Language Assessments & DLD

I'm cooking DLD. Developmental language disorder. One in 14. DLD. The DLD project. The total DLD project. Brought to you by the DLD project. Hi everyone, it's Sean here. Thanks for joining us on this episode of the Talking DLD podcast. In this episode, we're speaking language assessments with associate professors, Natalie Monroe from the University of Sydney. And Marleen Westerfeld from the Griffith University. Together, they will combine their extensive expertise as researchers and speech pathologists to help you understand what happens in a language assessment, why they are important, and how you can prepare to make the most of your session. [MUSIC PLAYING] Welcome, everyone. I'm really looking forward to today's Talking DLD podcast. I will introduce you very quickly to Marleen Westerfeld and Natalie Monroe. I might start with you, Marleen. Can you tell us a little bit about your connection to DLD, and I'll throw the nap to follow up? Yeah, so I've had a longstanding interest in child language right through from the minute I started practicing as a speech pathologist to becoming an academic, I suppose, or a clinical researcher, and in teaching as well. And what really sparked my interest then in DLD is when I was invited by Dorothy Bishop to join the catalyze consortium. It's been a real eye-opener to understand or to get an appreciation of the differences in opinion of what do we label these children. And since then, I've become a real advocate for developmental language disorder and a real interest in getting the message out there. Do you want to tell us a little bit about your role at DLD University as well in some of the areas that you research? Sure. So I'm an associate professor in the Master of Speech pathology program at Griffith. And my teaching is all around child language and literacy developments. My main areas of research interest at the moment are looking at children's emerging literacy skills, which really then includes both the print-related skills we need to learn to read, but also the oral language skills that we really need to learn to read. And I look at children with Down syndrome, children with developmental language disorders, children with autism spectrum disorders. And yeah, that's the main focus at the moment. Awesome, thanks so much for sharing. Nat, I'll pass to you now. What's your connection to DLD? So I'm an associate professor in speech pathologist at the Faculty of Medicine and Health at Sydney University. And I teached research quite similar to my lane in terms of child language development and disorders, like to devil in language and literacy a little bit. And I've kind of always been fascinated with how kids learn words and then springboard from there in terms of developing communication skills. So my work covers across childhood. So I look at late talkers all the way up to young people. Awesome, and I'm so pleased that we've got two speakers today 'cause you're both so knowledgeable in our topic, which is going to be looking at assessment. So before we get to the diagnostic component, I'd really want to talk a little bit about why is it actually important to assess a young person's language skills and happy for either of you to start by answering. Oh, I'll start. Go for it, Nat. Well, I mean, from a parent perspective, it's usually like trying to answer it. The question of, is my child okay? You know, I've got some, I've got some concern, you know, does my child have, you know, some communication difficulties and, you know, are they bad enough or why am I worried about this? I need some more opinion, you know, some expert opinion or I need a better understand, you know, where my child is at compared to other kids, their age. And for the young person themselves, if they're a little bit older, it might help explain, you know, that a diagnosis can help explain that they're not dumb because sometimes, you know, they might get feedback that, you know, they're naughty or their behavior is in issue and they might think that they're just not clever, which is actually, as we know, definitely not the case for kids and young people with deal today. So that's the broad kind of reason why I think it's important to assess a young person's language skills from their perspective. And from our perspective, from a speech pathologist perspective, I think it comes down to what's your purpose of assessment, you know, and there's many reasons why a speech pathologist might want to assess a young person for DLD or another type of communication disorder. So it could be diagnostic, right? So we could want to look at a communication disorder or a label. We could want to look at differential diagnosis. So is it DLD or is it language difficulties associated with another neurodevelopmental disorder like autism? It could be that we want to assess a child to detect change before and after therapy to look at outcome measures. It could also be just to describe the child's communication skills and in that situation, you don't necessarily have to use a diagnostic label. And then it could also be that you do an assessment because you want to select an intervention and plan goals for your treatment. So there's many reasons why a speech pathologist would like to, you know, assess. I think it's really important for us to look at those distinctions because they do, depending on what your purpose is, your assessment approach will be different. Yeah, absolutely. Malene, anything else to add to that? No, I absolutely agree. I think perhaps another couple of thoughts are that we sometimes know that children are at risk of developing language difficulties or not developing their languages we would expect. And we could think, for example, of children who are born very prematurely. So we would like to keep an eye on those children. And in those cases, we might become involved before they even learn to speak. And I clearly remember parents asking me, like, oh, my child doesn't talk yet. Like, what are you doing here? And it's really important then we sort of look at those early signs of communication before children learn to talk. And another reason is that we sometimes know that children, even though their language skills or their communication skills might seem alright, especially during the preschool years, we might sort of know that they're at risk of developing reading difficulties, for example. And those language problems could be more subtle. And especially in children who have been diagnosed with a specific disorder that sometimes makes it easier for us to know they'll be at risk. Not always, of course, because every child's different. And I'm thinking autism spectrum disorder, for example. So again, we might just want to do an assessment to sort of look at those language related skills that we know are so important to do well at school and to do well in life more generally. - I get often asked at kids birthday parties or at the park, you know, what does the speech pathologist do and don't you just do lists and all of these other things and even just that understanding of the fact that, you know, there's speech and language and that the communication is how it all comes together. I think it's still at a population level something that we're grappling with, you know, and one of the reasons why I do say go ahead and get an assessment by a speech pathologist is A, in often it's a cost effective way of actually looking at, you know, how are they communicating with the world around them, which is we can't really avoid it, can we? - No, and the other thing that I think people aren't always aware of, there may be children who have behavior difficulties at school and nobody thinks about their language skills or their communication skills and those behavior difficulties or challenging behaviors might actually assign of underlying communication difficulties and it's their way of telling the world, hey, hang on, something's not right. So again, in those cases, we want to rule out language difficulties or communication difficulties and there's some research and it's, you know, confronting research that has shown us that many adolescents in the juvenile justice system, for example, have significant language difficulties and nobody picked that up. Now I'm not saying that's why they ended up there, but if we sort of, you know, a diagnosis, those difficulties early on or we at least understand what's going on, then hopefully we can prevent some of these more serious consequences later on in life. - Yeah, absolutely. And thinking about how it looks across the lifespan, which is, brings us beautifully to our next question, which is that we've got a range of people that listen into the podcast, we've got families and teachers and other health professionals, including speech pathologists. What should they be looking out for to know when a language assessment might be needed? - Well, for little ones, Sean, we could look at how their vocabulary is growing. And so children typically, you know, start their first words around 12 months. If you've got a toddler who has less than 50 words or is not combining two word combinations, you know, around that 24 months of age, then that can be a red flag. So can, you know, pour speech intelligibility. So if an unfamiliar listener has trouble understanding what your child says. you know, around three, three and a half, you know, that can be a concern as well, so that's the speech sound accuracy side of things. You know, following instructions and looking at how a child follows others, rather than following the words that someone says, that could be a concern that you can notice at home or adding in early childhood care, you know, early childhood care. When you read a story to a young child and then you ask some questions about the story, if they're not following or answering their questions about the story in a sense that you would think that they would be able to understand those kind of questions, then that could also be concern as well. Sentences that sound immature, so it could be there might be some grammatical errors and they're common in preschoolers, but if they stay longer than what you would anticipate, you know, maybe they use words like get it or eat it and they're, you know, they're at school early school, that's, you know, a bit of a problem. Or if they're using non-specific words like stuff and thingy instead of more precise vocabulary, you know, particularly as they get into that kind of school age early school age range, then that to me would be a bit of a concern for parents or teachers. Yeah, so what net is referring to us sort of what we might call red flags that will definitely indicate to parents or people working with young children to seek help from a speech pathologist. And Sean actually was involved in creating the communication milestones poster that is really available on the speech pathology Australia website, so I'm sure a link will be added to this podcast. Absolutely, so for those of you who couldn't keep up with net amazing list of red flags, we really strongly suggest that you go to that communication milestones. And then yeah, moving into the early school years, often children do not have obvious language difficulties, so their language may actually sound alright, so they can get their message across their sentences may be a little bit what we call immature, but they will be mostly grammatically correct, although they may drop some past tense ending. So for example, instead of saying walked, they may still say walk or they may say things like, you know, some sentences may be oddly structured and the word order isn't quite right, but often these kids actually at face value sound alright, and it's quite tricky for parents, especially to sort of know whether that is a red flag or not. One of the big red flags would definitely be difficulties learning to read, so when children start prep and in the first six months of their school eight years, and I really hate this way to fail approach, but if you do notice that a child has difficulty sort of learning to read. And then it's definitely a very good idea to get an assessment, because there are lots of spoken language skills that under underpin learning to read, so learning to read is more than learning what the letters me what the letters are and what a word says, but it also requires, for example, phonological awareness skills, which is knowing that words are made up of sounds, which is a real spoken language skill. So we sometimes find that children may have had difficulties with intelligibility, like Nat just said, so they were difficult to understand during the school eight year, but it sort of came right and not quite perhaps so that that is definitely a red flag to us. And then sometimes my lane I was just thinking about, you know, even with the school age kids where they have subtle speech production difficulties like with poly syllables, so poly syllables are words that have three or more syllables in them, those longer words like I don't know binoculars or helicopter. Yeah, and those kind of sometimes speech pathologists will probe into those kind of words to see how accurate young kids can kind of produce those because it's still while the speech sounds might have kind of resolved a little bit, you still have some subtle difficulties and those skills are also related to literacy acquisition as well. And another big red flag to me is children who enter school and cannot retell a simple unfamiliar story, so you might sort of read a little story to them and you asked them, okay, now it's your turn to tell the story and the story may be completely out of sequence or they may only give you a few little details or sometimes children refuse, but most kids give it a little go. And that may reflect the fact that they haven't been asked to do that before, and in those cases, you want to give them some exposure and try that again in six weeks time, because at school they'll have lots of exposure to books, but if they still find that difficult, then to me, that is definitely a reason for further language assessment. And another one really is if you read a story to a child and you ask them questions following the story, especially upon school entry, if a child is difficulty answering who's the story about what happened in the story, what was the problem in the story, then again, that might be a sign of underlying language difficulties when they're older as well, like, you know, I'm thinking about the grade four. You know, you four you five kid that might be able to have cracked that code they can read right, but when they actually learn how they've learned how to read and now they're reading how to learn, right, and then they have a difficulties actually understanding what they're reading that's also can be a red flag and then I've, oh, the other one that I was thinking of as yours, you were talking about is like the social kind of consequences or the social difficulties that some children can have because of. Language disorder so you know things like having trouble making friends and keeping friends can can be a concern and and if your child's being teased and and it's having an impact the child is upset, you know, and having an impact on that on that their life, then I think that's another reason why to kind of explore, you know, that behavior that interaction skills as well because some kids can with language disorder can present with difficulties. You know, with social interaction and and developing that coming back to reading comprehension, which is what nets or starting to talk about so we often see children who are in their third or fourth year of schooling have never seen a speech pathologist and have always sort of been OK, you know, been able to communicate OK and the language sounded OK. They've learned to decode or crack to code as net said, but when you didn't ask some questions about what they've read they have significant difficulties and when we didn't do an assessment and we'll talk about the, you know, the ways we do assessments later what we find is that they're actually. They're vocabulary maybe alright so they may know lots of words their sentence structure maybe alright so they'll be able to formulate sentences and understand sentences but when we go beyond sentences so understanding how to. Given explanation of something or how to persuade someone or to understand those kind of passages that are explanatory not necessarily narrative or storytelling those kids have real difficulties and that's when we sometimes see a late diagnosis of developmental language disorder. And yeah and that again leads us back to why we so firmly believe in early diagnosis or early detection. So let's move on to adolescence then because we often think developmental language disorder is something that is sort of confined to the under 10 year old, for example. And then with in adolescence actually difficulties may not be that obvious and we find that some adolescence develop strategies to sort of mask their language or their developmental language disorder. And their difficulties are often more with higher order language skills or we call them higher order language skills so that could be failing to get jokes for example to really understand what is meant something that wasn't explicitly mentioned but it is sort of an underlying meaning. It could be again like I said difficulties at that text level or discourse level like explaining something it could be struggling to keep up with social banter with peers so like Natalie says we see that sometimes in school age kids but it becomes more obvious in adolescence. And then these children may end up with academic difficulties of course and again that could then show up as adolescent behavior so again comes back to my behavior comment earlier on it is so important to keep thinking. Is it the language is there an underlying language difficulty and if not just rule it out please and then yeah many many adolescents with DLD will have difficulties with literacy because of their oral language. problems. And yeah, DLD then goes into adulthood. If we don't detect it or don't assist or support these adolescents as they go through their high school years and we might see early dropout of school failing to learn because as they said right at the start, these kids may be considered dumb, that's a horrible term, but you know, or not being able to learn, well actually if we support them, they can probably learn very well, but we just need to know what types of support we need to give them and that's where assessment is absolutely vital. You've raised a couple of really good points, both of you, one of which is that the fact is that these young people can and do talk. And I think that often people hear about doing a language assessment and go, well, they're talking and so there's not actually a problem here and particularly for me who works primarily with adolescents nowadays, having come from early childhood through schooling, I just kind of keep on following them along, but you know, they do struggle with that academic elements and the social elements and often the upper primary and high school kids say that, you know, their concern isn't their understanding and using language in the way that they were seeing a speech pathologist if they were, you know, seeing one earlier, it's all of the social interactions and managing their friendships and trying to maintain them, they find them so stressful and, you know, impact them so much. So there's lots around that social and verbal, but what I'm hearing here in the biggest, it was a bigger harm moment for me to teachers event or conference a couple of years ago, where teachers said, I want to have some sort of justification or evidence before I say to a family, hey, it's worth pursuing going down this route. And I think that often it's that initial leap and for teachers to know and, and for family members to know that if you've got concerns in anything that either of you, Marlene or Nutter's just said, that there is really good reason for saying, hey, look, let's look at a language assessment, it's a really valuable tool and it provides such helpful information, it can help inform and we don't want to also get to the point where they're so far down the track that we can't, you know, provide the best quality support that we'd like to. So I say early interventioners as early as identified nowadays because more and more I'm working with these young people who were 15 and 16 who've never had a language assessment before in their life. And there's still so much we can do. I also think it's important to realize that a language assessment is not just about pinpointing the challenges, right? It's very much looking at what are a person's strengths in language and then what are the challenges and what can we do to help them become strong across the board. So I just want to get that across because we often have this and we talk a bit like impairment based and you know, impairment focused but that is definitely not our intention here. We really want to understand, yeah, what are our child strengths and weaknesses across the board and we'll talk a little bit more about what across the board means when we delve into assessment a bit deeper I think. Yeah, so assuming we've got a really bold, you know, family or teacher who, you know, we've joined the dots and the young person and their family are working with the speech pathologists, what sort of process would a clinician undertake to complete this sort of assessment? So it's a bit like a fact finding mission to start off with, right? So you've got to look at background history, you know, the speech pathologist will ask lots of questions and it might be with this survey or a questionnaire about developmental history, social history, medical kind of education, kind of history. And so you should anticipate parents should anticipate filling out questionnaires like that to find out more about what your child, you know, social history and academic history and so on. And that's a good thing because we want to try and get a more of a holistic picture. And I think that's encouraging to have that part as, you know, an essential part of an assessment process. So then you might also get some questionnaires about how your child's coping with social skills, for example. And these are also good because the speech pathologist doesn't know your child and you as the parent do, right? So you're the best informant or the teacher or someone who actually interacts with that young person in a natural kind of environment. It's, they're the best informant for us to kind of work out how the child is going socially. So I would anticipate a questionnaire along those lines as well. And you'll also observe, you know, will a speech pathologist like to observe you parents interacting with their young child. So if it's a clinic-based assessment, you might be asked to, you know, talk to your child and with a picture book, you might be asked to talk with your child, have a conversation during play and go through things like that. And that's helpful because, like I said, the parent child interaction is the most naturalistic. And so then you can, we can get a better representation of what your child's skills are like, rather than, you know, just relying on us talking with your child all the time because sometimes kids are shy, you know, and they might not show their best, then their selves in that first or second or third contact. So you might anticipate that. You might also anticipate that the speech pathologist would like to do what's called a standardized test. And this is usually some sort of picture-based or computer-based kind of language test usually involves looking at pictures. Your child does a lot of listening and pointing to pictures looking at their oral comprehension or their spoken comprehension skills. Or it could be about asking your child questions and your child can answer questions about vocabulary, answering words, might be repeating words or sentences. So whole series of kind of little activities that happen in what's called a standardized test. It might be that the speech pathologist tells you a story and my lane might talk about this as well and then shows you a story and the child's asked to repeat that story back and answer some questions about that story. And the other crazy thing that we like to do and this is common across all of our assessments is that we like to look inside your child's mouth and you might be wondering why? Well, that's because we want to check that the child's oral structures and function are okay because it might surprise some of your listeners, Sean, that we still get kids with say like a sub-ucus cleft that hasn't been identified before and they're at school. And you know, it's just something that we like to do. So don't worry about it if that's the case. And also hearing that would be another thing that some speech pathologist might screen. Hearing or certainly make a referral for a hearing test with an audiologist as just due process as, you know, as part of that kind of diagnostic assessment. Yeah, so basically then to summarize what we want to do if we're talking about diagnosis. So no, let's just backtrack. So assessment, as we said, is about effect finding mission and we will have our hypotheses. We will have questions that we want to answer through our assessment process. And if we suspect developmental language disorder that are really three things, three questions that we ask. And the first one is, is there a significant language difficulty? The second one is, is the language difficulty? Has it, is it persistent? Has it been there for a while? And the third one is, is there a functional impact? So what nets has just sketched for us is the persistence we often find out through parent report or through teacher report just to know has this child had difficulties in communicating for a long time or is this something that has developed recently? Has the child seen another speech pathologist? Perhaps when there were three and then our six years of age or when there were five and then our 12 years of age? And what did that speech pathologist find or what did the teacher think at the time? So that is sort of looking at persistence. The second one is significant and a standardized test is very good at giving us a standard score. And all it does really is it is one way of asking the child to perform a language task, for example, receptive vocabulary, so it's understanding words, we get the point to pictures and then we compare them to other children, the child's age and then we get a standard score and we know whether that is significant or not. Or we ask the child to repeat sentences or we get them to listen to sentences and again we know how far away, below or sometimes above the average range the child is and that will give us significance. But then the third one that's really important is that functional impact. And we get a sense of functional impact when the child, when we ask you to talk to the child to see how the child communicates in a more natural situation rather than just sitting the child at the desk pointing the pictures, answering questions by asking the teacher how the child's going in class and also by asking the child to retell a story or to explain how to do something because it is how to use language that is actually the most important thing to participate at school at home and in the community. I think the idea of being a bit of a detective, going on this fact-finding mission is something that I think comes up a lot, particularly in speech pathology training, but it's really, really true because we want to make sure that we're not just jumping to conclusions. However, we do know from quite a number of good epidemiological studies that some conditions are more common than others. So if we're looking for information, my sister-in-law coined this term when talking about DLD, we're here who think horses rather than zebras or unicorns. So you often want to start with something that's quite a logical thought process and go, well, let's look at language. If we've got concerns around academic behavior, parent report, teacher report, whatever it might be, and go, okay, well, let's look at this language skills and see what they're like. And then we use that information to help inform. Often I talk to this a lot with clinicians and students and people in the community that a diagnosis isn't always static as well. And so that's why assessment is so important that we can use this dynamic approach to assessment to really inform diagnosis, but just like our medical colleagues, if more information comes to light, then we will revisit that as well. That's right. That's a fundamental principle, right, assessments and ongoing process. So you might, it's more than one appointment, okay? So I'll tell you what's not the process, getting a diagnosis in 45 minutes, right? That's not the process. We need to actually have, we might offer a provisional hypothesis at this point, but we really do need to see that child more than just a one-off assessment. So I'm just going to put that out there, you know, and what else is not the process is when parents, when the parent doesn't get answers to their concerns, if we're not addressing the parents' concerns or if we can't do it, then we need to refer to someone who can, right? So that's also not the process. Yeah. Couldn't agree more. It's just a fundamental thing to kind of identify. You often see you go, Malay? Yeah, and I understand that often therapists, teachers, parents want to jump into intervention, but we know enough about intervention that just giving the child intervention one-on-one, you know, once a week, perhaps for six weeks or ten weeks is probably not enough to really effect change. So again, what we want to do is we want to really make sure that we include all what we call significant others in the child's life, so that what we do if we saw the child in a clinic, I'm just putting that as an example, that we can involve other people so that the child goes out into a world where everyone is trying to help or support the child to become a better communicator. So intervention is important, but I think we need a good, solid assessment of what strengths and challenges are. We then need to inform everyone else, and our intervention will be very much around teaching the child some skills, but also teaching others around the child how to best support the child or adolescents or adults. Yeah, absolutely. I think that there's tension in all of this when it comes to service delivery as well. You know, that sometimes your service provider will have stipulations around the way in which things do or do not work, you know, and I like to, I work clinically, and I like to think I'm pretty good, but by hell, I couldn't, I couldn't do a really clear assessment and diagnosis sometimes, you know, and, and no parents might be told, "Oh, look, you've got an initial appointment," but it's actually part of the initial conversations is saying that I'm going to need to see you multiple times and just establish those expectations, and then one of the ways I manage that is around, you know, having an assessment cost, but then also saying to them, "I also have a therapy cost, and I actually often charge my therapy cost," because I'd much prefer them to come back and get access to this information, but have clear answers, because one thing I do see happening quite a lot within the speech for theology community is that they might do assessments, they might provide intervention, but they don't actually answer the question. So the question of all the hypothesis might be, "Does this child have a developmental language?" which is all, "I know there's a whole can of worms that I'm not going to get into in the under-fives," because there's ways and means that we can go around that, but, you know, it's when somebody says to me, "You know, they've got a 16-year-old with a pervasive history of intervention, and, you know, language assessments from three and six and nine, and nobody's willing to put, you know, a label to clarify it for families." I think it's such a big disservice to our families. If we don't give them, you know, I've talked a lot about in previous podcasts the importance of a label and how my views have shifted on this all won't go into it today, but by providing parents equitable access to information is critical and making sure that they can find information, know what they're dealing with, just in the case of any other condition that they might face across their lifetime. Yeah, absolutely. Yeah, so there's a lot that I think we really need to unpack both from a family perspective, but also from a clinician perspective, so we're talking broadly here. Hopefully there's lots of fodder for people to take a part and think about as they're going. Yeah. The other thought, sorry Sean, I was going to say the other thought I have is like language is multifaceted, right? So we really, you know, need to consider doing a really comprehensive assessment, you know, and like we say, that's going to take more than just, you know, one session, because there's different ways of assessing language, right? So broadly speaking, we could talk about standardized testing, comparing performance of oral language to children that also receive that test. You can look at language sampling and analysis, and I'm sure my language would love to chat about that in a minute. We can also look at parent reports of language and communication performance and parent concern. That's another approach, right? Dynamic assessment, right? That's another approach that's got a lot of traction. So looking at testing a child's skill and then giving a period of teaching that skill or in intervening and then retesting and seeing whether or not the language performance improves, and also looking at how the child responds to cues or supports during that intervention period, that can be really diagnostically informative. But also things like portfolio assessment as well. So, you know, working with early childhood teachers or schoolteaches, looking at examples of schoolwork and examples of work where the child was supported and not supported, right? So all of that collectively will give a really rich, comprehensive assessment and so much more information to then plan what's next. And you said beautifully already moved on to my next question, so very eloquently put that. Thank you. You know, when we hear the word assessment, we often just think there's a number and there's a rating and there's so much more to consider, which you've just, you know, summarized beautifully. And that it doesn't have to just be like the numbers are helpful and I would say isn't early, put my hand up, early career speech pathologist, the quantitative side of assessment made me feel more confident and I felt that I could be more, you know, I could be clear in my communication with families because I had a number on my side. It's actually been through, you know, particularly changes in some of the standard I've been around long enough. They've changed some of the standardized measures and gotten to know the psychometric properties of the assessment that have maybe go actually all of these other areas are so valid and provide such rich information, particularly I was nodding vehemently for those of you who are listening in when that was talking about portfolios because, you know, there's so much rich information that already exists. You don't even have to elicit anything, you know, just by looking at it and going, ah, right, this is what's happening and teachers often think I'm crackers because I'm asking for all these things from school, but it's just incredibly useful data that's sitting there readily available that I can look at, but there's other ways in which we can do that as well. It might throw you mulling to talk about some of the, you know, assessment processes that we've talked about quite a few different ones, but any of the ones that you'd like to specifically hone in on. I think we really have, I think the only thing that we've probably haven't delved into a little bit, a little deeper is language sampling as not necessarily kindly alluded to. So language sampling is really getting the child to talk about something that is meaningful to them, right, meaningful to their participation at home, at school or in the community. And every speech pathologist, as part of their assessment battery, should do take a spontaneous language sample. There is really no way around it. And what does this spontaneous language sample mean? It means, you know, trying, perhaps it's a story retail, as I said earlier, so I'm asking a child to listen to a story and asking them to retail that story. It could be, um, so ask a child what's your favorite game or sports. Say you explain that game or sport to me because I've never heard of it, a bit of pretending going on here. It could be asking the child to persuade you about should we have junk food and tuck shops, for example, or should we have circus animals, you know, in circuses? things like that. So the kind of communication or discourse level language that they would need to do well in society or it could be a personal narrative. Like tell me about a time when there was a problem and you had to fix it. Tell me about a time when you were really sad or you know you can tap into emotions or really talking about past experiences. And then what we do is we record that and we analyze it. And that's where it gets a little bit tricky because how do we know that this particular child is actually doing okay or what's expected. And what I often do in my class is I ask my students to watch my daughter when she was 16 to explain the game of hockey and she was very, she loved her hockey and was really up to speed with the rules but there were lots of little words that were still wrong. You know she had like a carbon stick and she had sort of weird sense in structures and she was trying to think on the spot and it wasn't that easy and I asked the students what do you think and they go oh and they think she's got a language disorder and she really doesn't. She's just your big great you know English student. So my point in this is we then need to ask ourselves what information do we want to get from that language sample. Do we want to know how does this child compare to other peers and then what we need to do is we need to find a task that has norms or has some benchmark data and we can then compare the child whether it's a four year old or a 16 year old. If that is not our aim our hypothesis or our question what we could do is say okay this child actually seemed to know all the words but can they find their words when they're trying to tell us what happened three weeks ago when they had a problem or do they use lots of non-specific language like a thingy and you know that or yeah and that which merely makes it hard for the listener to understand what went on in that child's life which is important when you end up you know in the sick bay with a broken leg you can't tell the teachers what happened in the playground for example. So what a spontaneous language sample tells us it confirms or refutes our standardized language sample standardized assessment results which might have given us a standard score. The child might have done really well on that and absolutely you know born out on a language sample or the child might have been very poorly on a standardized test just because they found it hard and made you well in conversation and it will really direct our intervention practices. It will also tell us how do they formulate sentences put words together to construct a sentence and how do they plan their story right? Is that something that's difficult? Maybe they're fine at just giving one sentence at a time in a task where you just give them a picture and they give you the sentence but when the planning is involved you really there's no cohesion so you really don't know where their story is going or what's going on in the story or they're talking about he and she and you have no idea what they're talking about and again that is such an important skill to do well at school and to talk to other people to form friendships that we need that information for our intervention planning. So yeah that's my little high horse but we've done lots of research into language sampling right from three year olds to 16 year olds and it is such a great tool in the toolkit. So if you are a parent and your speech pathologist seems to be simply talking to your child there's probably what's happening and ask them if you're not sure why they're doing certain assessments ask them say why are you doing that? What are you trying to find out? There must be a question that drives that assessment piece. Absolutely and I think that especially the lovely thing about language sampling is that you can grade it based on you know the sorts of things that they would be doing for their age so you're not doing something that a four-year-old would be doing for a 14-year-olds and I love the example of you know explaining the rules of a sport you know a lot of teenagers would much prefer to talk about I don't know soccer or netball or whatever it is at their genuinely interested in then something that I've fabricated in a you know the small white clinical room you know that that's what we're assessing them in you know I always have that question in my mind is this what they'd be like outside of these little four walls you know and language sampling enables me to gather some of that evidence and also gives them more of a it's more their own voice in it rather than a standardized assessment which is just you know it's you you follow the rules and you administer it it's you know very prescriptive so I think actually sometimes children can shine doing something that's on their terms and if it's something that they're really interested in you think that they'd have practiced a lot talking about something they're interested in so they might be able to give you a bit of a glimmer into it actually was just thinking how lucky I've been over the last couple of years to listen to my daughters talk and I've listened to your daughter my lane talk on that video many times over the last few years I like that video but how beneficial it is actually to have listened to typically developing language you know and that's something that some people might need to think about I'm just thinking about some clinicians here that might need to go out and spend some time with you know other kids to be able to hear those differences as well I feel like we've answered the next question already so I might just ask it and see if there's anything you'd like to add around what assessment information might a speech pathologist need in order to diagnose the LD and I think my lane you hit on those three points beautifully earlier but is there anything else you'd like to add I would just kind of argue that you know kind of convince everybody around the world that that an assessment for you know for oral language we need to this kind of three you know areas so like looking at word knowledge looking at their lexical skills and then looking at utterance level skills right there there's your sentence you know for parents it's like that sentence level skill and then like what my lane was talking about the discourse level skill so where there's chunks of you know spoken sentences together for a meaningful purpose I find that a really kind of nice framework for speech pathologist to just check in and go has my assessment protocol covered those three areas and in terms of comprehension as well as expression and if you've done that you're going to have a comprehensive assessment yeah absolutely so but once a person's diagnosed you know we've talked about assessment and we've talked about it being often for the purpose of diagnosis in the initial stage is it kind of all one and done or is there a need to do further assessment down the track well I think it goes back to what your purpose of assessment is in the first place and and sometimes we like to review the language skills so that might be after a period of intervention but it could also be because language demands over development changes and you know adolescent young people rather have really have really kind of complicated and nuanced language demands placed upon them and they do require quite sophisticated spoken language skills and literacy skills so if we think about how language demands change over time be that from a curriculum or from a developmental perspective then you should warrant looking at assessment again not just at one developmental time point absolutely and unfortunately there is no cure for DLD right so we need to make sure that they're ongoing support in place and the the support will change and the level of support will change but the presenting difficulties may yeah like the net set be very different for an adolescent than when they were four years of age for example so a diagnosis is great and I don't think we need to re-diagnose all the time but we definitely want to monitor progress and we want to use different types of assessment tasks that are more appropriate to that developmental stage and to that child's daily life really yeah I completely agree I was you know giving a thumbs up just then because I think often you know we reuse standardized assessment and some of those assessments are designed to be used diagnostically and in fact as somebody who's delivered many many many standardized assessments for children longer tunely because that was a funding requirement for children I actually find sometimes it's really unhelpful for me to be able to determine what to do you know and and actually there's other forms of assessment that actually better inform if I'm wanting to look at assessing for intervention purposes and to see where to go next versus you know making some decisions around I've just had a lovely instance where I've had two young people with DLD who've been discharged for a period because you know they're at a point where they're self-advocating they still got language difficulties but what we set out to achieve in our intervention has been achieved and we can demonstrate that through our assessment so you know there's been really you know robust measures put in place to make sure that I feel really comfortable that now is a good time because as you've said my lane DLD is a lifelong condition does that mean that they need to come in and see me weekly for a 45 minute appointment for the rest of their lives no you know so what how do we make those decisions and actually it's through having that that evidence and assessment as a part of that. And standardised assessments I have never, ever been designed for progress monitoring, even though it says in the manual you can redo it after six months. There is really, you know, there's no reason to redo a standardised assessment unless it is for certain funding providers, absolutely. And what I really, really warn against is teaching to the test. Because we can teach the child basic concepts, right? The ones that are, for example, assessed in a very commonly used standardised assessment is speech pathology practice. And sure, the child will then all of a sudden have an amazing standard score on that and will be way better than any of his or her peers after six months. But does that mean that the child's language difficulties have been fixed? No, because it still doesn't tell us what's going on in the child's life and how does the child deal with language. Because a standardised test is really just, it's a litmus test to see, is there a significant discrepancy between the child's language skills and his or her peers? Doing that again after three or four years, sure. To see his child, you know, keeping up with his or her peers, is there some acceleration in skills or maybe the skills at the gap is widening? Sure. You can, you can convince me of that, but not for progress monitoring. Do another language sample or, you know, talk to the teachers, talk to the parents, much better ways. I'm much more enjoyable often as well. Yes, no, it's good because I think the thing that we often forget is somebody is always paying for this as well, whether it's through government funding or whether it's families or self-funding. So, you know, we do have a, have to consider the cost and one of the examples I always give is that in schools, I would assess language and as soon as I determined that was language, I would always then be probing on literacy, like instantly doing that because I had the resourcing in order to do that now with somebody who works in a private practice. My parents have, you know, nobody has an unlimited bag of money. And so what I always say is that once we've determined that there are difficulties with language and we're going to provide a period of intervention. I always sort of put that stipulation in my recommendations that we can and do want to do other assessments, likely looking at literacy and possibly after a period, maybe we might do it after a term. And so the parents can plan for that and think about that, you know, in their decision-making and I try to make sure that parents are really well informed. I even got to the point of recently I do quotes up for what we can do and how much information we can do and how much time it will take because the parents are informed make decisions as to how much information I can and can't provide. And I've had a family that said to me recently, look, I want all the language and literacy information. So we did that over a quite a number of sessions so that they left with an assessment report that met their needs and their school's needs, whereas another family was really, you know, making tough decisions to be able to forge to do speech pathology assessment and intervention. So we went with the language assessment that I felt would give us the most information first. And then they know that after a period that we're going to go back and get more information. And that's really responding to our family's needs. And I think that, you know, we can be as we could try and be prescriptive as to what language assessment looks like. But there's always going to be that overlay of service delivery and at the end of the day, somebody's paying for it. Yeah. And I do actually, you mentioned literacy and I'm well aware of the fact that we haven't really spoken about literacy enough. It just feels there isn't enough time today, but for teachers, for teachers or speech pathologists or parents who are listening, I am going to give a little plug of my book. It's called reading success in the primary years and it's open access or freely available and we'll put the link up and it really gives. We've tried to be as easy accessible as possible if that's a good way of putting it. Just to sort of explain what are the links between spoken and written language. What kind of assessments do you need to do to really understand what may underpin a child's reading difficulties. We'll leave it at that, but literacy and language are so closely connected. They're just different mediums, really. If you do not have the spoken language, then it's really hard to actually access written language. Okay. I'm going to start bringing us to a conclusion. I do want to know in your opinion, what do you hope to see in the future for DLD, either in research, clinical work or service delivery? Okay, I'm going to start this one. Future for DLD, no aging out of SLP services for that publicly funded. That would be an incredible achievement because we have inequity and it's, you know, the assessment, aging out of services at seven, is just unjust for those children and young people that are going to present with a lifelong condition. We need DLD to be recognised as a lifelong communication disability and supported as such. I think the future is co-designed of children and young people working with us and families with for DLD services for DLD. And maybe one thing that is close to my heart is more clinician research or partnerships for treatment research because we really do need to increase the evidence base for interventions for these young people. I think you've summed it up beautifully, that's it. Thank you for that. I absolutely agree. It is absolutely heartbreaking that some parents don't get funding for DLD when they other parents who have children with sort of more commonly known diagnoses, you know, do receive funding, even when, if we look at the children's communication skills, they're very similar. But because it's a hidden condition, it's not well known enough, you know, parents often actually keep knocking on doors and do not get the support they need. So, yeah, it's so, so important. From a research perspective, I really like where we're going, I think the catalyzed consortium has done a great job in putting DLD on the map. And I am absolutely so blown away by all the advocacy initiatives that have happened around the world and shown your, your such a shining example of that. Because that's what's needed, you know, that is what will help drive research, help drive clinician research, your partnerships, it will help parents feel more confident about advocating for their children. So, and that should ultimately help service delivery as well, or for people to take notice and go, hang on, we are speech pathologists, we're in the business of improving communication for all children and definitely children with DLD. 100%, I think that I keep saying this, I think at the end of every podcast, but I do feel like the future is bright. I think I entered into this space in a period of, you know, we were using different terminology and nobody knew what population I worked with and it was really hard to breathe, like recruit and research, you know, in this space and I feel that just even the increase in publications in this space has been overwhelming, I don't know that even the DLD project probably would exist before the catalyzed consortium. So I just think that, you know, and there's more and more organisations and not for profits and, you know, you know, ambassadors that are, you know, raising awareness of the condition I think it's such an exciting time, really fortunate I feel in some ways that it's been at a good point in my career. We are drawing to close and I have one more question for you at the DLD project, we are trying to focus on self-care and I say this with a, you know, a grin because we're not very good at it sometimes and we do try to find time to breathe in our busy day as very busy academics because I know you both well, what do you do to look after yourself? I love going outside, I love riding my bike to be honest, that's the best part, I go to RPM during the week which is just inside in the gym because it's quick and easy 45 minutes but my absolute down time is, yeah, hopping onto that bike and going for a long bike ride preferably for days on end but not always possible and family, I just love family, family time for me is gold, I love having dinners together, I love cooking together, I love having glasses of wine with lots of olives. And in holiday times I read, I read novels, I read anything that is not to do with research because I absolutely love reading, I just find during the semester there's just no time to read, we get into a book because once I start I don't want to put it away so yeah, I can go on but I'll let Nath have a turn. Oh well, I'm just like going to the beach or any kind of water. I find that calming. and I like taking the dog for a walk. It's very therapeutic. - Which body of water is behind you? For those who are listening, there's a beautiful picture behind Nat's head at the moment. I've been wondering all podcasts. - Oh, that's actually on the central coast, which is an hour north of Sydney. - Yeah, beautiful. - Yeah, that's not where I am at the moment, but that's where I would like to be. - No, with your beautiful family, I'm sure. - Yes, absolutely. Thank you. - Yeah, wonderful. Well, I just wanted to recap in your mind, what would be the sort of key points you'd love listeners to take away from our chat today? - So I thought about this because I think it's really important. So I'm gonna break it down in terms of key points for parents and then key points for speech pathologists. So for parents, I would advocate that, get ready for your child's assessment. Keep a file of examples of their work. Keep a file with their medical reports or their allied health therapy results. Maybe take an audio sample or a video of your child having a conversation at home or in the car. Your speech pathologists might like to listen to that. That would be really helpful as well. Partner up with the speech pathologists. Get to understand the process, ask questions. Let them know your goals for assessment. I think that's really important. And be mindful that assessments not gonna be a one-off process. DLD is persistent. So if you do need an updated plan over the course of your child's development, then think about those key time points across the child's development from child care to preschool, from year six to high school, those kind of key points from high school to the workforce or for further education. Think about how your child might need some support at those critical time points. And to be frank with you as well, if your speech path service doesn't provide a comprehensive assessment, go elsewhere, right? I'm gonna advocate for student-led university clinics because you will know that student-led university clinics will offer a comprehensive assessment because that's what we're teaching them. So that's one side of things. And then for the speech pathologist, I really feel that comprehensive language assessment shouldn't be just for the privileged. We need to be in schools, we need to see all kids, we need to see kids that are vulnerable and for whatever reason. If your job is about differential diagnosis, then if you haven't already looked at the catalyzed papers, please do or look at the training that's being offered around raising awareness of what DLD is and what the different kind of differential diagnoses might be, say between DLD and speech sound disorder or DLD and or language disorder associated with a biomedical condition like autism. I think if that's not part of your framework at the moment, get into it, right? There's lots of wonderful fabulous resources now available for that. And doing the comprehensive assessment is gonna be the better you assess the better your management of the child and/or young person. And really just go set with the parent and the teacher and the child. That's where I'm gonna leave that. - Awesome, thanks, Nat. My lane, anything to add? - We're in agreement all the time, Natalie. - I'm not surprised. - I know, I know sometimes I'm being accused of being the academic and not being out in the real world because time is so precious and it is. But as we've hopefully convinced everyone, a good solid assessment will actually help us to understand what supports the child needs and who is the best person to provide that support and also give us a baseline, right? To sort of monitor progress. So assessment is key and it doesn't mean that we can't start to provide some suggestions or recommendations during the assessment sessions. But please, you know, as clinicians do not try to do an assessment in 30 minutes because you will be doing everyone a disservice. And parents, I think, try to be patient and really understand why the assessment process is so important. And then the other one is the report. I know that report writing is a very onerous process. It takes forever, it's time consuming. It is so important. It is important and I know that you've got another podcast coming up about this, but it is important because it captures what the child could do at that particular moment. Now the report and I'm sure that'll be discussed but needs to be readable and it needs to be to really showcase not just the impairment, the significance but also the functional impact of the language difficulties. And as parents, ask questions. If that report is 10 pages long and you do not understand the word of what's in there or you disagree, ask questions and say, "Actually, that's not what I'm seeing at home." So again, that's what NASA referred to in partnership with your speech pathologist. You're the expert, really. We know a lot about language development. I'd like to think we have lots of expertise in that area but you're the expert on your child. So we need to work together and in partnership, we can probably do a very good job. There's more and more research coming out. We know what's evidence-based. We know what works well. And sometimes it's a little bit of trial and error but yeah, the future should look much brighter if we have a good solid plan in place. - You've alluded to two things beautifully, Marlene, which is that we are going to be following up on report writing. So that's a really important point. I do want to highlight that we do have a resource on the DLD project website, which is questions to ask your speech pathologist. So we do want parents to be empowered to be, or families to be empowered to be equal contributors to this process. You're so important and teachers we want also to understand because without you, we can only do so much. It's actually the fact that we can all come together and best support this young person who will benefit from that. And I do want to highlight as well that we haven't had a chance to talk about multilingual language assessment but I do want to highlight to a very early podcast about which was with Emily Hunt. So if you're interested in talking about all listening to more about assessment within the context of working with multilingual young people who may or may not have DLD, I think it's episode four of our first season would be a great reference to some people as well. - And I think the final message is that language development is complex. And it is amazing how many kids actually just learn to speak so well without seemingly a lot of effort. It's a miracle. Language is really what makes us human, I think, and communication is so important. So when things don't go that well, you will start to understand what a complex process it is and you'll start to appreciate that. And that's why again, assessment really can take a little bit longer than many people want. But we need to get to the nitty-gritty of what in this complex process is the thing that needs the most support so. Yeah. - Awesome. - Well, thank you both so much for giving up some time to talk to us today. And we look forward to sharing this with all of our listeners. Thanks again. - Pleasure. - Thanks for joining us on this episode of the Talking DLD podcast. If you're a therapist who'd like to grow your knowledge of developmental language disorder, why not join me for one of our workshops. 2022 dates have just been released. Plus, you can access the content on demand 24 hours a day, seven days a week at the dldproject.com. The live workshops will sell out, so make sure you book as soon as you decide. I look forward to working with you this year. Thanks, everyone.