1. Children with SLI are usually late in their acquisition of first words: 2. Children with SLI are usually late to produce word combinations:

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1 By Lauren Lowry Hanen Certified Speech-Language Pathologist and Hanen Staff Member Research has uncovered several factors which predict persistent difficulties with language for late talking children. Last month we reported on a study by Hadley, Rispoli & Hsu (2016), which provided information about one of these risk factors: a limited verb repertoire. Hadley et al (2016) studied typical children s verb growth over time and looked at how their verb lexicons related to their later grammatical abilities. Another recent study by Rudolph and Leonard (2016) looked at other risk factors for persistent language difficulties. They examined the likelihood that a child would receive a diagnosis of specific language impairment * (SLI) if he or she were positive for any of the following risk factors: late acquisition of first words late acquisition of word combinations family history of communication disorders low maternal education Take our poll below and test your assumptions about the impact of some of these risk factors on a child s outcome. The answers will be revealed as you read on Children with SLI are usually late in their acquisition of first words: True 2. Children with SLI are usually late to produce word combinations: True 3. Children who are late to produce first words and late to combine words are at great risk for SLI:

2 True 4. Late acquisition of word combinations is a better predictor of SLI than late acquisition of first words: True Predicting persistent difficulties with language As discussed by Rudolph et al. (2016), current guidelines developed by the American Academy of Pediatrics (AAP) suggest that children should be producing: first words by 15 months word combinations 24 months (Hagan, Shaw, & Duncan, 2008) While these guidelines are widely accepted, what remains unknown is how well delays in each of these milestones predicts whether a child will have ongoing difficulties with language, and whether a delay in one milestone is more predictive than the other. Furthermore, some research suggests that many children with SLI are not late to use first words, so factors that contribute to a child s language learning context (like family history or maternal education) might assist with predicting a child s risk (Rudolph et al, 2016). Therefore, Rudolph et al. (2016) designed their study to answer the following questions: How well does Late Word Producer (LWP) status or Late Word Combiner (LWC) status predict an outcome of SLI? Are significantly more children with SLI identified when family history and/or maternal education are considered in combination with delay in the most predictive language milestone identified in the above question (LWP or LWC)? Study design Rudolph et al. used data for 150 children (aged 4 to 7 years) that was gathered during studies conducted from 2000 to These studies examined a wide range of language abilities and included both typically developing children and children who had suspected language impairment. Information about the children was gathered through case history measures and standardized diagnostic measures:

3 Case history measures: demographic information was gathered as well as the child s developmental, medical, educational and speech and language history. The current study focused on questions pertaining to the child s onset of first words and word combinations, the mother s years of schooling, and information pertaining to any family history of speech, language, or reading problems. All of the children in the study were from monolingual English-speaking backgrounds. Diagnostic measures: several standardized tests and protocols were administered to determine the children s nonverbal cognitive skills, receptive and expressive language skills, hearing status, and oral motor abilities. All children in the study had cognitive, hearing, and oral motor skills that were within normal limits, and they had no evidence of autism or neurological deficits. A diagnosis of SLI was based on the child s performance on the Structured Photographic Expressive Language Test (SPELT-II, Werner & Kresheck, 1983; or SPELT-P2, Dawson, Stout, Eyer, Tattersall, Fonkalsrud, & Croley, 2005). Two groups of children were identified based on these measures: 76 children with SLI and 74 children with typical language outcomes. Results (LWP = Late Word Producer; LWC = Late Word Combiner) 18 of the 150 children in the study were late to produce first words (LWP) o 13 of these LWP children were also LWC (Late Word Combiners). All of these 13 children were later diagnosed with SLI. Therefore, all children who were late in their onset of words and word combinations ended up with an SLI diagnosis. However, late word production on its own was not a sensitive indicator of SLI risk as it only identified 17% (13 out of 76) of the children with SLI in this study. o 5 of the LWP children were timely in their production of word combinations. These children all had typical language outcomes. Therefore, late word production but timely word combination resulted in a typical outcome. 132 of the 150 children in the study were timely in their production of first words o 98 of these children were also timely in their production of word combinations. Interestingly, 34 of these children went on to receive an SLI diagnosis. Put another way, timely onset of first words and word combinations did not preclude an SLI diagnosis. 45% of the children with SLI in this study demonstrated timely onset of first words and word combinations. o 34 of these children were LWC. Many of these children (85%) went on to receive an SLI diagnosis. In other words,

4 A sizeable proportion (45%) of children with an SLI outcome did not exhibit early delays in word production or word combinations 55% of children with an SLI outcome were late to combine words All of the children who were late with both word production and word combination had an SLI outcome What these results mean: SLI could not be reliably predicted based on the presence or absence of first words at 15 months (only 17% of children with SLI were late to produce first words) Children who were not combining words by 24 months were significantly more likely to be diagnosed with SLI (55% of children with SLI were late to combine words). While not a remarkably high indicator, LWC was a significantly better predictor of SLI than LWP. While LWC on its own is not a reliable indicator of SLI, a combination of LWP and LWC indicates a very great risk for developing SLI. LWP + LWC cannot be used as a primary method of identifying children who will develop SLI as this pattern only identified 17% of the children with SLI in this study. But Rudolph et al. (2016) explain that this profile virtually guarantees that the individual has the disorder (p ). Children who were combining words by 24 months were significantly more likely to have a typical language outcome than a diagnosis of SLI What about family history and maternal education? Because LWC was a better predictor of SLI than LWP, LWC was entered into a logistic regression analyses with family history, maternal education, and family history plus maternal education. Results of these analyses revealed that both of these factors significantly increased a child s odds of having SLI. However, when maternal education was included in the predictive model with LWC, it did not result in the identification of significantly more children with SLI than when LWC status was considered alone. However, the combination of family history and LWC status did result in identification of almost 90% of the children with SLI (significantly more than with LWC status alone) (Rudolph et al., 2016). Rudolph et al. (2016) explain that the odds of having SLI were 5 times higher for children who had a positive family history of communication or reading disorders (p. 51). Unfortunately, though, many typically developing children were misdiagnosed using the combined model of LWC + family history. Putting this all together Looking back to the poll at the beginning of this article, we can see that: Children with SLI are NOT necessarily late to acquire their first words (question number 1 is false) Children with SLI are NOT necessarily late to start combining words (question number 2 is false) Children who are late to produce first words and late to combine words ARE at great risk for SLI (question number 3 is true) Late acquisition of word combinations IS a better predictor of SLI than late acquisition of first words (question number 4 is true)

5 Rudolph & Leonard (2016) summarize that given the results of the current study, word combining should receive more attention (p. 53). And while family history and maternal education indicate more risk of SLI, the inclusion of these factors does not provide definitive predictive information. But a child is at greater risk if he or she is late to combine words and has a positive family history. So which late talkers need our help? Rudolph et al. (2016) suggest that: 15 month old toddlers who have not produced first words but are otherwise developing typically may not need our help 24 month old children who have not yet combined words may need further assessment and early intervention, especially if their first words were also delayed Furthermore, children who exhibit delays in the acquisition of both early language milestones [LWP and LWC] are highly likely to have long-term language deficits (Rudolph et al., 2016, p. 54). They also suggest that other factors need to be taken into consideration when deciding which toddlers need intervention, since many of the children with SLI in this study did not evidence delays in early language milestones. Looking at risk factors Besides the risk factors for persistent language difficulties that were examined in this study, several other factors have been identified in other studies. The risk factors that are considered when determining latetalking toddlers appropriateness for the Target Word Program include the following: Risk factors used to determine children s eligibility for Target Word quiet as an infant; limited babbling family history of speech, language, learning or academic difficulties history of ear infections parent variables (i.e., socio-economic status, interaction style) limited consonant repertoire limited sequenced pretend play mild delay in comprehension skills lack of, or reduced use of, representational gestures lack of verbal imitation expressive vocabulary consisting of mostly nouns with few or no verbs poor social skills limited change in expressive language skills over time (Earle & Lowry, 2015, p. iii)

6 Research has shown that the more risk factors a child has, the more concerned we should be that his language difficulties will persist (Earle & Lowry, 2015). Therefore, children who meet the criteria for being a late talker and who present as positive for two or more of the above risk factors are considered appropriate for intervention in the Target Word Program. And considering the results from Rudolph et al. (2016), we should be particularly concerned about toddlers who are late to produce both first words and word combinations. Promoting early word combinations According to Rudolph et al. (2016), more attention needs to be paid to children s early word combinations. Before we intervene, we need to think about a child s readiness to combine words together. Some indicators that a child is ready to combine words include (Earle & Lowry, 2015): Presence of supplementary gestures before children can combine two words together, they must first send two-part messages. This is accomplished using supplementary gestures, which are gestures that provide additional information than is conveyed in the spoken word they accompany. Examples of supplementary gestures include: child lifts his arms up and says Daddy (meaning Daddy pick me up ), or child points to a teddy bear and says big (meaning a big teddy bear ). These gestures should not be confused with complimentary gestures, which provide the same information that is conveyed in the spoken word (e.g. child points to a cookie and says cookie ). A child s use of supplementary gestures indicates that he is sending two-part messages and is on the cusp of combining two words together. Lexical diversity children need some early verbs, adjectives, and/or prepositions in order to form early word combinations. Verbs are particularly important as word combinations which include verbs are actually early sentences, and they set the stage for grammatical development. Therefore, before targeting combinations, it s important to ensure a child has sufficient lexical diversity. In the Target Word Program, four of the child s ten target words are verbs in order to promote such diversity. In summary. Taken together, the information from last month s Wig Wag Minute article about verbs and this month s information based on Rudolph et al. (2016) inform our practice with young children who are late to begin talking. We should be concerned about 24 month old children who: have few or no verbs and do not show acceleration in their acquisition of verbs over the next several months are not combining words, especially if they were also late to acquire first words are also positive for the presence of additional risk factors such as family history of speech or language difficulties or low maternal education By helping parents use responsive language strategies with this group of children, we can hopefully change their language development trajectories so that they approach their peers as quickly as possible.

7 * The term "specific language impairment" has been removed from the DSM-V. However, Rudolph and Leonard (2016) use the term in their study. References Dawson, J., Stout, C., Eyer, J., Tattersall, P., Fonkalsrud, J., & Croley, K. (2005). Structured Photographic Expressive Language Test Preschool: Second Edition. DeKalb, IL: Janelle Publishers. Earle, C. with Lowry, L. (2015). Making Hanen Happen Leaders Guide for Target Word The Hanen Program for Parents of Children who are Late Talkers, Fourth Edition. Hanen Early Language Program: Toronto, ON. Hadley, P. A., Rispoli, M. & Hsu, N. (2016). Toddlers verb lexicon diversity and grammatical outcomes. Language, Speech, and Hearing Services in Schools, 47, Hagan, J., Shaw, J. S., & Duncan, P. M. (Eds.). (2008). Bright futures: Guidelines for health supervision of infants, children, and adolescents (3rd ed.). Elk Grove Village, IL: American Academy of Pediatrics. Rudolph, J. M. & Leonard, L. B. (2016). Early Language Milestones and Specific Language Impairment. Journal of Early Intervention, 38(1) Werner, E. O., & Kresheck, J. (1983). Structured Photographic Expressive Language Test II. Sandwich. IL: Janelle Publishers.