risk for disorder (Gatt, 2013).
Another factor which we must consider is inheritance. According to Choudhury and Benasich (2003), studies have found that SLI runs in families. Despite family history being found to be the most pronounced predictor of language outcomes in young children, it has also been found that prenatal and perinatal factors, gender, socioeconomic status, and inherited autoimmune diseases also contribute to the risk of SLI. Therefore, such factors must be questioned during the initial interview as their presence could contribute to the risk of disorder and possibly make the prognosis worse. Numerous studies have shown higher rates of SLI in males in comparison to females with the ratio of approximately 2:1 to 3:1 of affected males to females (Choudhury & Benasich, 2003). The parent’s educational background determines certain factors including their understanding of the importance of working with their child, consequently affecting the prognosis. It is also important to question the child’s social interaction with peers at pre-school and his siblings. Observing John’s siblings interacting with him may expose how they may be speaking for him, affecting language development. The mother should also be asked if she gives the child enough time to communicate his needs rather than providing them to him instantly. It must also be noted whether the child is receiving enough attention from parents considering his siblings might be taking away some required attention. Such environmental causes of language difficulties pose a good prognosis as a change in environment will cause considerable improvement (Alic, 2012).
According to Watt, Wetherby and Shumway (2006), the presence of prelinguistic skills in the early years of life contribute greatly to later receptive or expressive language outcomes. These skills include: joint attention, gestures, vocalizations and words as well as early comprehension skills. Their absence can greatly contribute to predictions of outcomes of language delay or SLI. This is why these skills must be questioned during case history taking, including the ages at which the child started exhibiting them. Studies show that gestures may serve as a bridge between language comprehension and active production in the second year of life thus considering John uses gestures; this makes his prognosis better (Watt et al., 2006). As can be seen, SLI risk results from both genetic and environmental factors. Otitis media with effusion on its own, does not lead to SLI but can be a co-morbidity. Possible hearing impairment could impede language acquisition (Luckner & Cooke,-2010). If this is the sole cause for language difficulties, then the prognosis should be very good considering the right intervention, his language skills should enhance considerably (Tate, 2002).
Attention control and listening skills are important pre-verbally and thus considered when observing a child with language problems. Children with SLI often have attention problems and it is difficult to conclude if these problems co-exist or occur primarily or secondarily to the language problem. Considering attention-deficit-disorder/ADD is often observed in children with language problems, you may find out that ADHD or ADD is the cause of the language problem (Webster & Shevell, 2003). A holistic approach must be adopted, taking different pieces of information to reach a conclusion. Children with SLI are often observed having some coordination difficulties resulting in clumsiness. According to Webster and Shevell (2003), slow performance on motor tasks and an increase in the incidence of motor abnormalities are common in children with SLI. Thus, when assessing the child you may want to observe him placing blocks on top of each other or placing wooden pieces in their place on a form board. The child may find difficulties or take long to carry out the tasks.
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Classification is important in children with possible SLI due to the heterogeneity/variation between the children with the disorder. Different subgroups exist and researchers agree that before three years of age, a clinical subtype should not be assigned. However, in this case John is older than three years so it would be helpful to classify his difficulties further if it is found that he is at risk for SLI. Using subtypes does not exclude other difficulties in other areas but these would be minor problems. A child is said to have prominent lexical and semantic deficits usually if he experiences a delay in emergence of first words, a marked delay in both receptive and expressive vocabulary during preschool and more pronounced lexical deficits later on. Problems with memory are also observed particularly affecting form-meaning mapping (Gatt, 2013).
If the child in question has word finding difficulties and participates in compensation strategies, he falls under this subtype of SLI. Some children with language problems experience most difficulty in the morphosyntactic area and this is most commonly seen in English speaking children (Webster & Shevell, 2003). The first indication of problems in young children would be difficulties with word combinations. One must look out for difficulties when producing syntactically complex sentences as well as when understanding morpho-syntax. Relative clauses, passives, wh-questions and forms such as the passive language pose particular difficulties.
Another subtype of SLI experience pronounced phonological deficits resulting in difficulties with speech production, perception and phonological awareness. Non-word repetition production is as important as a clinical marker. Through their study, Gathercole and Baddeley found that children with SLI performed similarly to their control children on one and two syllable non-words. Nevertheless, when it came to longer non-words, they performed worse suggesting limited performance due to poor working memory rather than articulatory impairments (Webster & Shevell, 2003). A child with such difficulties loses sensitivity to certain sounds and usually finds problems when identifying the number of syllables, first or last sounds produced in a word. This suggests a phonological processing difficulty. This is the foundation for reading and writing so dyslexia and SLI may co-occur making the deficits in phonological awareness more marked.
Children with SLI may show pragmatic deficits as their language problems will impact their social use of language. Social communication disorder, previously termed pragmatic language impairment has been launched in DSM-5 which suggests that it is distinct from SLI. A pragmatic impairment is often related to autism but can also stand on its own. There is a difference between social difficulties stemming from autism and those stemming from a language problem. According to the study conducted by Leyfer et al. (2008), repetitive and restricted interests and behaviours are rare in children with SLI and occur in autism accompanied by social and communication difficulties. Nonetheless, in order to diagnose a disorder such as autism or SLI, the child must be observed in various different contexts.
When attempting to diagnose and find out more about a child’s prognosis, formal and informal assessments must be ongoing processes. Assessment is not distinct from therapy but part of it and allows you to not only document weaknesses, but also strengths which help you overcome the weaknesses. Through objective assessment you attain evidence which gives you a detailed insight on the child’s improvement allowing adequate planning of intervention. When assessing informally it is important to consider both spontaneous and elicited language data providing a more detailed and holistic view on the child’s communication skills (Gatt, 2013).
Ultimately, the progress made in response to intervention depends on multiple factors. All things being equal, prognosis depends on the severity of the language problem and in this case, on the number of risk factors for disorder. The greater the presence of risk factors in a child, the stronger the possibility of SLI or language problem, resulting in a poorer prognosis. The tendency also lies on a better prognosis when it comes to expressive-only language disorders. If the child is found to have problems which also affect receptive language and cognitive skills, the prognosis will be poorer. Positive support from the family and early identification amongst many other factors, contribute to a better long-term outcome (Catts-et al.,2002).
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