TIC May 2015 PDF

May
2015 www.shas.org.sg
Tongue-in-cheek
Speech-Language & Hearing Association (Singapore)
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May 2015 www.shas.org.sg
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Editors Letter
Article: Core Subjects at the End of Primary School: Identifying and Explaining
Relative Strengths of Children with Specific Language Impairment (SLI)
Interview: Direct from Singapore
Article: Does Bilingualism Influence Cognitive Aging?
Article: The Cognitive Science of Bilingualism
Interview: Direct from UK
Article: Terminological Debate over Language Impairment in Children: Forward
Movement and Sticking Points
Article: How Much Exposure to English is Necessary for a Bilingual Toddler to
Perform like a Monolingual Peer in Language Tests?
Interview: Direct from HK
Article: Learning Difficulties or Learning English Difficulties? Additional Language
Acquisition: An Update for Paediatricians
Interview: Why Choose a Career in SLT
Article: Longitudinal Trajectories of Peer Relations in Children with Specific
Language Impairment
Article: Improving Comprehension in Adolescents with Severe Receptive
Language Impairments: a Randomized Control Trial of Intervention for
Coordinating Conjunctions
Article: Do Infant Vocabulary Skills Predict School-Age Language and Literacy
Outcomes?
Article: Tracing Children's Vocabulary Development From Preschool Through the
School-Age Years: An 8-year Longitudinal Study
Events
;
Dear Fellow SLTs,

One year ago we published our first issue under this new Publications Committee. It has been a
fabulous year of meeting new people who so kindly helped us with their professional and clinical
insight, and finding avenues to bring you contemporaneous and relevant articles. This time
around, we were able to compile some great articles that address many areas of language
development, from the ever so tricky terminology issue that our community across different
countries considers we should use, recent findings in bilingualism and specific language
impairment, to therapeutic approaches related to the development of vocabulary. We hope you
find these articles interesting and we hope you can use them to enhance your service delivery
(and hopefully generate some pretty good discussions at lunch time!).
We were also fortunate to have a number of people who wanted to contribute to TIC with their
valuable professional and clinical experience, including SLT students who shared what made
them choose this fantastic profession and their hopes for the future. A heartfelt thank you to
Fatimazahra Khaki, Raphaela Hew, Marie Robert, Carolanna Rodriguez, Mrcia Filipe, Ctia
Ribeiro, Ana Athayde Campos, Raquel Vieira, Zlia Fernandes, Ndia Silva, Ins Mestre, Daniela
Silva, Siew Li Goh and Alison Cannon.
Last, but not least, there are some great workshops happening in the next few months, from
Autism - What every parent ought to know, Autism What every education professional ought
to know to Leading From One Step Behind: A Solution-Focused Brief Approach To Working With
Clients.
Happy May everyone.

We all have ability. The difference is how we use it.
Stevie Wonder
Research
Article

The following article was published online on http://onlinelibrary.wiley.com on 03/12/2014,
DOI: 10.1111/1460-6984.12137.

Core Subjects at the End of Primary School: Identifying and Explaining Relative Strengths
of Children with Specific Language Impairment (SLI)
Kevin Durkin, Pearl L. H. Mok and Gina Conti-Ramsden
International Journal of Language & Communication Disorders
Volume 50, Issue 2, pages 226240, March-April 2015

Background: In general, children with specific language impairment (SLI) tend to fall behind their typically
developing (TD) peers in educational attainment. Less is known about how children with SLI fare in
particular areas of the curriculum and what predicts their levels of performance.
Aims: To compare the distributions of performance of children with SLI in three core school subjects
(English, Mathematics and Science); to test the possibility that performance would vary across the core
subjects; and to examine the extent to which language impairment predicts performance.
Methods & Procedures: This study was conducted in England and reports historical data on educational
attainments. Teacher assessment and test scores of 176 eleven-year-old children with SLI were examined in
the three core subjects and compared with known national norms. Possible predictors of performance
were measured, including language ability at ages 7 and 11, educational placement type, and performance
IQ.
Outcomes & Results: Children with SLI, compared with national norms, were found to be at a disadvantage
in core school subjects. Nevertheless, some children attained the levels expected of TD peers. Performance
was poorest in English; relative strengths were indicated in Science and, to a lesser extent, in Mathematics.
Language skills were significant predictors of performance in all three core subjects. PIQ was the strongest
predictor for Mathematics. For Science, both early language skills at 7 years and PIQ made significant
contributions.
Conclusions & Implications: Language impacts on the school performance of children with SLI, but
differentially across subjects. English for these children is the most challenging of the core subjects,
reflecting the high levels of language demand it incurs. Science is an area of relative strength and
mathematics appears to be intermediate, arguably because some tasks in these subjects can be performed
with less reliance on verbal processing. Many children with SLI do have the potential to reach or exceed
educational targets that are set at national levels for TD children.
What does this study add: The study confirms that children with SLI do perform, overall, below national
norms in core subjects at the end of primary school but shows also that some attain the levels expected of
TD peers. Performance varies among subjects (poorest in English, with relative strengths in Science).
Children with SLI undoubtedly face many hurdles due to the language of education but may profit from
learning opportunities that d raw on other capacities, such as visual representation.
;
Raphaela Hew & Marie Robert work as Speech and Language therapists at K K
Womens and Childrens Hospital.
Interview
Corner
Caseload:
Marie: Most of my caseload is outpatient and is made up of children with language difficulties
(delay and disorder) ranging from very young all the way up to 18 years of age. I also have an individual
social skills clinic and a social skills paired clinic where the children come in pairs to work on pragmatic
goals. I run the baby feeding clinic for our premature babies, after they have been discharged from the
wards, and a combined OT, SLT, PT clinic for assessment of complex cases. Finally, both Raphaela and I
cover the wards for children with d ysphagia and when other therapists are off, and we also see the warded
children with language difficulties as much as we can. Life is never dull!
Raphaela: The majority of my caseload is outpatient. I see children from 0 - 18 with language delays,
language disorders, stuttering and children who have feeding difficulties. I also cover the wards and see
children with dysphagia.
Duties: Duties for outpatient clinics cover the range of the therapeutic process, from assessment through
therapy until discharge. There is also a hefty amount of paper work and follow up involved. We spend a lot
of time contacting other people working with the children to make sure everyone is on the same page. It is
a little different for inpatients, as they are only warded temporarily, so we try and get as much done as
possible in a short space of time. There is direct assessment and therapy both for the usual speech and
language difficulties and dysphagia, or other feeding problems. Parent education is also a major factor in
every patient we see, no matter what their difficulties are.
Typical Day:
Marie: I usually get into work very early. I like to have time to prepare over my cup of tea, check all my files
and plan. Depending on the clinic I am running, I will prepare all the toys or equipment I might need. I also
do clinic education of colleagues, so I might need to do preparation for that, as well as pull my weight for
research. As I mostly cover outpatient clinics, my day is often back to back patients, squeezing
administration into the spaces inbetween. As I always say, Id rather be busy than bored!.
Raphaela: A typical day is a big, exciting rush with pockets of joy in between, e.g. when a child learns to say
a new word, or initiates communication for the first time, or when parents report progress noted in their
childs language and/or feeding development. I split the day between individual and/or group therapy,
clinical education of new colleagues, as well as administrative d uties. As a team, we are very much involved
in research (so there is always an ongoing research project). Other administrative duties include
multidisciplinary projects with doctors and nurses (e.g. to train nurses to screen for communication delay
for toddlers 8 months and upwards) and dieticians, for example. As you can tell, there p robably isnt a dull
moment in the day.
Challenges: Marie: As a therapist who is not Singaporean, I initially found it a challenge to get used to the
way language works here and the effects those differences can have on therapy (since my area is
language!). But since Ive been here for such a long time, my current challenges are more based in teasing
out the often complex language difficulties some of my patients present with, and always coming up with
new and fun ways to improve childrens skills.
5

;
Continuation.
Raphaela: I really value the partnership parents can offer when it comes to capitalising
on a childs strengths and remediating his/ her areas of difficulties. I find it challenging
when parents are not ready to offer that yet, either because they are still coming to terms
with their childs condition or they are looking for a magical quick fix instead of the hard work
we are telling them well need to do together.
Interview
Corner
Surprises: We are constantly surprised by the variety of difficulties children in our language clinics present
with. Some children could look exactly the same on paper, based on report or test scores, but present
totally differently in our clinics. It is one of the things we like about language; no one uses it the same way.
We are also constantly surprised (and delighted) by the lengths some parents, carers and sometimes
siblings, will go to to help a child who is having d ifficulties.
Carry Over: This is an area we find difficult in our setting. We cannot see the children as often as we would
like due to the large numbers of patients, so we engage significantly in parent and carer education. This
way, the carers can go home and implement the strategies at home. I try to make sure the carer
understands what we are doing and, more importantly, why we are doing it. No one will work on
something at home if they dont see how it will benefit their child. We also adjust tasks according to the
childs interests.
Impact: Everything! We use language all day every day. How do you tease apart language from everything
else? Apart from poor academic achievement, language disorder may also result in poor acquisition of
world knowledge, which can be simply understood as what the child understands of the world. We find this
is through general poor understanding of what people around the child are saying/ teaching as well as
inability to learn from reading. It is, therefore, important to also target this from an early age! We also
often notice language disordered kids have social skills difficulties. They cannot read the signs other
people send in their voices or with their bodies. That means that a world, which is already reduced thanks
to lack of language, is further impoverished by lack of friends and social connections. The impact of a
language disorder is everything. Language is life!
Success Story:
Marie: H is a girl who is now around 8 years old. She has a rare, mosaic form of genetic disorder. When
she first attended my clinic, she was about 3 and had severely delayed motor (she is not yet able to walk)
and language skills. She had just started using some single words and mostly used gestures. Her
understanding was also significantly poor; however, she had such potential shining out of her eyes! Given
the rare quality of her d isorder, her mother was very concerned that n o one was able to tell her how well
H would do in the long run. There was counselling needed to help her see that H had potential to learn,
and that maximising her skills should be our focus, regardless of the end point! Her mum rose to the
challenge wonderfully and now, thanks to her family and a lot of therapy, H can not only use sentences
but we are now working on basic narrative. She is functional in speaking to new people, her school teachers
and friends. She is in a special needs school, albeit in the academic stream, and learning well.

6

;
Continuation.
Interview
Corner

Loved Resources:
Marie: Toys! Any toy! Fun is a major key to therapy and anything boring can always be jazzed up
with a fun reward.
Raphaela: Social media and the internet, because it is inherently motivating to many of our older kids.
Youll be surprised to see how many language tasks we can incorporate into social media and tasks on the
internet! A great resource is always going to be the childs motivation so we always maximize that.
Wish List:
Marie: We are well resourced here and I am a big fan of being flexible. You will often catch me using the
same toys to target different skills. My rule is if you cant use it for at least 3 different things, its probably
not worth having!
Top Tips for Clinicians:
1. Always remember to first see what your child can do, as too many people will point out what he
cannot do.

2. Remember to always find out what is motivating for the child; many, many language tasks can be
done within contexts that are personally motivating for the child.

3. We find task analysis is always helpful to tease apart task demands, which lead to task breakdown!
It is not important that they cannot do something, as what is important is why they cannot do it.

Top Tips for Other Professionals/ Parents: Always remember to see what your child can do first and work
up from there. Also, celebrate small achievements. Too many language disordered children feel like they
never achieve anything. Parents are so important because they can be reminders of how far the child has
come! The praise of a parent is often worth a lot more than that of someone else, so praise small
achievements, perseverance and effort. These kids work so hard! They need more than your average
encouragement.

Always remember to first see

what your child can do, as
too many people will point
out what h e cannot do.
Research
Article

DOI: 0.1002/ana.24158.
Does Bilingualism Influence Cognitive Aging?
Thomas H. Bak MD, Jack J. Nissan PhD, Michael M. Allerhand PhD and Ian J. Deary MD
Annals of Neurology
Volume 75, Issue 6, pages 959963, June 2014

Abstract: Recent evidence suggests a positive impact of bilingualism on cognition, including later onset of
dementia. However, monolinguals and bilinguals might have different baseline cognitive ability. We present the
first study examining the effect of bilingualism on later-life cognition controlling for childhood intelligence. We
studied 853 participants, first tested in 1947 (age=11 years), and retested in 20082010. Bilinguals performed
significantly better than predicted from their baseline cognitive abilities, with strongest effects on general
intelligence and reading. Our results suggest a positive effect of bilingualism on later-life cognition, including in
those who acquired their second language in adulthood.

Discussion: Our results suggest a protective effect of bilingualism against age-related cognitive decline
independently of CI. The effects are not explained by other variables, such as gender, socioeconomic status, or
immigration. Importantly, we detected no negative effects of bilingualism. The cognitive effects of bilingualism
showed a consistent pattern, affecting reading, verbal fluency, and general intelligence to a higher degree than
memory, reasoning, and speed of processing. The effect on the NART could be explained by its loanwords with
cognates in other languages: bilingualism leads to higher familiarity and hence better performance. The effects
on general intelligence are likely to be related to frontal executive advantages, the best documented nonverbal
cognitive feature of bilingualism. In terms of types of bilingualism, early versus late acquisition showed
differential effects, depending on childhood IQ. Overall, individuals with high intelligence seem to benefit more
from early acquisition and those with low intelligence from late acquisition, but neither group showed negative
effects. Early and late acquisition of a second language might have different effects on frontal executive
functions, possibly modulated by baseline intelligence. Knowing 3 or more languages produced stronger effects
than knowing 2. This variable has yielded contradictory results in previous studies and requires further research.
Little difference was found between active and passive bilinguals, possibly due to low frequency of second
language use, even in active bilinguals. However, it is conceivable that acquisition of a second language leaves
lasting cognitive traces independently of its subsequent use. If bilinguals automatically and unconsciously
activate both languages, they constantly need to select, monitor, and suppress linguistic information, stimulating
frontal executive functions. The observed effect sizes are comparable to those reported for other factors
contributing to differences in cognitive ability and cognitive change, such as the effect of variation in the gene
for apolipoprotein E, physical fitness, and (not) smoking. Accordingly, the interpretation of our data should be in
terms of cognitive epidemiology, rather than clinical application to an individual. As a small reduction in a
population's blood pressure can have a sizeable effect on the number of strokes despite blood pressure
accounting for only a small variation in stroke, a modest change in the proportion of people who learn 1 or more
extra languages could have a population effect on cognitive pathology rates.

Our study has limitations. The knowledge of language was defined by a questionnaire, not proficiency. Only few
participants acquired their second language before age 11 years, so we could not study the classical cases of
parallel, perfect, early acquisition of both languages. However, this limitation is also a strength. Millions of
people across the world acquire their second language later in life: in school, university, or work, or through
migration or marriage to a member of another linguistic community. Many never reach native-like perfection.
For this population, our results are particularly relevant; bilingualism in its broad definition, even if acquired in
adulthood, might have beneficial effects on cognition independent of CI.
8

Research
Article

DOI: 10.1111/lnc3.12099.
The Cognitive Science of Bilingualism

Yanping Dong and Ping Li
Language and Linguistics Compass

Volume 9, Issue 1, pages 113, January 2015

Abstract: Recent research in cognitive effects of bilingualism has generated both excitement and
controversy. The current paper provides an overview of this literature that has taken a componential
approach toward cognitive effects of bilingualism, according to which bilingual advantages in executive
functions are measured in terms of executive control (inhibiting, switching, updating) and monitoring.
Findings to date indicate that the presence or absence of bilingual advantages may be influenced by a
variety of learner and environmental factors, including the bilingual individual's age, age of acquisition,
language proficiency, frequency of language use, and difficulty of the experimental task. The cognitive
effects of bilingualism must be interpreted in light of the bilingual's lifelong linguistic experience, which
results in adaptive changes in the mind and the brain. We suggest directions for future research in this
domain.

Conclusion: The bilingual's experience of learning and using multiple languages may be unique because it is
extensive, long-term, and brings an overall change to not only how linguistic tasks are carried out b ut also
how nonlinguistic tasks are performed, resulting in an enhancement of both linguistic and domain-general
nonlinguistic functions (e.g., Bak et al. 2014). The bilingual experience leads to positive changes in both the
mind and the brain, and in both the function and the structure of the brain. Although specific patterns of
bilingual advantage are subject to debate, enough evidence has accumulated to motivate us to carry on
research in this domain and to study neuroplasticity as a result of learning and using a n ew language. In this
short review, we have identified the role of a set of learning and input factors such as the bilingual's age,
task difficulty, and language history (e.g. frequency of language use, age of acquisition, and L2 p roficiency)
and pointed out how these factors and their interactions may jointly influence measurements of bilingual
versus monolingual performance in executive functions. While our review has focused on specific
components of executive functions such as inhibiting, switching, updating, and monitoring, we are mindful
that a more holistic approach needs to be taken to examine bilingualism (Kroll and Bialystok 2013). Finally,
we suggest that it is important to examine not only the cognitive effects as consequences of bilingualism
but also the mechanisms and locus of these effects reflected in the bilingual mind and the bilingual brain. A
significant direction for future research is to identify the causal relationship through longitudinal studies of
bilingual experience and the corresponding neurocognitive and neuroanatomical changes. As a final note
for future research, we should also attempt at an understanding of the cognitive science of bilingualism by
studying not only the cognitive effects due to bilingual experience (i.e., bilinguals compared to
monolinguals) but also individual differences in cognitive effects due to the same type of experience (i.e.,
bilinguals compared with bilinguals).

;

Interview
Corner
Fatimazahra Khaki works as Special Educational Needs Learning Support

Assistant (SEN LSA) in ARK Aryton Primary Academy, Southsea, UK.

Caseload: My caseload consists of about 13 children with various types of difficulties. I have children in
the autistic spectrum, including a child with Asperger's syndrome, a child with dyslexia, one with
dyspraxia, and the other children have specific language impairment.
Duties: My role involves creating long-term and short-term targets, planning each session, making
resources and activities for the session, building a report with the children, giving 1:1 as well as group
speech and language interventions, writing case notes and keeping evidence of the children's progress,
and giving feedback and discussing children's progress with my Line Manager and the relevant
teachers. Since I work as an SEN LSA, I have break time duty where I'm in the playground with the
children - this gives m e a chance to observe them during play as well.
Service Structure: The school does not have an SLT visiting every week to give therapy to the children.
I am the only person providing speech and language interventions to the children. The children, who
have been flagged up, are initially seen by an SLT who comes in to assess them and sets some targets
to be followed. Someone in my position would then provide intervention regularly to those children
and the SLT would come back after a couple of months to see the children's progress. In the meantime,
I assess them informally so that I can prioritize an area of difficulty, as I'm only given around 10 to
15min with each child, 2 to 3 times a week.
Typical Day: A typical day would be coming in to school, planning for that day's session, taking children
out of class one by one for intervention from 9:00am or 9:30am (depending on whether they have
assembly or not) until 10:30am, taking a short break, and resuming interventions from 10:50am to
12:00pm. Then I'd take another break for lunch from 12:00-1:00pm. During the first hour of my
lunchtime, I usually finish m y notes for the morning and plan for the afternoon. After lunch, we have a
read & write session, where children from the whole school are divided into groups according to their
abilities and they are taught phonics. After phonics, it's back to providing interventions, after which I
write my case notes for the afternoon.
Challenges: The most challenging thing for me, so far, is providing intervention for the children with
Asperger's Syndrome and Autism. I haven't had much experience with children with these difficulties,
so I'm learning as I go. At the moment, I'm working on social behavioural skills.
Surprises: Well, children are full of surprises generally! However, I've noticed, in my short time
working, that the children who have language difficulties will seem very quiet and shy in class.
However, when put together in an intervention group or during 1:1, they will talk, comment, and shout
out!

10

;
Continuation
Carry Over: Im going to describe my own carry over skills. I'm ensuring that I do it
by looking out for opportunities for further training, so that I'm continuously able
to develop the skills that I already have. However, as an LSA, I sometimes have to
work with phonics with other children, and I make sure I use the skills I've learnt as an
SLT student and a SEN LSA, to promote better learning for the children.
Interview
Corner
Impact: My client group's difficulty mainly impacts on their access to the curriculum, since most of the
children I see have a speech and language difficulty, i.e. following instructions, understanding what is
said/taught in class, and expressing themselves with clarity, and by using long and meaningful
sentences, so that they are understood. Behaviour difficulties also impact on their learning, i.e. they
may not understand the consequences of their behaviour, have tantrums during class and, thus, access
less learning time.
Success Story: I have a child who has difficulties with her speech - she could not say /sk/ in initial
position, when blending sounds to read. I've taught her a strategy where you ignore the /s/, read the
rest of the word, and then add the /s/ back to the beginning, for example 'skate' can be read initially as
k-a-t-e, add the /s/ and then read as s-kate. We h ad a bit of difficulty at first because when she cannot
do something, she gets anxious. Thus, I had to talk to her before every session, explaining that it didn't
matter if she couldn't do it the first time, and that repetition would help. Eventually, she learnt the
strategy, and is now able to read words beginning with /sk/.
Loved Resources: I love using picture cards to play memory games. I use this to teach 'he/she'
pronouns and verbs, with simple pictures of a girl and a boy doing the same action. Recently, I also
used this game to teach the concept of same/different. It works well because it is fun, so the children
enjoy it. They use their language while describing the pictures every time they turn them over, and it is
a great resource for attention and memory, since they have to watch carefully and remember where
each picture is to win.
Wish List: I would like to have more resources targeting social skills, cause and effect, and
consequences of behaviour.
Top Tips for Clinicians: Always remember that every little progress counts!
Top Tips for Other Professionals: Working in a team with an SLT or someone working with SEN
children can be beneficial to both the professional as well as the child, because the child is then looked
at holistically. Targets would also be easier to set knowing each professional is working on an area to
help the other.
Top Tips for Parents: Continue to spend time with your children while supporting them at home by
using lots of modeling techniques, e.g. talk to your children and if they say anything that is not clear or
grammatically correct, repeat the sentence to model the correct way. Also, get your children to look
at/ read books, as it will help them improve their attention, vocabulary, sentence structure and
thought processing.
11

Research
Article

DOI: 10.1111/1460-6984.12111.

Terminological Debate over Language Impairment in Children: Forward Movement and
Sticking Points
Sheena Reilly, Dorothy V. M. Bishop, Bruce Tomblin
Volume 49, Issue 4, pages 452462

Background: There is no agreed terminology for describing childhood language problems. In this special
issue Reilly et al. and Bishop review the history of the most widely used label, specific language
impairment (SLI), and discuss the pros and cons of various terms. Commentators from a range of
backgrounds, in terms of both discipline and geographical background, were then invited to respond to
each lead article.
Aims: To summarize the main points made by the commentators and identify (1) points of consensus and
disagreement, (2) issues for debate including the drivers for change and diagnostic criteria, and (3) the way
forward.
Conclusions & Implications: There was some common ground, namely that the current situation is not
tenable because it impedes clinical and research progress and impacts on access to services. There were
also wide-ranging disagreements about which term should be adopted. However, before debating the
broad diagnostic label it is essential to consider the diagnostic criteria and the systems used to classify
childhood language problems. This is critical in order to facilitate communication between and among
clinicians and researchers, across sectors (in particular health and education), with the media and policy-
makers and with families and individuals who have language problems. We suggest four criteria be taken
into account when establishing d iagnostic criteria, including: (1) the features of language, (2) the impact on
functioning and participation, (3) the presence/absence of other impairments, and (4) the language
trajectory or pathway and age of onset. In future, these criteria may expand to include the genetic and
neural markers for language problems. Finally, there was overarching agreement about the need for an
international and multidisciplinary forum to move this debate forward. The purpose would be to develop
consensus regarding the diagnostic criteria and diagnostic label for children with language problems. This
process should include canvassing the views of families and people with language problems as well as the
views of policy-makers.
()
What terminology should we adopt?
Our focus here is on terminology for children's unexplained language difficulties, and we do not consider
further the term speech, language and communication needs (SLCN). This term was used in the Bercow
Report (Bercow 2008) and now is widely used in educational contexts in the UK, though not in North
America or Australia. Although it includes language impairment, it is much broader than this, including a
wide range of problems that have different causes and intervention needs, such as stuttering and voice
disorders. In addition, as defined by Bercow, it also covers secondary problems associated with conditions
such as autism, cerebral palsy and hearing loss. The papers by Bishop (2014) and Reilly et al. (2014) made
specific points about the pros and cons of different terminology for unexplained language problems, and
the commentaries gave some additional arguments. We feel that some of these were strong enough to rule
out three of the potential labels for children's language problems, as follows.
12

Research
Article

Continuation.
Language delay
None of the commentators favoured this term. There were three strong arguments against it. First, we
need to bear in mind that children with language difficulties grow up to be adults who may still have
difficulties that need recognition. We need therefore to have a term that highlights the dynamic,
changeable nature of the condition. Second, delay is confusing because it implies eventual catch-up in
skills, which is not typically what is seen. And finally, it seemed that this term is often used to deny services
to children by those who draw a distinction between delay, where the child's language is uniformly behind
age level, and disorder where there is an uneven profile (Wright 2014). As noted by Bishop (2014), this
distinction has no validity as an indicator of either aetiology or prognosis, and accordingly, we
unambiguously recommend that this term be abolished.

Primary language impairment
Bishop (2014) suggested this term might be a useful alternative to unadorned language impairment, but
the points made by commentators reveal that it is not interpreted in a consistent fashion. For a start, as
Clark and Carter (2014) noted, in the UK, primary school refers to schools for children under 12 years of
age, so there is potential for misunderstanding it to indicate a child's age. Second, several commentators
interpreted primary language impairment as meaning that the language impairment was the child's
primary problem. This is a subtly different meaning from the one intended by Bishop (2014), which was that
the language impairment was not secondary to another condition. In addition, as pointed out by Conti-
Ramsden (2014), it is not always easy to judge which condition is primary in this sense when the child has
more than one area of impairment. For these reasons, we recommend against the use of this term.

Language disorder
Although this is the preferred terminology in DSM-5, Bishop (2014) argued against it on the grounds that if
entered in a search engine, it would yield many results that were unrelated to children's unexplained
language difficulties. In effect, it identifies a symptom that can arise for many different reasons, and so is
over-inclusive. To establish how serious this might be, language disorder was entered as a search term in
the Web of Science database and the titles of the first 100 returns were scrutinized to see if they referred
to children's unexplained language problems. Just under half were relevant. The remainder focused solely
on other conditions, specifically: ADHD (N = 1), ageing (N = 1), Alzheimer disease (N = 2), aphasia (N = 2),
autism (N = 11), bilingualism (N = 1), brain tumour (N = 1), childhood stroke (N = 1), cobalim C deficiency (N
= 1), encephalitis (N = 2), epilepsy (N = 7), fragile X (N = 1), frontotemporal dementia (N = 1), hearing loss (N
= 1), hyperthyroidism (N = 1), mood disorder (N = 1), neurogenic communication disorder (N = 1),
nosocomial infection (N = 1), primary progressive aphasia (N = 5), schizophrenia (N = 6), sexual abuse (N =
1), subjective cognitive complaints (N = 1) and Tourette syndrome (N = 1).
The remaining terms elicited much more varied reactions from commentators.

13

Research
Article
Continuation.
Specific language impairment (SLI)
Bishop (2014) presented d ata to show this was the most widely used term in the English-speaking research
literature, but others noted that it is less familiar to those in clinical contexts. Rice (2014) noted that SLI was
a research priority area for the US National Institute for Deafness and Other Communication Disorders
(NIDCD), and that this had been a fruitful category in terms of research progress.
Reilly et al. (2014), in contrast, argued that the term SLI:
Does n ot reflect the heterogeneity of language problems.
Does n ot d escribe the majority of the children with language problems.
May as a result deny access to services to children who do not fit the narrow diagnostic criteria.
Has variable support among the scientific and clinical community.
Causes confusion amongst clinicians, families and policy-makers.

Many commentators agreed that this term was too restrictive if used in a strict sense that required the
child to have a substantial mismatch between nonverbal ability and language level, and to have no other
exclusionary criteria. They were, however, divided as to how best to deal with this. Around half of them
supported Bishop's (2014) proposal that we could retain the term but redefine it so that specific was taken
to mean idiopathic, allowing us to retain familiar terminology, which could also ensure a link with an
existing body of research. Taylor (2014), for instance, commented that Rather than changing the term SLI,
the definition can be updated to include children whose most conspicuous, but not their only,
developmental difference is in the language domain. Others, however, felt that this would be too
confusing, because use of this term would encourage people to persist with inappropriate exclusionary
criteria, and that a change was therefore needed.

On this point, it may be worth noting that there are some precedents for retaining a label while redefining
how it is used. For instance, the diagnostic criteria for autistic disorder broadened markedly between 1980
and 1994 (Gernsbacher et al. 2005). This does not seem to have led to particular problems in clinical
settings, but it has created major problems in epidemiology, as it is extremely hard to judge whether an
increase in prevalence of autism is genuine or just reflects more liberal diagnostic criteria. As Baird (2014)
notes, the criteria for ASD have recently changed again in DSM-5, in the light of research evidence that
some diagnostic distinctions were not valid. Fletcher (2009) noted that the concept of dyslexia has
changed over the years so that the notion of a discrepancy between reading level and IQ is no longer part
of the definition. However, changes in definition can be confusing for those who are familiar with the
original, more restrictive meaning. This is likely to be exacerbated in the case of SLI, where specific has
potential for different interpretations.

Is there a balance between acting and not acting? Gallagher (2014) raises concerns about the impact of
removing a diagnostic label that affected individuals have come to identify with. However, we have new
knowledge from population studies that was not available when the term originated. Of course, we need to
be sensitive to the fact that for many people labels have connotations that go far beyond a simple
definition. As Bishop (2014) argued, a label can give a person a sense of identity and worth, and make them
feel their problems are validated. Nevertheless, retention of labels that hinder communication cannot be
justified, and if the evidence d emands it, we need to reconsider our terminology. If we retain labels solely
on the grounds that they have been used for a long time, we would n ever be able to progress in the light of
new knowledge, and would still be u sing diagnostic terms such as minimal brain damage.
14

Research
Article
Continuation.
Language impairment
The solution of simply dropping the specific part of the SLI label appealed to many commentators. It is
noteworthy that language impairment is almost universally employed by State Departments of Education in
the United States as one of the special education categories. Language impairment in this case is always
listed in parallel with other categories such as autism, intellectual disability, hearing impairment and
specific learning disability. Usually, language impairment refers to the presence of p oor language, but does
not require that it be distinct from these other conditions. Thus, language impairment may or may not
occur in conjunction with other conditions. Bishop (2014) argued against this term for the same reason as
language disorder. It is hopeless as a search term because it generates too many false positives. The
exercise of searching for the first 100 returns from Web of Science was repeated using language
impairment as the topic search term. This yielded 68 returns that could be construed as broadly or
potentially relevant to unexplained language problems in children. The remainder focused on other
conditions, predominantly autism, acquired language disorders in adults, or hearing impairment.

In addition, several commentators noted that in the absence of any additional modifier, the term LI would
encompass a much wider range of cases than most other terms, but they d iffered in terms of whether they
thought this was a good or bad thing. Huneke and Lascelles (2014) were concerned that this broadening of
the diagnostic category would simply mean that scarce resources would be spread across a greater range of
children, with the notion of language impairment as a specific need disappearing. Gallagher (2014)
expressed similar concerns, arguing that it would be unethical simply to remove a diagnostic distinction
that many were familiar with, and that we would in effect be abandoning a whole clinical and research
history before we know how to rewrite it. Snowling (2014) was concerned that it was important to
convince policymakers of the primary needs of children with language impairments, and that by
abandoning the term SLI we might risk throwing the baby out with the bathwater by removing a term that
was useful in advocacy. Rice (2014) stressed the negative consequences of abandoning a term that had
served researchers well, and Leonard (2014) noted the confusion that could ensue if, for instance, we
attempted to contrast children with LI and those with autismwho might or might not have additional LI.
Others argued that a b enefit of the term LI was that, while it had much in common with the term SLI, it
did not carry connotations of specificity which were often unjustified, and could lead to children being
denied services (Strudwick and Bauer 2014). Note that this argument is the mirror image of that proposed
by Huneke and Lascelles (2014), who argued that there should be some demarcation between those with
primarily language problems and children with broader intellectual limitations. Another argument in
support of LI was the fact that it was already being used in the research literature by researchers such as
Tomblin and Nippold (2014) and Bishop and McDonald (2009), who recognized the lack of justification for
use of IQ criteria.

Essentially, this line of argument comes back to the extent to which it is reasonable to incorporate at least
some exclusionary criteria in a d efinition. If we abandon them altogether, we will increase both the number
of children we include in the category, and the heterogeneity of the group. Whitehouse (2014)
acknowledges this fact but argues we nevertheless need to take this step in order to shift health and
educational services from a diagnostic-based funding paradigm to a model based on the level of functional
impairment.
15

Research
Article
Continuation.
Developmental dysphasia
Huneke and Lascelles (2014), representing a parental perspective, came d own in favour of developmental
dysphasia, n oting: it is clearly a medical term; it equates SLI with other specific learning d ifficulties such as
dyslexia and dyspraxia. It also works well as a search term and is the standard label in many non-English
speaking countries.

However, we note that many would object to both parts of this term: as discussed below, some object to
developmental as unsuitable for older children and adults, and dysphasia is seen as misleading precisely
because it has medical connotations, when there is no clear neurological basis to most cases of language
impairment. While we can see the reasons behind this preference, we doubt it would be acceptable to
many in the field of education, who are already concerned about medicalization of children's
developmental difficulties.

Developmental language disorder/impairment
Developmental language disorder is likely to be adopted in ICD-11 as the preferred term for children's
unexplained language difficulties (Baird, personal communication). Several commentators thought this was
a useful label, stressing as it does the congenital nature of a language problem. In general, there were
relatively few objections to this term, but one point that was raised was whether it was suitable for older
children and adults. In traditional classification systems, developmental generally marks a contrast from
acquired, and does not imply anything about the age of the affected individual; however, one can see that
this label might be misinterpreted by lay persons, and seen as inappropriate for older children and adults.
Clark and Carter (2014) suggested that affected individuals might want to drop the developmental part of
the label as they grew older, much as often happens with developmental d yslexia in adulthood.

Language learning impairment
Not many commentators discussed this term, but reactions from those who did were broadly positive,
noting that it stresses learning and was education-friendly. The only negative came from Huneke and
Lascelles (2014) who reported that a small group of parents who were surveyed disliked the term because
they felt it would be seen as equivalent to low ability.

Future directions
We agree with those commentators who suggest that we need to have an international and
multidisciplinary forum to take forward the momentum generated b y this debate.
The goal of the panel should be first to build consensus about the diagnostic criteria and second the
diagnostic label. We recommend using the many existing global collaborations to bring clinicians and
researchers together. The views of families and people with language problems should be sought as well as
those of policy-makers. Given the n otable overlaps between developmental language difficulties and other
neurodevelopmental disorders (Bishop and Rutter 2008), it would make sense also to gather views from
those who see children with a broader range of conditions, such as ADHD, developmental coordination
disorder and developmental dyslexia. Consensus should be built around the best evidence currently
available; it is important that participants set aside any vested interests. The outputs of this panel might
take the form of a position statement and technical paper such as those on Childhood Apraxia of Speech
(American SpeechLanguageHearing Association (ASHA), 2007a, 2007b).

16

Research
Article

Continuation.

Ultimately we are working towards a diagnostic label that is a superordinate heading or overarching term
that describes the problem(s) and works for services, for families and for individuals. This label should be
supported by a scaffold that is the diagnostic classification system. This should not be set in stone but
change as knowledge becomes available. It should also adapt to encompass an individual's changing profile
and needs across the lifespan. As Callard et al. (2013) put it: Diagnosis allows problems to be quantified
and tracked over time and space. A diagnostic classification, well defined, is the starting point to research
into causes, consequences, and solutions (p. 2).

In conclusion, we do not have all the answers for this complex topic, but we are pleased to find that,
despite points of disagreement, there is some common ground between the current authors and the range
of commentators who offered their views. Our aim in this overview is to identify the remaining points of
disagreement and to summarize arguments for and against different viewpoints, so that we will be able to
move the debate forward.

()

For more information on the discussion surrounding terminology in the area of language
development, please check the following articles:
1. Bishop, D. V. M., (20/08/14), Ten Questions About Terminology for Children with Unexplained
Language Problems, Volume 49, Issue 4, pages 381415, July-August 2014, International Journal of
Language & Communication Disorders, DOI: 10.1111/1460-6984.12101.

What does this paper add: () This paper aims to open up discussion about the use of different labels that
have been used to refer to children's unexplained language impairments. It notes the wide range of
terminology that has been applied and the confusion that results, and links this to debates about the
appropriate criteria that are used to identify children in n eed of intervention. A range of diagnostic terms is
evaluated in terms of their advantages and d isadvantages. ()
2. Reilly, S. e al, (20/04/14), Language Impairment: A Convenient Label for Whom?, Volume 49, Issue
4, pages 416451, July-August 2014, International Journal of Language & Communication Disorders,
DOI: 10.1111/1460-6984.12102 .

What does this paper add: () We review how and why SLI came into use and examine the evidence for
and against its use. We conclude the term SLI was proposed and used prior to evidence from population
studies being available. Subsequent research has provided little evidence that supports the continued use
of the current definition and the exclusionary criteria. To address these shortcomings we propose a set of
short-term changes and recommendations for the future. ()

17

Research
Article

DOI: 10.1111/1460-6984.12082.

How Much Exposure to English is Necessary for a Bilingual Toddler to Perform like a
Monolingual Peer in Language Tests?
Allegra Cattani, Kirsten Abbot-Smith, Rafalla Farag, Andrea Krott, Frdrique Arreckx, Ian Dennis and

Caroline Floccia
Volume 49, Issue 6, pages 649671, November 2014
Background: Bilingual children are under-referred due to an ostensible expectation that they lag behind
their monolingual peers in their English acquisition. The recommendations of the Royal College of Speech
and Language Therapists (RCSLT) state that bilingual children should be assessed in both the languages
known by the children. However, despite these recommendations, a majority of speech and language
professionals report that they assess bilingual children only in English as bilingual children come from a
wide array of language backgrounds and standardized language measures are not available for the majority
of these. M oreover, even when such measures do exist, they are n ot tailored for bilingual children.

Aims: It was asked whether a cut-off exists in the proportion of exposure to English at which one should
expect a bilingual toddler to perform as well as a monolingual on a test standardized for monolingual
English-speaking children.

Methods & Procedures: Thirty-five bilingual 2;6-year-olds exposed to British English plus an additional
language and 36 British monolingual toddlers were assessed on the auditory component of the Preschool
Language S cale, British Picture Vocabulary Scale and an object-naming measure. All parents completed the
Oxford Communicative Development Inventory (Oxford CDI) and an exposure questionnaire that assessed
the proportion of English in the language input. Where the CDI existed in the bilingual's additional
language, these data were also collected.

Outcomes & Results: Hierarchical regression analyses found the proportion of exposure to English to be the
main predictor of the performance of bilingual toddlers. Bilingual toddlers who received 60% exposure to
English or more performed like their monolingual peers on all measures. K-means cluster analyses and
Levene variance tests confirmed the estimated English exposure cut-off at 60% for all language measures.
Finally, for one additional language for which we had multiple participants, additional language CDI
production scores were significantly inversely related to the amount of exposure to English.

Conclusions & Implications: Typically developing 2;6-year-olds who are bilingual in English and an
additional language and who hear English 60% of the time or more, perform equivalently to their typically
developing monolingual peers.

18

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Carolanna Rodriguez is a Speech and Language therapist at a private therapy

clinic in Hong Kong.
Interview
Corner

Caseload: I work in a private therapy clinic in Hong Kong and we accept both paediatric and adult
referrals. As a result, I have a mixed caseload, including a range of paediatric speech clients, language
delay, ASD, and some professional voice users. I am also based 2 days a week in an Adult Learning
Disability facility, and once a week in an International school where I have a largely consultative role.
Duties: I am the lead Clinician at the clinic. As part of this role, I manage my individual caseload, liaise
with our Director during weekly clinic meetings, and supervise another SLT colleague. From time to
time, we have student SLTs from overseas come to us, whom I act as clinical supervisor for. Other
aspects of my role include carrying out assessments, maintaining client records and carrying out
screening assessments in international schools to identify children who may need SLT input.
Service Structure: As we are a private practice, the majority of our referrals come directly from
parents, carers and adult clients, and from other professionals. We are fortunate enough to have a
minimal waiting list and so the process between referral and assessment is usually quick (a matter of
days). Our clinicians take telephone and email referrals, contact the referee back with assessment
process information and book the initial consultation and assessment. Following assessment, a
summary and recommendations are sent out, and then a package of care is offered (individual
treatment/ home and classroom recommendations/ mixture of both).
Typical Day: A typical day involves going to my base (be that clinic, ALD facility or School) and setting
up the resources for m y groups or 1:1 sessions. I then usually see about 3 clients before lunch time for
1:1 sessions, have an afternoon social skills group (if I am based at the ALD Centre that day), followed
by 2 or 3 more 1:1 clients, then do my paperwork, including plans for the next day's therapy sessions,
go home and repeat it all the next day!
Challenges: So far the attitudes and lack of awareness towards SLT as a profession and towards any
perception of 'disability' in Hong Kong have been something I've found highly challenging. Having
trained in the UK, I have always worked in a culture where having any sort of diagnosis or individual
communication need was addressed with additional help and differentiation. Here the need for that is
largely perceived in a negative way, i.e. children with these needs can be denied school access solely
on this basis. There is also reluctance to address the problem through early intervention, the prevailing
idea seeming to be that ignoring the problem will make it 'go away' or that children are immediately
'written off' once they have an additional need. Very challenging and somewhat frustrating!
Surprises: The huge capacity that clients have for change once given the right tools always surprises
me. Not because I dont know it can happen, just because it is always a lovely thing when clients do
make progress, and every little achievement for clients still makes me love what I do.
19

;
Continuation

Interview
Corner

Carry Over: I ensure carry-over of skills by providing home tasks after each session and
reviewing the progress of these at the start of the next session, through discussion with carers/clients
and a quick review task. I also, where applicable, provide school based recommendations and carry out
classroom observations periodically to see what I need to do to review the current skills being
targeted.
Impact: As I have such a mixed client group, the impact varies. For my paediatric clients, the difficulties
impact mainly on the child, as well as their parents and teachers. For my ALD clients, often they are not
aware of their difficulties, which can then be frustrating for them when they are socially or
communicatively impeded, because they often perceive the breakdown to be coming from the
listener. This can be hard on their families too. And for m y 3 adult voice clients the impact is directly on
them, as it affects their ability to perform their professional role (teacher, singer, yoga instructor), but
also on their partners because of the impact on the mental wellbeing of the client, and employers
because it impacts on their work. In a nutshell, the answer to that question is it impacts on everyone
with whom the individual interacts in his or her daily lives.
Success Story: I have been working with a young lady who has Downs syndrome and Selective
Mutism. Her receptive language skills are age appropriate and so are her expressive skills when she is
in an environment she feels confident speaking in. At the start of therapy in December, she would only
be able to speak at home with her parents, not in any other contexts. The aims of therapy have been
to reduce her anxiety around speaking situations so that she can speak in a wider number of contexts
and with a wider number of people. Therapy takes place at the ALD centre she attends daily with me
(and her father present at first). She now speaks within the Centre to me without her father being
present, and is beginning to speak to m e in front of other people outside of the therapy room. For this
young lady that is a huge achievement because, although speaking still makes her anxious, she is
finding coping with this much easier and has reported to me that she feels that her quality of life has
improved as a result.
Loved Resources: My 'What's in the box?' box! This is a colourful box filled with sensory-stimulating
toys and objects, e.g. bubbles, things that light up, wind up, are colourful, textured, make noises, you
name it! Children sit in a circle around me while I hold the box, we sing a song with accompanying
Makaton signs, then I take out an item from the box and the children name it, have turns playing with
it, put it back and then we start over again with a new item. It is an amazing resource for targeting so
many different areas with young children, including attention and listening, turn taking, sharing and
expressive vocabulary, as well as being something children always really enjoy and look forward to
using.
Wish List: Am I allowed to say m ore items for my 'what's in the box?' box?

20

;
Continuation
Interview
Corner
Top Tips for Clinicians: Be confident in your knowledge and ability as a professional, all the while
realising just how important peer support and supervision is - there is nothing wrong with asking
colleagues for advice when you experience a particular case/issue which is either outside of your
professional comfort zone or which you feel a colleague would know more about. In fact, I think this
recognition of your own limitations makes you a better professional because it means you
acknowledge there is always room to grow.
Top Tips for Other Professionals: If in doubt about a possible communication need, always seek SLT
advice. Most SLTs are more than happy to provide informal advice with no obligation and often just
having that conversation can put parents/clients at ease. Where the discussion leads to a referral and
assessment, it means that you are on the way to getting help. Its all about early intervention, early
intervention, and early intervention!

Be confident in your knowledge

and ability as a professional, all the
while realising just how important
peer support and supervision is -
there is nothing wrong with asking
colleagues for advice when you
experience a particular case/issue
which is either outside of your
professional comfort zone or
which you feel a colleague would
know m ore about.
'What's in the box?' box!

This is a colourful box
filled w ith sensory-
stimulating toys and
objects, e.g. bubbles,
things that light up, wind
up, are colourful,
textured, m ake noises,
you name it!
21

Research
Article

DOI: 10.1111/jpc.12396.

Learning Difficulties or Learning English Difficulties? Additional Language Acquisition: An
Update for Paediatricians
Vanessa Clifford, Anthea Rhodes and Georgia Paxton
Journal of Paediatrics and Child Health
Volume 50, Issue 3, pages 175181, March 2014
Abstract: Australia is a diverse society: 26% of the population were born overseas, a further 20% have at
least one parent born overseas and 19% speak a language other than English at home. Paediatricians are
frequently involved in the assessment and management of non-English-speaking-background children with
developmental delay, disability or learning issues. Despite the diversity of our patient population,
information on how children learn additional or later languages is remarkably absent in paediatric training.
An understanding of second language acquisition is essential to provide appropriate advice to this patient
group. It takes a long time (5 years or more) for any student to d evelop academic competency in a second
language, even a student who has received adequate prior schooling in their first language. Refugee
students are doubly disadvantaged as they frequently have limited or interrupted prior schooling, and
many are unable to read and write in their first language. We review the evidence on second language
acquisition during childhood, describe support for English language learners within the Australian education
system, consider refugee-background students as a special risk group and address common misconceptions
about how children learn English as an additional language.

Key points:
Students take 5 years or more to develop academic competency in a second or subsequent
language, even those who have received adequate prior schooling in their first language. Cognitive
development, proficiency and schooling in first language are key variables affecting additional
language acquisition; thus, older children learn additional languages more quickly than younger
children. Adolescents may not h ave enough time to develop academic language proficiency during
their time in high school.
Refugee students may be further disadvantaged by limited or interrupted prior schooling, low first
language literacy, their refugee/trauma experience, medical or mental health issues, and factors
related to settlement.
Current provisions for teaching newly arrived refugee children tend to encourage subtractive
bilingualism and are likely to be less than optimal for the needs of migrant and refugee-background
children.

Recommendations:
Encourage continued first language development for children, including interaction with family in
their first language (on increasingly complex topics) and positive family attitudes to maintaining
first language.
An explanation of additional language acquisition is often helpful for both students and their
families in order to counter unrealistic expectations, support parents and families to maintain
cultural integrity and help families make informed choices about schooling options.
Encourage attendance at English language schools and centres during early settlement wherever
possible and first language schooling where available.
22

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6 SLT students from Portugal shared with TIC what made them choose a career in SLT, their views
on the profession, and their hopes for the future. A big thank you to:

Mrcia Filipe

Ctia Ribeiro Ana Athayde Campos Raquel Vieira

Zlia Fernandes Ndia Silva Ins Mestre Daniela Silva

Sofia Veloso
23

;
Were all in our last year of a 4 year degree in Speech and Language Therapy.
Why did you decide to study SLT?
M. F.: When I finished high school, I didnt know what to choose and since I had many friends studying
physiotherapy in Escola Superior Sade do Alcoito (ESSA) I decided to register in this school. Thats when I
saw they had SLT too and decided to go ahead it.
C. R.: Aside from limited knowledge from some acquaintances in this area regarding their duties and work
areas, I honestly did not what I was getting myself into. Over time, I realized that we are able to help and
provide a better quality of life to the population and this makes me want to continue my course every day.
A. A. C: Because I saw communication as something necessary to live with quality; it keeps us in touch with
each other and allows us to share ourselves with others and build relationships. I knew these professionals
help people to communicate and one day I just thought that this was what I would want to do as much as
possible.
R. V.: I decided to study SLT because I was interested in a profession that was related to health and allowed
for h uman interaction. Having dealt with some difficulties myself with being bilingual, I felt that this would
be an area of interest.
Z. F.: Because I love language and to help people who may have difficulties in this area.
N. S.: I chose SLT by chance. I knew I wanted to work with people who need help, in the field of health. I
read about the course and I thought I would like it!
I. M.: Having ongoing and specific training in this area is a plus.
D. S.: I decided to study SLT b ecause I can see myself doing it.
S.V.: My mum works really close to an SLT (she's a special needs teacher) and my grandfather had a total
laryngectomy. This allowed me to be in touch with two different intervention areas.
What has been the m ost rewarding and the most difficult so far?
M. F.: It is rewarding to receive positive feedback during the clinical placements. Coordinating all subjects
with personal life is challenging.
C. R.: The time that some steps take to work is challenging; however, it is rewarding to see how these small
steps become significant, for us and for the family, and how our intervention has a big impact in that
person's life and family.

24

;
Continuation.
A. A. C: The most rewarding has b een to see people evolve in the rehabilitation process: a boy with severe
dysphagia at first who now eats all consistencies, for instance. The most difficult has been adapting my
behaviour towards the patients, their families and the team I work with; to know when to talk and when
not to talk, when to touch, when to move.
R. V.: Knowing and feeling that my intervention contributes to the wellness and quality of life of the
patients I work with is the most rewarding aspect for me. The most difficult is being confronted with some
of the family situations, and the general health of some of the people I work with.
Z. F.: It is rewarding to learn so many things about care, health, and pathologies, and to meet teachers and
other people who are passionate about SLT. It is difficult to have so little time for my personal life.
N. S.: The fact that SLT can make a difference and contribute to a persons quality of life is rewarding. On
the other hand, it is difficult that this profession is not valued in Portugal enough.
I. M.: The most rewarding is to known that I can, from now on, help individuals who need support.
D. S.: The impact we can have as SLTs in a persons life through direct and indirect intervention is the most
rewarding. The most difficult is, undoubtedly, the management of information from all the SLT areas.
S. V.: Clinical placements! They were the most difficult and the most rewarding parts!
Has anything surprised you/ something you werent e xpecting?

M. F. & Z. F. & I. M. & D.S. & S. V.: I had no idea how wide the SLT scope can be, from paediatric dysphagia
to voice.
C. R.: SLT may cover many areas that people may be unaware of and, subsequently, they may not seek our
services. It is concerning that many health professionals may not be aware of their professional boundaries
and work on areas that pertain to SLT without having all the necessary knowledge that is required.
A. A. C: An SLT can actually make a huge difference in ones life. Once someone communicates, (s)he is
valued, accountable. I saw a man wth aphasia who had a stroke four years ago and who only produced
stereotyped speech. After four years of SLT, I saw him chatting effortlessly in a complex conversation. I saw
a child with ASD u sing a commnication device to talk to his mom, who until then had to guess what was on
his mind.
R. V.: Having chosen a profession where one has to be an expert at communicating in every situation,
sometimes it happens that we are the only ones who understand, and are willing to spend the time to
understand, the patients we work with. This is important because we are almost like therapists to these
patients, and constitute their only support.
25

;
Continuation.
N. S.: What surprises me in a positive way is knowing that the SLTs have a wide job scope and that we can
work with patients since birth to the end of their lives.
What has been the m ost influential teacher/ SLT you have met and why?
M. F.: The most influential teacher/ SLT were Dlia Nogueira and Lusa Taveira because they think out of
the box. They see things in a different, better way.
C. R.: Professor M argarida Grilo, who has given me confidence from the start. She is an example of not only
a good person and teacher but also of an excellent SLT.
A. A. C: I have met many influential and inspirational SLTs who share their knowledge, experience and
motivation with their students and peers. These special ones take time to answer our questions, search
what we dont know yet, and are not afraid to show they care. They are sensitive to our thoughts,
questions and insecurities. They all are also very demanding with themselves and with us, students. We
are proud of having them as teachers and models and want to learn the most with them. They always want
us to improve, and if needed, they will help us doing so.
R. V. & Z. F. & I. M.: Every teacher I have been taught b y has affected my learning and who I am in different
ways. Some have accompanied my school life longer than others, and some have had a bigger impact than
others. I believe that, without that group of teachers, I would not be the student I am today.
N. S.: It is difficult to point out a name. I value the professional who vales evidence-based practice. As a
student, I have been given the privilege of b eing in contact with several professionals with this quality.
D. S.: The teacher who influenced me most was Professor Dlia Nogueira - her knowledge and willingness
to learn more and her ongoing concern about transmitting all her knowledge to her students.
S. V.: Dlia Nogueira! S he introduced me to the world of dysphagia and scientific research.
What has been the m ost challenging case you have w orked w ith during clinical placements?
M. F.: A woman who has primary progressive aphasia. Its the 1st case that I came across that had n o visible
improvements.
C. R.: A child with ASD characteristics. Many people label children and have low expectations. However, a
child is always changing, his/ her language skills can always progress. Cognitively, it does n ot mean that the
child is not capable of learning, only that he/she may learn slower.

26

;
Continuation.
A. A. C: A woman who suffered a traumatic brain injury, the lesions are significantly extensive and she has
severe dysphagia and cognitive-communicative disorder. We are trying to inhibit pathological reflexes,
stimulate the typical ones, increase time of attention, and establish consistent answers. However, it has
been difficult to succed in all the above.
R. V.: An adult with global aphasia and with stereotyped discourse. It is not easy because the SLT goes from
working with a patient who is not completely aware of their condition in the beginning to one who is aware
and gets easily frustrated with not being able to say what they want or being understood. The learning
curve when working with these cases is of great importance in this profession.
N. S.: The patient who presents with more than one impairment. It forces you to define intervention
priorities, always having in mind the patients well being and taking into account his/her circumstances at
the moment.
I. M.: A 79 years old lady who had thyroid surgery and, as a result, had vocal cord paralysis.

D. S.: The most challenging case I ever had was a 9 year old autistic child who was non-verbal and had
sensory needs.
S. V.: A patient with Parkinsons who had significant dysphagia difficulties (with obvious signs of aspiration)
and who did not accept his diagnosis, putting himself at risk.
What hopes do you have for your profession in the future?
M. F.: In the future, I hope more people who need SLT treatment will be able to access it. Lack of awareness
about what we d o means that most health p rofessionals dont refer patients to us.
C. R.: That all the knowledge acquired along with the different experiences and professionals that I dealt
with serves to h elp those in need of our care.
A. A. C: I hope the SLT profession keeps developing through research and learning opportunities, and that it
continues to be a useful profession that targets what is best for patients. I also wish people were more
aware of what we do.
R. V.: I hope that there is an increase in awareness of SLT, so that we are allowed to contribute, to our full
potential, to the health and wellbeing of those who need u s.
Z. F.: To find a place to work with a good team, one that works collaboratively.

27

;
Continuation.
N. S.: That our professions importance is recognised in Portugal.
I. M.: I hope to be a successful professional, do my job well and help people.
D. S.: I hope that the profession continues to evolve and that there is an investment in scientific research as
well as a sharing of knowledge between all SLTs.
S. V.: Public recognition! So many people don't know anything about SLT. But this needs to b e done by all
the SLT community.
Children or adults and w hy?
M. F.: I dont know. I had clinical placements in both areas and I like them both.
C. R.: I have always wanted to work with children due to their characteristics, work dynamics and the way
they progress.
A. A. C: Adults. They may not often know how to depend on others but they have others who depend on
them.
R. V.: I would prefer to work with adults because it is a different kind of interaction that, personally,
appeals to me more.
Z. F.: I dont know if I can choose it right now, but I like working with acquired language impairments.
N. S.: As the prospects of having a job are reduced, I think it is important to be open minded to all ages and
areas. However, if I could choose, I would choose adults.
I. M.: I love adults but with my last clinical paediatric placement I was torn between the two.
D. S.: Adults because I find it more interesting and challenging in terms of therapy planning and
intervention.
S. V.: I always thought it would be adults, but now Im not sure now. I'm sure that dysphagia is an area of
interest.
The best advice you have been given by your teachers/ supervisors?
M. F.: Dont stop working and see the patient as a person with multifactorial barriers.

28

;
Continuation.
C. R.: During my last stage of intervention, D r. Nuno Lobo Antunes said something that resonated with me -
"We believe that no child is a detached island from school and their parents and siblings, so if we want to
help, we must be in solidarity with the equal sides of this triangle." This aspect does not concern only
children but the general population we work with, i.e. the different partners of communication.
A. A. C: Not all knowledge comes from books. Observe, think, practise and always evaluate the result.
R. V.: The best advice I have been given so far is to trust my instinct and to think for myself. Books will teach
the why of things but, in the end, I need to trust my own judgment to adapt the know how to real life
situations.
Z. F.: Walk in their shoes.
N. S.: Always value what is important/relevant to the individual, and guide the intervention in that
direction.
I. M.: To never give up on your dreams. M ake your work as SLT valuable.
D. S.: To continue to invest in education research and specialisation.
S. V.: Take all the opportunities you can get, you never know what is going to happen and every person is a
different.

"We believe that no child is a

detached island from school and
their parents and siblings, so if we
want to help, we must be in
solidarity with the equal sides of this
triangle."
29

Research
Article

DOI: 10.1111/jcpp.12190.

Longitudinal Trajectories of Peer Relations in Children with Specific Language Impairment
Pearl L. H. Mok, Andrew Pickles, Kevin Durkin, Gina Conti-Ramsden
Journal of Child Psychology and Psychiatry

Volume 55, Issue 5, pages 516527, May 2014

Background: Peer relations is a vulnerable area of functioning in children with specific language impairment (SLI), but
little is known about the developmental trajectories of individuals.

Methods: Peer problems were investigated over a 9-year period (from 7 to 16 years of age) in 171 children with a
history of SLI. Discrete factor growth modeling was used to chart developmental trajectories. Multinomial logistic
regression analysis was conducted to investigate factors associated with group membership.

Results: Four distinct developmental trajectories were identified: low-level/no problems in peer relations (22.2% of
participants), childhood-limited problems (12.3%), childhood-onset persistent problems (39.2%) and adolescent-onset
problems (26.3%). Risk of poor trajectories of peer relations was greater for those children with pragmatic language
difficulties. Prosocial behaviour was the factor most strongly associated with trajectory group membership. Overall,
the more prosocial children with better pragmatic language skills and lower levels of emotional problems had less
difficulty in developing peer relations.

Conclusions: Analysis of developmental trajectories enriches our understanding of social development. A sizeable
minority in the present sample sustained positive relations through childhood and adolescence, and others overcame
early difficulties to achieve low levels of problems by their early teens; the majority, however, showed childhood-
onset persistent or adolescent-onset problems.

Clinical implications: We provide encouraging evidence that some children with a history of SLI progress from
childhood to adolescence with relatively low levels of peer problems. Nevertheless, the majority showed childhood-
onset persistent or adolescent-onset difficulties. This is important information in terms of our understanding of the
developmental course of peer relations in those with language impairments and has implications for identification,
referral to services and the targeting of interventions. Clinically, our findings suggest that the identification of
pragmatic difficulties and emotional problems could be critical to the amelioration of potential difficulties in peer
relations. In this study, the use of teacher report of pragmatic difficulties were informative at age 7 as was the CCC and
the SDQ emotional scale in middle childhood, at age 11. Results of randomized controlled trials show that pragmatic
difficulties (Adams et al., 2012) and emotional problems (Sanders, Baker & Turner, 2012) can be addressed effectively,
in at least some children. Our results also suggest that, clinically, it is advisable not only to identify deficits but to
evaluate the extent to which potential protective and/or positive factors are present. We found that the SDQ prosocial
scale in middle childhood to be a particularly strong predictor of differences in the trajectories of peer relations of
children with a history of SLI. Prosocial behaviours are also open to contextual influence and intervention. For
example, children whose parents express responsiveness and warmth are more likely to display prosocial behaviours
(Zhou et al., 2002), as are adolescents whose best friends engage in such behaviours (Barry & Wentzel, 2006).
Interventions, such as Family Talk Intervention (Solantous, Paavonen, Toikka & Punamki, 2010) and school-based
strategies (Riedel, 2002; Solomon, Battistich, Watson, Schaps & Lewis, 2000) have been shown to be effective in
improving prosocial behaviours in children. To the authors knowledge, however, there are no intervention studies
that have directly targeted prosocial behaviours in children with language impairments. Finally, it is salutary to reflect
that, in most countries, provision for language therapy diminishes for children post- the elementary school range, and
provision for social skills training in peer relations in these children is scant at all ages.
30

Research
Article

The following article was published online on http:// http://www.laryngologyandvoice.org on 11/09/2013,
DOI: 10.1111/1460-6984.12047.

Improving Comprehension in Adolescents with Severe Receptive Language Impairments:
a Randomized Control Trial of Intervention for Coordinating Conjunctions
Susan H. Ebbels, Nataa Mari, Aoife M urphy, Gail Turner
Volume 49, Issue 1, pages 3048, January-February 2014

Background: Little evidence exists for the effectiveness of therapy for children with receptive language
difficulties, p articularly those whose difficulties are severe and persistent.

Aims: To establish the effectiveness of explicit speech and language therapy with visual support for
secondary school-aged children with language impairments focusing on comprehension of coordinating
conjunctions in a randomized control trial with an assessor blind to group status.

Methods & Procedures: Fourteen participants (aged 11;316;1) with severe RELI (mean standard scores:
CELF4 ELS = 48, CELF4 RLS = 53 and TROG-2 = 57), but higher non-verbal (Matrices = 83) and visual
perceptual skills (Test of Visual Perceptual Skills (TVPS) = 86) were randomly assigned to two groups:
therapy versus waiting controls. In Phase 1, the therapy group received eight 30-min individual sessions of
explicit teaching with visual support (Shape Coding) with their usual SLT. In Phase 2, the waiting controls
received the same therapy. The participants comprehension was tested p re-, post-Phase 1 and post-Phase
2 therapy on (1) a specific test of the targeted conjunctions, (2) the TROG-2 and (3) a test of passives.

Outcomes & Results: After Phase 1, the therapy group showed significantly more progress than the waiting
controls on the targeted conjunctions (d = 1.6) and overall TROG-2 standard score (d = 1.4). The two groups
did not differ on the passives test. After Phase 2, the waiting controls made similar progress to those in the
original therapy group, who maintained their previous progress. Neither group showed progress on
passives. When the two groups were combined, significant progress was found on the specific conjunctions
(d = 1.3) and TROG-2 raw (d = 1.1) and standard scores (d = 0.9). Correlations showed no measures taken
(including Matrices and TVPS) correlated significantly with progress on the targeted conjunctions or the
TROG-2.

Conclusions & Implications: Four hours of Shape Coding therapy led to significant gains on comprehension
of coordinating conjunctions which were maintained after 4 months. Given the significant progress at a
group level and the lack of reliable predictors of progress, this approach could be offered to other children
with similar difficulties to the participants. However, the intervention was delivered one-to-one by speech
and language therapists, thus the effectiveness of this therapy method with other methods of delivery
remains to be evaluated.

()

Implications for theories of SLI: The therapy approach in this study used explicit teaching with visual cues.
This could be argued to increase the processing demands on the participants. If the main reason for failing
comprehension tasks was processing limitations, then it is unlikely that this therapy approach would
improve their performance on these tests.
31

Research
Article

Continuation.

The success of the therapy approach therefore makes it less likely that impaired processing was the cause
of their difficulties. More likely, however, is that the therapy worked by allowing the participants to use
their relative strengths to compensate for their weaknesses. Within the framework of the PDH, it could be
that the explicit therapy enabled them to use their better declarative memory system to compensate for
their more impaired procedural memory system. The visual support could also have enabled them to enlist
their b etter visuo-spatial skills to compensate for their weaker verbal working memory. However, this study
was not specifically designed to examine the underlying processes, thus these hypotheses remain
speculative.

Implications for clinical practice
Clinicians are under increasing pressure to base their intervention on evidence. Unfortunately, we have
little or weak evidence for many of the approaches which we commonly use (particularly for receptive
language). The publication of recent UK government-funded research (Law et al., 2012) investigating the
current evidence base is very welcome, as are initiatives to make the evidence more easily accessible to
clinicians, such as the What Works website being set up by the Communication Trust.

This study provides evidence of effectiveness of speech and language therapy for older children with RELI,
as, on average, our participants made progress with targeted therapy which was maintained. Combined
with the findings of other studies, it seems that the Shape Coding therapy approach can be effective for
improving a range of areas of grammatical comprehension and production in older children with RELI. Its
effectiveness for younger children or children with other profiles of difficulties remains to be established.

We were not able to find factors which predicted which participants would make the most progress, as
diagnostic criteria seemed to make no reliable difference and pre-therapy language levels (within the small
range in our study), visual perceptual skills and non-verbal reasoning abilities as measured on Matrices also
seemed to have little effect. It is difficult to draw strong conclusions given the small size of this study, but it
seems that based on our evidence, this approach could be tried with any adolescent with a severe receptive
language impairment affecting comprehension of grammar. However, we do not know whether young
people, like participant T2, with listening and attention difficulties will benefit when given the full amount
of therapy (albeit in smaller chunks) or whether such children would be able to complete the full therapy
programme and make progress given sufficient time.

()

32

Research
Article

The following article was published online on http:// http://www.laryngologyandvoice.org on 04/01/2015,
DOI: 10.1111/jcpp.12378.

Do Infant Vocabulary Skills Predict School-Age Language and Literacy Outcomes?
Fiona J. Duff, Gurpreet Reen, Kim Plunkett and Kate Nation
Journal of Child Psychology and Psychiatry
Early View (Online Version of Record published before inclusion in an issue)

Background: Strong associations between infant vocabulary and school-age language and literacy skills
would have important practical and theoretical implications: Preschool assessment of vocabulary skills
could be used to identify children at risk of reading and language difficulties, and vocabulary could be
viewed as a cognitive foundation for reading. However, evidence to date suggests predictive ability from
infant vocabulary to later language and literacy is low. This study provides an investigation into, and
interpretation of, the magnitude of such infant to school-age relationships.

Methods: Three hundred British infants whose vocabularies were assessed by parent report in the 2nd year
of life (between 16 and 24 months) were followed up on average 5 years later (ages ranged from 4 to
9 years), when their vocabulary, phonological and reading skills were measured.

Results: Structural equation modelling of age-regressed scores was used to assess the strength of
longitudinal relationships. Infant vocabulary (a latent factor of receptive and expressive vocabulary) was a
statistically significant predictor of later vocabulary, phonological awareness, reading accuracy and reading
comprehension (accounting for between 4% and 18% of variance). Family risk for language or literacy
difficulties explained additional variance in reading (approximately 10%) but not language outcomes.

Conclusions: Significant longitudinal relationships between preliteracy vocabulary knowledge and
subsequent reading support the theory that vocabulary is a cognitive foundation of both reading accuracy
and reading comprehension. Importantly however, the stability of vocabulary skills from infancy to later
childhood is too low to b e sufficiently predictive of language outcomes at an individual level a finding that
fits well with the observation that the majority of late talkers resolve their early language difficulties. For
reading outcomes, prediction of future difficulties is likely to be improved when considering family history
of language/literacy difficulties alongside infant vocabulary levels.

Key Points
There is a drive towards early intervention as a means of preventing later language and literacy
difficulties. Assessment methods with long-term reliability are thus needed for identifying at-risk
children.
This study presents the first UK investigation of the relationship between parent report of infant
vocabulary skills and school-age language and literacy outcomes, considering also the impact of
family history of language/literacy difficulties.
Infant vocabulary significantly predicted school-age vocabulary; however, the relationship is not
sufficiently strong enough for parent report of vocabulary skills at 1624 months to b e used to
predict an individual child's language outcomes.
Infant vocabulary and family history significantly p redicted school-age reading. Children with small
vocabularies together with a family risk are more likely to develop reading difficulties.
33

;
Siew Li Goh is a Speech and Language therapist at KK Womens and Childrens Hospital.
Interview
Corner
Caseload: At KK Womens and Childrens hospital (KKH), Rehabilitation department, I

have both inpatient and outpatient duties. The bulk of my outpatient caseload includes
children with articulation difficulties. On my inpatient caseload are children with dysphagia
and communication impairments. Besides the typical caseload of developmental speech and
language delay and disorder, I also get the opportunity to manage children with acquired communication
disorders, secondary to cerebral trauma. This population of children is particularly interesting because
neurological based deficits are acquired as the childs language skills are developing. They present with
dysarthria and aphasia like symptoms, similar to those of adult dysarthria and aphasia. However, the
nature of paediatric acquired communication disorder differs from that exhibited by adults, as the
developing brain responds differently to neurological damage.
Duties: I work in a team of Speech and Language therapists who follow up on inpatient referrals for
paediatric patients. We assess and manage the patients swallowing and communication impairments while
they are warded. Patient care is delivered together with other p rofessionals, including nurses, occupational
therapists, physiotherapists and doctors. My outpatient duties include articulation cases and outpatient
feeding clinic, which is jointly run with dietetics.
Service Structure: KKH doctors refer all our patients. A team of Speech and Language therapists, rather
than a single therapist, manages the patients during their inpatient stay. Whenever necessary, they will be
followed up as outpatients when they are d ischarged by the doctors. On top of direct therapy, we strive to
empower caregivers with necessary strategies or home programmes in all areas of our work, including
feeding, language and articulation. Outpatient services are provided at regular intervals based on the
childrens needs. We provide direct therapy to address the childrens feeding and communication issues.
We devise home p rogrammes so that parents can facilitate practice at home. We also help parents problem
solve for any difficulties that they may encounter when they practise with their children. As appropriate, we
will refer children to other professionals (e.g. audiology, occupational therapy, primary doctor) within KKH
or external organisations (e.g. early intervention centres, community therapy services).
Typical Day: Most days begin with an early morning handover from my colleagues who were on inpatient
duty the p revious day. After the updates on patients progress, each therapist will contact the Ward nurses
to make arrangements to assess our patients during their feeding times. Suitable time slots for therapy are
also arranged. At the end of the morning inpatient duty in the wards, we return to the department to
update the files and the afternoon therapist on the childrens progress. My outpatient duties are usually in
the afternoons. After lunch, I get the toys and materials ready before the patients arrive. We see up to 4
outpatients per half day. The day ends with packing up and documentation. I also get some time in the
week for in-services, research and administrative duties.

Challenges: The management of paediatric acquired communication disorders can be challenging, as
literature in this area is sparse. Assessment in this area can b e tricky, as the therapists have to separate the
developmental trajectory of language development from the acquired communication deficits. Some
children may also have had pre-morbid language difficulties on top of the newly acquired communication
disorders. Hence, the language assessment can be complicated. Many of these children are also quite
medically involved, especially patients who are undergoing cancer treatment. The management of their
communication needs has to be prioritised in the context of other medical and therapy n eeds.
34
;
Continuation.
Surprises: Improvements in some of the children with acquired communication disorder
can be quite remarkable. They can move from non-verbal communication to sporadic
single word use and to short narratives in a short span of time, once their neurological issue
is resolved. The way the brain recovers never fails to amaze me.
Interview
Corner
Carry Over: When the patient is medically stable for rehabilitation, we will see the patient regularly up to 3-
5 times a week. Therapy focuses on functional tasks such as requesting and communication repair.
Metacognitive strategies, such as talking about the difficulties the child faces and summarising what they
understood are also explored as therapy targets. We will usually carry out direct therapy in the presence of
the caregivers, while demonstrating the necessary communication strategies/ prompting hierarchy to
facilitate rehabilitation in language. Caregiver training is an important emphasis during therapy sessions.
We aim for parents to be competent in managing the childs communication difficulties and engage their
child in practice during the inpatient stay, and when the child is discharged. Our team, especially upon the
childs discharge, would constantly review the impact of communication deficits on the childs activity and
participation levels.
Success Story: Let me share about this 9 years old child with severe traumatic brain injury (TBI) after a
traffic road accident. He was developing typically until the accident. Upon admission to KKH for
rehabilitation a year after his accident, h e p resented with oropharyngeal d ysphagia, dysarthria, oral apraxia
and aphasia. He also demonstrated some inappropriate behaviours, which were associated with reduced
inhibition and impacting on communication. He had difficulties following single step instructions. His
receptive vocabulary could not be fully assessed as English wasnt his first language. His expressive
language assessment was limited given his reduced speech output. He received rehabilitation, including
physiotherapy, occupational therapy, music and speech and language therapy as an inpatient. He received
speech and language therapy 3 to 5 times a week. His therapy focused on the use of core vocabulary
identified by his family members. He worked on following instructions involving common nouns and verbs.
For his speech, he worked on increasing his phonetic inventory through oromotor exercises, as well as
imitation of phonemes and nonsense words. Alternative and augmentative modes of communication were
explored as he worked on matching single words to pictures. Our team was pleased with his progress, as
the childs ability to communicate effectively with familiar people improved, including his overall ability to
communicate verbally. At the point of discharge, after 4 months of therapy, he was more consistent in his
ability to follow single step instructions. He was able to use his core vocabulary appropriately to
communicate. His ability to match words to pictures improved. His phonetic inventory and the range of
syllable shapes also increased. Even though he did n ot achieve his pre morbid communication abilities, my
team would deem his story a success, as he was able to make significant progress, given the severity of his
TBI, a year post injury.
Loved Resources: As an inpatient therapist, I tend to be minimalist. I carry very few toys and make use of
items by the patients bed. Spoons, pillows, curtains, cups or the childrens own toys can be used as
conversation topics or therapy materials. As a backup, sets of flash cards (everyday items, verbs, whats
wrong pictures), bubbles and the cookie theft picture have b rought me a long way.

35

;
Continuation.

Interview

Corner

Wish List: We are very well resourced at KKH rehab. We are usually able to use the same toys or books for
many different communication goals. Its all about the imagination.
Top Tips for Clinicians:

1. It is important to know how to motivate patients according to their preference. Each patient is
different and may be motivated by different things. I try to include toys and activities based on the
childrens interests so they are more willing to interact and complete challenging tasks. When
children are not able to communicate their preference for activities, I would allow them to lead the
session by presenting a variety of toys. I will then try to weave in my goals according to their choice
of activity.
2. We tend to be sensitive to childrens attention and fatigue levels. We adjust the duration of therapy
sessions based on their attention and fatigue levels, planning more challenging tasks before they
fatigue.

Top Tips for Other Professionals and Parents:
1.
2.
3.
Even though patients appear to be minimally responsive and dont seem to understand
instructions, it is still important to speak to them as if they understand. Continue to greet the
children and inform them about the examination or therapy procedures.
Set small goals and celebrate any achievement. Patients are sometimes making a b ig effort just to
achieve small gains. Hence each small achievement is worthy of a celebration.
Give patients some time to respond to your questions/ instructions. They may require a longer
time to process the language and respond. Opportunities to respond could prevent them from
developing learned passivity, which can be a major barrier to progress and motivation.
Set small goals and

celebrate any
achievement.
Patients are
sometimes making a
big effort just to
achieve small gains.
Hence each small
36

Research
Article

The following article was published online on http://www.laryngologyandvoice.org, on 24/06/2014,
DOI: 10.1111/desc.12190.

Tracing Children's Vocabulary Development From Preschool Through the School-Age
Years: An 8-year Longitudinal Study

Shuang Song, Mengmeng Su, Cuiping Kang, Hongyun Liu, Yuping Zhang, Catherine M cBride-
Chang, Twila Tardif, Hong Li, Weilan Liang, Zhixiang Zhang and Hua Shu
Developmental Science
Volume 18, Issue 1, pages 119131, January 2015

Abstract: In this 8-year longitudinal study, we traced the vocabulary growth of Chinese children, explored
potential precursors of vocabulary knowledge, and investigated how vocabulary growth predicted future
reading skills. Two hundred and sixty-four (264) native Chinese children from Beijing were measured on a
variety of reading and language tasks over 8 years. Between the ages of 4 to 10 years, they were
administered tasks of vocabulary and related cognitive skills. At age 11, comprehensive reading skills,
including character recognition, reading fluency, and reading comprehension were examined. Individual
differences in vocabulary developmental profiles were estimated using the intercept-slope cluster method.
Vocabulary development was then examined in relation to later reading outcomes. Three subgroups of
lexical growth were classified, namely high-high (with a large initial vocabulary size and a fast growth rate),
low-high (with a small initial vocabulary size and a fast growth rate) and low-low (with a small initial
vocabulary size and a slow growth rate) groups. Low-high and low-low groups were distinguishable mostly
through phonological skills, morphological skills and other reading-related cognitive skills. Childhood
vocabulary development (using intercept and slope) explained subsequent reading skills. Findings suggest
that language-related and reading-related cognitive skills differ among groups with d ifferent developmental
trajectories of vocabulary, and the initial size and growth rate of vocabulary may be two predictors for later
reading development.
Conclusion: This study explored the long-term vocabulary d evelopment of Chinese children from ages 4 to
10 years. Three growth profiles with different starting points and growth trajectories were observed,
namely a high-high group, a low-high group and a low-low group. Familial factors and reading- or language-
related cognitive skills were found to b e associated with these developmental subgroups. M eanwhile, both
the initial size and growth rate of vocabulary from ages 4 to 10 could well predict children's reading level in
fifth grade. These results highlight the importance of focusing on the combination of intercepts and slopes
for understanding lexical development. Our findings on the characteristics of the low-high group may
stimulate educators to explore better instruction for at-risk children.

37

;

Alison Cannon is a Speech and Language therapist at an International school in
Singapore.
Interview
Corner
Caseload: I work with mainstream students in a large international school (4000

student). The children are almost all expatriate with about 60% holding a U.S
passport and the remainder coming from Korea, Japan, Europe, Africa, South America and
Australasia. About 30% speak a language other than English at home. Because we have a sound
academic support program, we tend to attract students with known or suspected learning disabilities,
including children on MoE exemptions from the Singaporean school system. About 80% of m y caseload
is comprised of students with mild to moderate speech or language impairments (i.e. standard scores
of 2-7 on a CELF, ASD, or one or m ore phonological processes). About 20% of my students are in need
of a "little push" because they have late developing skills in areas like phonological awareness. Thus,
we offer them some early intervention to head off future problems in literacy.
Duties: There are 6 people employed as SLTs at the school (4 FTE and 2 people doing part time) and m y
FTE work is with K2-P1 (around 500 children). I conduct whole-grade screening of the 220 K2 children
each year. I then run therapy (mostly in groups or sometimes 1:1) for speech, phonological awareness,
language, fluency and social thinking throughout the school year for children who fail our screening or
who have already identified needs. I write IEPs for the students, meet with parents frequently (parent
meetings are very frequent at our school and I like to have parents in to observe my sessions). I also
provide advice to teachers and assessment on request to school students, as well as liaison for arriving
or departing students using other SLT services.
Service Structure: Any parent can request an assessment at any time (free of charge) and we use the
most common tests such as the CELF and Goldman Fristoe, among others. My personal interest is
literacy, so in my age groups I also do specific assessments for literacy sub skills like phonological
awareness and rapid naming. I really like the CTOPP. Teachers are usually the source of our referrals.
As they have significant exposure to kids with known learning difficulties, I find that what would be
dismissed as "naughty behaviour" or "not listening" or even "attention deficit" in other settings is
usually spotted by teachers here as information processing deficits. For children who are highly
concerning, we have a "student services meeting" where parents, teacher, counselor, SLT, learning
support, and psychologist (if needed) meet to determine the best course of action. I have also had
referrals from our ESL teachers because they have a keen sense of when a child is not developing
language competence at the same speed as others.
Therapy is left to our own discretion but is typically once a week for 30 minutes in a small group for
milder/speech difficulties, and up to 5 days a week 1:1 for severely impaired children. Children can
also access daily learning support for reading and m aths (as well as ESL if they are multilingual) on top
of the speech and language program. We do not usually do psychological testing on children unless we
have been working with them for some time and they are not making progress (thus, we need to find
out why). Most students respond readily to intervention so, unlike many other school systems, you
don't see a psychologist here (we have 3 on staff) unless something is not working after a period of
time.
38

;
Continuation.

Interview
Corner

Typical Day: It is rushed! We have what we call the "SAS walk", which is sort of speed
walking. In a typical day, I would have 6 to 7 sessions of 30 minutes each. That fits best with the school
curriculum but is not optimal for speech therapy because you can waste a lot of time rounding up kids
and be left with short sessions. I try and write quick progress notes after each session or at least at
midday and end of day, and I get 40 minutes for lunch. We have staff m eetings twice a week. There is
recognition by admin that you cannot do a good job if you have no life, so there is encouragement to
go home and have one.
Challenges: By far, and I know this is true for education based therapists in any country, it is trying to
integrate the classroom activities with my IEP. I may have very specific goals for following directions or
developing memory compensations but if the class is working on "non-fiction writing: narratives" then
I have to choose between "my goals" and what the child will have missed when they re-enter their
room after 30 minutes with me. I find I do very little advance session planning these days and I am
getting quite good at picking up a class worksheet on "my community" or "snails", and figuring out
how we can link an IEP goal with the activity the class will be doing while I have that student. If I make
my sessions too removed from classroom activities, the children don't get a chance to carry over and
the teachers see no relevance of what the child does while they are gone.
Surprises: How tiny skills can be missing - sometimes you really have to dig - but they can significantly
derail a student academically (and functionally).
Carry Over: I try and link my goals with what the student was doing when I collected them (I always ask
them if they know what their class was doing because many of my LD children do not know it). I also
try and have parents in to watch their child's session at least every quarter, so they are aware of what
the therapy looks like and can do some simple follow up activities at home. That isn't always possible
with our parent body so next year I am going to try videos on my iPad which I will try to share via a
private YouTube channel. I piloted that this year so I could share sessions with the teachers.
Impact: Their life. I used to work in hospitals and although injuries are devastating and life altering,
they often signal "I may have trouble" to the public. Learning disabilities are silent. They limit a child's
childhood (especially if they impact socially) and occupational future (if they do not have help to cope
academically), and there is no visible external sign, so children are often assumed to be "dumb" or
"willful". As a team here at school, we feel very strongly that one of our most important jobs is
diagnosis and "explaining a student" to the family and to that child, so they know themselves better,
and to our colleagues so they can help.

39

;
Continuation.

Interview
Corner

Success Story: With the luxury of time available to us and usually great home support, I am lucky that I
frequently get to discharge kids because they have met their goals. One that particularly stands out is
a little boy who entered our school for K2 "at risk", meaning we weren't sure if we would be able to
meet his needs and might have to ask his parents to withdraw him. He has autism and, in the U.S, had
never been at a school without a 1:1 aide (which we do not allow). The team met often with his
supportive parents and worked hard to meet his needs. He had language intervention multiple times
weekly, a friendship group weekly with our counselor, his teachers were handpicked every year to
make sure they were flexible but firm, and everyone communicated honestly about the challenges. He
is now a thriving 4th grader who told his counselor (in 2nd grade) "I don't need to come to friendship
group anymore because I can make friends by myself". When I see him in the playground, he looks like
any other student. There is still some way to go but he is now a well settled student who has
blossomed here.
Loved Resources: For assessment, I love the Renfrew Action Picture Test because I've done it so many
times I can do it in my sleep. It serves as language screen, but also speech evaluation tool (I know what
the child is likely to say so I can focus on their production of connected speech), basis for conversation
(so I can get a feel for their pragmatics), and it can be done in minutes. For therapy, I have an old set
of books focusing on "main idea" and "inferences", which I use all the time. Everyone who's seen them
has made copies. Other than that, I can do pretty much anything with some coloured pens and blank
paper!
Wish List: Time. We are very lucky to have great resources in terms of classroom, equipment and
colleagues. But there is always too much to do and not enough time to do it.
Top Tips for Clinicians: There's no such thing as a dumb question. In my time in Singapore, I have
often been dismayed by the fact that people are nervous to ask questions or share publicly what they
do. Our SLT staff meetings here are required by admin to be student-focused so we share questionable
assessment results with each other weekly ("do you think I should do some extension testing for this?"
or "what would you suggest if I've done this and this but still don't know what's going on?"). It is a daily
exercise that one of us will ask the others a question even though each of us has over 20 years
experience. We all have our specialist interests (mine is literacy, other people have Lindamood Bell
visualising, or Michelle Garcia Winner social thinking, or even narrative language development) and I
never feel like I can't ask the others something that might be obvious to them, but isn't to me.

40

;
Continuation.
Interview
Corner
Top Tips for Other Professionals and Parents: Trust your team and work with them. Your SLT can
guide you but no one can "fix" a child on their own. Teachers need to ask, as do other professionals,
how they can help students generalise skills. For parents, it may be hard to hear difficult news (that
your child has a lifelong learning disability) but no SLT gets up in the morning planning to upset
people. We are trying to do our best for your child, so please trust that if we have upsetting news to
deliver, we are trying to do so sympathetically and so we can help your child move forward.

There's no such thing as a
dumb question. ()
I never feel like I can't ask the

others something that might
be obvious to them, but isn't
to me.
As a team here at school, we

feel very strongly that one of
our most important jobs is
diagnosis and "explaining a
student" to the family and to
that child, so they know
themselves better, and to our
colleagues so they can help.
If I m ake my sessions too

removed from classroom
activities, the children
don't get a chance to carry
over and the teachers see
no relevance of what the
child does while they are
gone.
41

Upcoming
Events
29 May at 2:30, AWWA Resource Centre: Autism What every education professional ought to
know by Dr. Penny Tok

25 June at 6:30: Key Word Signing by Eva Loh, SLT, SHAS
20th July at 6.30pm, Singapore General Hospital: Leading From One Step Behind: A Solution-
Focused Brief Approach To Working With Clients by Ms Ms Cheryl Ng, SLT & Dr Valerie Lim,
Singapore General Hospital
10 July at 2.30, AWWA Resource Centre: Strategies for education professionals in behaviour
management with children with special needs by Dr. Penny Tok
http://www.apsslh.org/
www.ialpdublin2016.org
Speech Language and Hearing

Association Singapore
300 Tampines Avenue 5, Level 09-02
Singapore 529653
Tel: +65- 6679 5846
Fax: +65-6679 5601
Opening hours: 8.30am - 6.00pm
42

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May

Dear Fellow SLTs,

May 2015 www.shas.org.sg

Always remember to first see

May 2015 www.shas.org.sg

Does Bilingualism Influence Cognitive Aging?

May 2015 www.shas.org.sg

The Cognitive Science of Bilingualism

Language and Linguistics Compass

Fatimazahra Khaki works as Special Educational Needs Learning Support

May 2015 www.shas.org.sg

May 2015 www.shas.org.sg

May 2015 www.shas.org.sg

May 2015 www.shas.org.sg

Carolanna Rodriguez is a Speech and Language therapist at a private therapy

Be confident in your knowledge

'What's in the box?' box!

May 2015 www.shas.org.sg

Ctia Ribeiro Ana Athayde Campos Raquel Vieira

"We believe that no child is a

May 2015 www.shas.org.sg

Journal of Child Psychology and Psychiatry

May 2015 www.shas.org.sg

May 2015 www.shas.org.sg

May 2015 www.shas.org.sg

Caseload: At KK Womens and Childrens hospital (KKH), Rehabilitation department, I

Top Tips for Clinicians:

Set small goals and

May 2015 www.shas.org.sg

Caseload: I work with mainstream students in a large international school (4000

I never feel like I can't ask the

As a team here at school, we

If I m ake my sessions too

May 2015 www.shas.org.sg

Speech Language and Hearing

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