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INT J LANG COMMUN DISORD,JULY–AUGUST 2014,
VOL. 49, NO. 4, 381–415
Review
Ten questions about terminology for children with unexplained language
problems
D. V. M. Bishop
Department of Experimental Psychology, University of Oxford, Oxford, UK
(Received November 2013; accepted March 2013)
Abstract
Background: In domains other than language, there is fairly consistent diagnostic terminology to refer to children’s
developmental difficulties. For instance, the terms ‘dyslexia’, ‘attention deficit hyperactivity disorder’ and ‘autistic
spectrum disorder’ are used for difficulties with reading, attention or social cognition, respectively. There is no
agreed label, however, for children with unexplained language problems.
Aims: To consider whether we need labels for unexplained language problems in children, and if so, what
terminology is appropriate.
Main Contribution: There are both advantages and disadvantages to labels, but they are important to ensure
children receive services, and to increase our knowledge of the nature and causes of such problems. A survey of
labels in current use found 132 different terms, 33 of which had 600 or more returns on Google Scholar between
1994 and 2013. Many of these labels were too general to be useful. Of the remainder, the term ‘specific language
impairment’ was the most commonly used.
Conclusions: The current mayhem in diagnostic labels is unsustainable; it causes confusion and impedes research
progress and access to appropriate services. We need to achieve consensus on diagnostic criteria and terminology.
The DSM-5 term ‘language disorder’ is problematic because it identifies too wide a range of conditions on an
internet search. One solution is to retain specific language impairment, with the understanding that ‘specific’ means
idiopathic (i.e., of unknown origin) rather than implying there are no other problems beyond language. Other
options are the terms ‘primary language impairment’, ‘developmental language disorder’ or ‘language learning
impairment’.
Keywords: diagnosis, DSM-5, labels, terminology, specific language impairment.
What this paper adds?
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 need of
intervention. A range of diagnostic terms are evaluated in terms of their advantages and disadvantages.
Introduction
Consider the case of 8-year-old George. He was rather
late to start talking, and he did not speak in sentences
until he was 4 years old. In other regards he developed
normally: he is a healthy child and a hearing check
Address correspondence to: D. V. M. Bishop, Department of Experimental Psychology, University of Oxford, Tinbergen Building, South Parks
Road, Oxford OX1 3UD, UK; e-mail: dorothy.bishop@psy.ox.ac.uk
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction
in any medium, provided the original work is properly cited.
found no problems. He attends mainstream school, but
he struggles with reading, and has a weak vocabulary for
his age. He does not always remember what his teacher
says to him, and his confidence, never good, has been
dented further by other boys teasing him for not under-
standing the punch line to a joke. George is having some
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online
C2014 The Authors International Journal of Language & Communication Disorders published by John Wiley & Sons Ltd on behalf of Royal College of Speech and Language Therapists
DOI: 10.1111/1460-6984.12101
382 D. V. M. Bishop
extra help with his reading in a small group, but he hates
being singled out and made to feel different from others.
He is beginning to be reluctant to go to school, except
on days when he has art lessons, which he loves. His par-
ents, concerned to see him so miserable, have arranged
a private assessment with a psychologist, who diagnoses
specific language impairment (SLI) and dyslexia. She
explains that George has a nonverbal IQ of 95, within
normal limits, but his vocabulary and comprehension
levels are lower, with scaled score equivalents of 80, and
his reading ability is at a 6-year-old level. The parents
look for information on the internet and learn that SLI
is thought to be a strongly genetic disorder that impairs
language development. When, however, they talk to the
head teacher about the assessment, he is not impressed.
He thinks that it is unhelpful to apply a diagnostic label
to George. All children vary in their language abilities,
he explains, and the best approach will be to continue
to support George with extra help in the classroom. He
offers to ask the speech and language therapist for her
opinion, as she is good at working with teachers to find
the best way to help children with speech, language and
communication needs (SLCN). The head teacher ex-
plains that there have been growing concerns that too
many children are being identified with special educa-
tional needs (SEN), which just creates stigma and low
expectations.
This vignette illustrates a number of tensions that
surround the identification and labelling of children
whose language development is falling behind their peer
group for no obvious reason. There is polarization be-
tween two extremes: those who treat identification of
children’s language problems as akin to medical diagno-
sis, and those who adopt a normative approach, which
eschews diagnostic labels as invalid and inappropriate.
Among those who use labels, there is no agreement as
to what is appropriate. In reviewing background litera-
ture, I shall use the term ‘specific language impairment’
(SLI) when referring to studies that have used this term,
but provisionally will otherwise talk of ‘unexplained lan-
guage problems’. The vexed issue of what terminology
should be adopted will emerge in the course of this
article.
1. Should we be concerned about children’s
language problems?
Should we just let children develop at their own pace
rather than worrying about those who progress more
slowly for no apparent reason? On this point, I suspect
there will be agreement between most professionals, re-
gardless of which discipline they come from. The evi-
dence is stark: children whose language lags well behind
their peer group are at increased risk of academic failure
(Durkin et al. 2012, Johnson et al. 2010), behavioural
and psychiatric problems (Conti-Ramsden et al. 2013,
Snowling et al. 2006), unemployment and economic
disadvantage (Parsons et al. 2011), and social impair-
ment (Clegg et al. 2005).
Age, however, is critical. Late-talking in toddlers is
not necessarily predictive of future problems, provided
language comprehension is adequate, there is no fam-
ily history of language or literacy problems, and other
aspects of development are proceeding on course (Lyyti-
nen et al. 2005, Zambrana et al. 2014). Many late-talkers
catch up with their peer group after a slow start, and do
not have significant difficulties later on (Reilly et al.
2010). But for children whose language deficits persist
into school age, the outlook is bleaker (Conti-Ramsden
and Durkin 2008, Stothard et al. 1998, Tomblin et al.
2003), prompting concern about whether we can effec-
tively intervene to prevent a downward spiral of negative
consequences.
2. Should we abandon diagnostic labels?
In many educational contexts, there is resistance to giv-
ing children diagnostic labels. The approach is educa-
tional rather than medical, with the goal being to iden-
tify children who will benefit from help by identifying
the specific kinds of need on an individual basis. The
more generic term ‘special educational needs’ (SEN) is
used to determine who gains access to special educa-
tional provision; this would encompass children with
serious communication difficulties alongside those with
other disabilities affecting education. ‘Speech, language
and communication needs’ (SLCN) is used as a non-
specific term, i.e., it covers a range of children including
those with English as an additional language, stutter-
ing, or speech/language problems due to hearing loss
or physical causes, as well as those with unexplained
language problems. Within the UK educational system,
diagnostic labels are not widely adopted, and the Di-
agnostic and Statistical Manual (DSM-5) classification
system of the American Psychiatric Association (2013)
and International Classification of Diseases (ICD-10)
of the World Health Organization (1992) are largely
ignored.
For some, labelling is seen as irrelevant, whereas for
others, it is explicitly rejected as having more negative
than positive consequences. Some of the disadvantages
of diagnostic labels are summarized in the first column
of table 1, which draws heavily on arguments advanced
by Lauchlan and Boyle (2007).
Avoidance of labels may seem an admirably prag-
matic approach which avoids potential stigmatization.
It also avoids the unfairness that can ensue if educational
support is restricted to those who meet arbitrary cut-offs,
such as the discrepancy criteria sometimes used to iden-
tify children with specific learning disabilities (Fletcher
1992). It does, however, have some serious limitations.
Terminology for children with language problems 383
Table 1. Pros and cons of diagnostic labels
Negative consequences Positive consequences
Focus on what is wrong with the child; may ignore aspects of
environment; localize problem in the child
Provides an explanation and legitimacy
Parents take no responsibility Removes blame from parents
Child feels failure inevitable, stops trying Removes blame from child
Excuse for what is really consequence of bad teaching Removes blame from teachers
Leads to stigmatization, social disadvantage and exclusion Promotes understanding and awareness of particular difficulties; legal
protection against discrimination; can give sense of belonging:
support groups; allows for group action; can lead to emphasis on
positive attributes
Resources denied to those who do not meet specific diagnostic
criteria; cynical use of labels to get extra funds
Leads to access to resources; in some countries may not be able to
access these without a diagnostic label
Focus on label rather than assessment of child’s specific needs;
tendency to stereotype; generalizations may obscure important
differences
Recognize common patterns across children with similar difficulties
Child may do better with skilled teaching and not need/ benefit from
other intervention
Child can receive targeted intervention
Same label used with different meanings leads to confusion Facilitates communication among professionals
Undue reliance on unreliable criteria, especially IQ Objective criteria from formal assessment identify problems that
might otherwise get missed
Medicalization of non-medical disorders; social problems attributed
to medical causes
Recognition of biological as well as social causes of difficulties
Planning in terms of numbers with difficulties, rather than making
changes that benefit all children
Need to know how many children affected, for planning resources
and documenting progress
Groups studied by researchers are artificial and findings may not
generalize to most children
Researchers need to generalize across groups; labels allow for
continuity across research
First, in avoiding medicalization of children’s difficulties,
we may swing too far in the other direction, denying any
role of biological risk factors in causing problems. The
net result can be a culture of blaming either the par-
ents or the teachers when children fail to achieve. A
more balanced approach recognizes that children vary
in their biological as well as their social backgrounds,
and educational approaches need to be optimal for each
individual, without introducing notions of inadequacy
or blame.
Second, without diagnostic categories, it becomes
easy for educational and governmental agencies to min-
imize children’s difficulties, especially if they are at-
tributed to poor schooling. With no clear criteria for
deciding who needs extra help, it is all too easy to re-
move support. Consider, for instance, a government re-
port issued in 2010 that argued that there was mas-
sive over-identification of children with SEN (Office for
Standards in Education, Children’s Services and Skills
2010). The authors of this report took the view that
a primary reason for children’s educational failures was
inadequate teaching, and that schools were using the
terminology of SEN to disguise their limitations and
imply that the reason for failure lay in the child rather
than in poor teaching. If there are no agreed criteria of
what constitutes a significant language problem, then
it is impossible for anyone to provide evidence either
for or against this statement—it is simply a matter of
opinion as to who merits special help. If we had clear
and objective criteria, we could then gather evidence to
determine which children actually benefit from support
and services.
This leads us to the third limitation of the ‘no labels’
approach, namely that it hampers research. In order to
find out more about the nature and causes of language
problems, and to discover which interventions are ef-
fective, we need to study groups of children. We can
only do that if we can agree who is to be in the group,
and hence we need to agree on diagnostic criteria. To
date, researchers have had notable successes in finding
out about the linguistic difficulties, correlates, outcomes
and causes of SLI, despite the fuzziness and heterogene-
ity of this diagnostic category. For example, we have
been able to identify specific deficits that might help
account for language difficulties (Conti-Ramsden et al.
2001), to evaluate efficacy of intervention (Washington
et al. 2011), to give parents a prognosis (Whitehouse et
al. 2009a), and to identify genetic risk factors (Bishop
et al. 1995): Our knowledge is far from perfect, but it
would be non-existent if we had not been able to iden-
tify groups for study. None of this would be possible
using a global category such as SLCN, which may be
workable for certain administrative purposes, but is too
broad for research contexts. It is sometimes argued that
in identifying children with SLI, we are assuming they
are all the same. That is wrong: they will differ in various
ways, but the point is that we can identify clusters of
children who share some key characteristics. In clinical
contexts, we need to beware of stereotyping and assum-
ing all children are the same, but if we treat each child
384 D. V. M. Bishop
as unique, we can never generalize and learn from our
experiences.
Arguments about labelling are not confined to the
field of language impairment, or even to neurodevel-
opmental disorders. In his critique of DSM-5, Saving
Normal, Frances (2013) noted the societal significance
of labels in psychiatry. He was particularly concerned
about the expansion of diagnostic categories in DSM-
5, whereby normal variations in behaviour were being
treated as diseases, so that a very high proportion of the
population would qualify for a diagnosis. Nevertheless,
Frances was careful to stress that he was not opposed
to diagnostic labels—quite the contrary. He noted that
in situations where resources are limited—which is al-
most always—budgets are a zero-sum game: if you do
not have a diagnosis, then nobody will pay for your
treatment.
Overall, Frances’s conclusions have broad applica-
bility to the case of children’s language problems. There
is a necessity for diagnostic labels if we are to advance
our understanding of why some children have language
problems, and identify those who might benefit from
intervention. However, there is considerable potential
for unintended consequences from labelling, and we
need to think carefully about what kind of labels we use
and whether we can take steps to mitigate the negative
impacts that can arise from their use.
3. Is a medical model appropriate for
unexplained language problems in
children?
Does use of diagnostic labels ‘medicalize’ children’s dif-
ficulties inappropriately? After all, language difficulties
are quite different from a condition such as Down syn-
drome, where there is a known aetiology (an extra copy
of chromosome 21), leading to a distinctive cluster of
physical and cognitive characteristics. Labels may give
the impression that they offer explanations for children’s
difficulties, especially when they are medical-sounding,
like ‘dyslexia’ or ‘Asperger syndrome’, but in fact these
are behaviourally defined conditions, and the labels are
really no more than shorthand descriptions of a cognitive
profile. The drawback of medical labels is that they can
lead to what Hyman (2010) has termed ‘reification’: the
assumption that our labels are defining ‘natural kinds’.
SLI is not a distinct syndrome. There is evidence for
genetic variants that increase the risk of language im-
pairment (Newbury et al. 2011), but individual genes
typically have very small effects, and, importantly, the
genetic variants associated with increased risk are com-
mon in the general population. Rare mutations that
cause major language problems are the exception rather
than the rule (Graham and Fisher 2013). SLI is best
conceptualized as a complex multifactorial disorder that
is usually caused by the combined influence of many
genetic and environmental risk factors of small effect
(Bishop 2009). In sharp contrast to Down syndrome,
there is usually no clear dividing line between normal-
ity and abnormality in its aetiology, and although SLI
is influenced by genes, it is not possible to diagnose it
using a genetic test.
The literature on brain correlates of SLI tells a simi-
lar story. Although striking abnormalities such as devel-
opmental cortical malformations are sometimes noted
(De Vasconcelos Hage et al. 2006), more usually, where
correlates of SLI are found on structural or functional
imaging, they tend to be subtle and not always consistent
from study to study (Lepp¨
anen et al. 2004). Overall, we
are not in a position to diagnose SLI from brain scans.
Of course, we cannot rule out the possibility that with
new techniques and better data, we might achieve what
many regard as the Holy Grail: a system for diagno-
sis of neurodevelopmental disorders based on biomark-
ers rather than behaviour. However, we are a long way
from achieving that goal: Even where biomarkers are
found, they are seldom specific to a particular condition
(Leonard et al. 2008).
It might be thought that such evidence invalidates
any attempt to apply a ‘medical model’ to children’s
language problems, but as Taylor and Rutter (2008)
pointed out, a view of medicine as involving only
categorical syndromes with single causes is unrealistic.
Medical conditions such as hypertension, obesity and
kidney disease are all diagnosed on the basis of measures
that are above cut-off on a quantitative scale. This
may identify a group of people who are heterogeneous:
hypertension can arise for a host of different reasons,
and may not have any one clearly defined cause; rather
it results when there is a constellation of genetic and
environmental risk factors. There will often be co-
occurring problems: the obese individual is likely also
to suffer from other physical and psychiatric problems.
Nevertheless, we find it worthwhile identifying these
conditions because, when a person falls on the extreme
of a normal distribution, they are at risk of further prob-
lems and may be helped by specific interventions. Those
interventions may include pharmacological agents, but
may also involve lifestyle recommendations such as
changes in diet and exercise. The analogy with children’s
language impairments should be evident: in applying a
label such as SLI, we are not assuming that the child has
a distinct medical syndrome, that all children so labelled
are the same, that language is the only problem that
is present, that the child is qualitatively different from
others, or that non-medical interventions will be inef-
fective. We are, however, acknowledging that biological,
as well as environmental, factors affect a child’s language
development.
Terminology for children with language problems 385
4. What are appropriate criteria for
identifying children’s language problems?
There is no simple answer to this question because the
specific criteria that are optimal will vary with the pur-
poses of diagnosis (Bishop 2004). In some contexts, we
may give most weight to evidence of poor skill on a test
of a specific component of language processing, such as
grammar or verbal memory. In other situations, the key
issue will be how well the child is functioning in every-
day life, at home and at school. A key point is that the
specific purpose of a labelling system will dictate which
criteria are used. We will first consider what types of
information are typically considered when evaluating a
child’s difficulties, and then discuss how these may be
applied depending on the purpose of diagnosis.
Information used in diagnosis
The traditional approach to identifying SLI has involved
three components of diagnostic criteria, which together
are intended to select children whose language difficul-
ties have no obvious cause:
Evidence of significant language impairment
Although this may seem simple enough, assessing and
quantifying language raises numerous questions. For in-
stance, should we measure language using standardized
tests,andifsowhichones?Tomblinet al. (1996), for
instance, made a case for excluding phonological impair-
ment (a linguistically based speech-sound disorder) or
pragmatic impairment in their diagnostic system for SLI,
focusing instead on vocabulary, grammar and narrative
skills. It could, however, be argued that phonology or
pragmatics are part of language that should be included
in a definition of SLI. Another question is what cut-offs
should be used? Traditionally, scores that are at least 1
or 1.5 SD below the population mean are regarded as
evidence of impairment, but this is an arbitrary criterion.
We also have the thorny problem that language tests
may not capture important aspects of everyday commu-
nication. Several studies have shown that children who
are judged to have language difficulties by parents or
professionals are not necessarily the same children who
are selected by language tests (Law et al. 2011, Roy and
Chiat 2013, Tomblin et al. 1997). If we rely on par-
ents or teachers to identify which children need help,
we need to be aware that factors such as social back-
ground, as well as the type of language difficulty, may
determine whether problems are detected (Bishop and
McDonald 2009, Tomblin et al. 1997). This is poten-
tially problematic: we do not want to waste scarce re-
sources on children who are not experiencing any day-to-
day problems, but some children with hidden language
problems—especially those affecting comprehension—
can get missed unless formal language testing is used. A
key point here is that a language problem may not al-
ways look like a language problem: an underlying com-
prehension impairment can present as poor academic
attainment, impaired social interaction, or behavioural
difficulties (Cohen et al. 1998).
‘Cognitive referencing’
‘Cognitive referencing’ is the practice of evaluating a
child’s language skills in relation to the level of nonver-
bal ability, rather than chronological age (Cole and Fey
1997). Implicit in this criterion is the notion that a child
with a mismatch between language and nonverbal skills
is different from one whose poor language is at a similar
level to nonverbal ability. However, as discussed further
below (Question 5), there is no good evidence that this
is the case (Tomblin 2008). Accordingly, this criterion is
now largely discredited, and the more usual approach is
to require only that the child achieve some minimum
level of nonverbal ability (though there is no consensus
about which nonverbal test and which cut-off to use).
Exclusionary criteria
The use of exclusionary criteria seems simple enough:
we wish to separate those children for whom there is
a known cause of language problems, from those that
are unexplained. In practice, however, this is not always
easy.
Genetic syndromes. A child with a known genetic
syndrome, such as Down syndrome, would not usu-
ally be categorized as a case of SLI, because there are
usually widespread cognitive deficits extending beyond
language –though language skills tend to be dispropor-
tionately worse than nonverbal ability (Laws and Bishop
2004). But what about Klinefelter syndrome (47, XXY
karyotype)? Children with this chromosomal constitu-
tion often have a cognitive profile that is similar to that
seen in SLI, with depressed verbal skills in the context
of normal nonverbal ability (Bishop and Scerif 2011).
Should they therefore be included as cases of SLI? The
answer, as always, varies according to the purpose of
diagnosis, as will be discussed further below.
Hearing loss. Another example that may be less sim-
ple than it appears is the case of the child with moderate
to profound sensori-neural hearing loss. A permanent
hearing loss of this level of severity will typically impair
acquisition of oral language, and may lead to a pattern
of language difficulties similar to that seen in normally
hearing children with SLI (Bishop 1983). Nevertheless,
there is still wide variation in the extent of language
386 D. V. M. Bishop
problems. This was demonstrated in a study of chil-
dren receiving cochlear implants, some of whom had
language problems that were far more severe than was
usually seen with that degree of hearing loss (Hawker
et al. 2008). The authors suggested that they might
have both hearing loss and risk factors for SLI. This in-
terpretation was supported by a subsequent study show-
ing evidence of increased language impairment in the
normally-hearing siblings of cochlear implant users with
disproportionate language impairment (Ramirez-Inscoe
and Moore 2011). There are also hearing-impaired chil-
dren who fail to master sign language, despite adequate
opportunity to learn, who can be regarded as having a
SLI for sign (Mason et al. 2010).
Social deprivation. Roy and Chiat (2013: 131–132)
noted that SLI can be interpreted as ‘poor language per-
formance that cannot be explained by limitations in a
child’s language experience’, but just how realistic is it
to identify cases where language problems are due to
such limitations? My view is that, if we set aside cases
of extreme neglect, it is not. While it is well-established
that there is a positive association between social disad-
vantage and children’s language skills (Letts et al. 2013,
Schoon et al. 2010), it is seldom possible to disentan-
gle the causal paths behind this association. Social de-
privation effects could arise because poor language in-
put from parents leads directly to language difficulties
in their children (Leffel and Suskind 2013, Pickstone
et al. 2009), as shown in figure 1. However, twin stud-
ies suggest a different interpretation of the association,
namely that parents and children share genetic risk fac-
tors for language impairment (Bishop 2006b). Factors
such as low socioeconomic status and parental educa-
tional level are not the independent environmental fac-
tors that they are often assumed to be: they can be
consequences of language impairment. This is amply il-
lustrated by follow-up studies of language-impaired chil-
dren. We know that when they grow up, children who
have language problems have poorer educational and
employment outcomes than those who do not (Johnson
et al. 2010, Whitehouse et al. 2009b). As adults, they
are therefore likely to have a lower educational level and
lower socio-economic status than other people. Con-
sistent with this, parents of children have, on average,
poorer language and literacy skills than control parents
(Barry et al. 2007, Law et al. 2009). We could thus have
an association emerging between lower socioeconomic
status and poor educational attainments in the parents
and language difficulties in their children even if there
were no causal route from parental language to child
language, simply because children share 50% of genetic
makeup with their parents. If a parent has heritable lan-
guage impairment, his or her child will also have a higher
Figure 1. Causal model in which there is a direct link from com-
municative behaviour in the parents to language impairment in the
child.
genetic risk for SLI. Figure 2 shows the causal chain sug-
gested by this account, and contrasts it with the causal
route that is typically assumed to account for the asso-
ciation (Figure 1). The shared causal factor responsible
for the association is labelled here as ‘(genetic) risk fac-
tor’ because of the evidence that language impairment
is often heritable, but there could also be environmental
risk factors that operate in the same way.
Of course, the different causal mechanisms shown
in figures 1 and 2 are not mutually exclusive, and it
is likely that in many children there is a mix of bio-
logical and environmental causes involved. It would be
unwise, however, to assume that a low educational level
of parents is the sole and direct cause of language dif-
ficulties in children in cases where there is social disad-
vantage. A distinction between language problems with
environmental versus biological causes would be more
justifiable if we could demonstrate some differences in
the nature and pattern of language problems for children
from different social backgrounds, or if they responded
differently to intervention. However, to date, I am un-
aware of any good evidence of that kind, and indeed,
Roy and Chiat (2013) found that language-impaired
children with high or low SES had similar language
profiles.
Terminology for children with language problems 387
Figure 2. Causal model in which shared genes account for associ-
ation between socioeconomic factors in the parents and language
impairment in the child.
Different goals of diagnosis
Deciding who gets intervention
In clinical settings, our principal goal is to identify
children who will benefit from intervention. In this
context, functional disability—evidence that the child’s
problems are interfering with everyday life or academic
attainment—is likely to be at least as important as lan-
guage test scores. However, as noted above, we need
to be alert to the possibility that the child’s difficulties
may not be obvious, especially if they principally involve
comprehension.
A further point relates to the discussion of exclu-
sionary criteria, above. In this particular context, it is
not clear that strict use of exclusionary criteria is jus-
tified, unless there is good evidence that the child has
difficulties that would not respond to intervention. For
instance, a child with Klinefelter syndrome may benefit
from the same kind of intervention as a child without
any additional diagnoses.
In the final analysis, we should be identifying those
children who will benefit from targeted help. Unfor-
tunately, there is a dearth of high-quality research on
effectiveness of intervention in this area, and this makes
it difficult to devise well-motivated, evidence-based cri-
teria.
Epidemiology and audit
Knowing how many children are affected with a condi-
tion is important for planning resources, and for identi-
fying causal factors that may vary across time and place.
Lack of an agreed set of criteria for language impairment
makes comparisons of prevalence rates problematic. A
widely adopted solution is to take a statistical defini-
tion, selecting children whose scores on a language test
are below some specified cut-off, e.g. the bottom 10%.
However, such a criterion will select a constant, and
arbitrary, percentage of children, and may relate only
poorly to measures of functional impairment. Tomblin
et al. (1997) noted that prevalence rates are not entirely
predictable from statistical cut-offs used for diagnosis,
because some of those falling below cut-off will meet
exclusionary criteria. In addition, if we use tests that are
normed for a representative population, we can consider
how rates of impairment vary within substrata of that
population. Nevertheless, use of statistical cut-offs cre-
ates the same problems that are seen when we try to set
standards for determining levels of poverty, or prevalence
of short stature. Income, height or language ability of
the whole population could improve substantially, but
a statistical cut-off will still select a specific proportion,
such as the bottom 10%. We can only avoid this by
identifying an absolute anchor point for impairment.
For instance, Rice (2000) argued against purely statis-
tical criteria, maintaining that some key differences be-
tween impaired and unimpaired children are not readily
assessed on tests that generate normal distributions of
scores. She suggested that, in English-speaking children,
a failure to use aspects of grammatical morphology re-
liably by 5 years of age can be used as an indicator
of language impairment—a view supported by a recent
study by Redmond et al. (2011). The field would ben-
efit from additional specification of absolute criteria for
language skills that should be mastered at given ages to
allow us to escape from the circularity inherent in statis-
tical definitions. This is a challenging task, which may
require different solutions for different languages.
Research on correlates of language problems
If the goal is to find the underlying neurobiological or
cognitive bases of language problems, then it may be
more important to select a group of children who are
homogeneous in terms of their language profile, rather
than to focus on those with the most severe functional
impairments. Furthermore, to isolate correlates of lan-
guage deficits, we may want to focus on children who
388 D. V. M. Bishop
do not have any additional problems. Such pure cases
are, however, rare, and not likely to be representative
of children who are seen in clinical contexts, where co-
occurring problems are the rule rather than the exception
(Dyck et al. 2011).
Research on genetics
When doing genetic studies it might seem sensible to
stick with published clinical criteria, such as those in
ICD-10 (World Health Organization 1992) or DSM-
5 (American Psychiatric Association 2013). For genetic
studies it would certainly make sense to use exclusion-
ary criteria to select out children with a known organic
disorder that could lead to language problems, such as a
chromosome anomaly, neurological disease or cochlear
damage. But in other regards, a focus on ‘pure’ disorders
has proved counterproductive. Relatives of children who
meet stringent diagnostic criteria often have a ‘broad
phenotype’, i.e. milder versions of the same problems
which would not usually qualify for a diagnosis (Barry
et al. 2007). In addition, they may have other disorders,
such as autistic features, or low nonverbal ability (Bishop
1994). A focus on textbook cases can therefore be un-
helpful in uncovering patterns of familiarity (Lewis et
al. 2006). Instead, we may get clearer results if we can
identify ‘endophenotypes’, i.e. measures that relate more
closely to the underlying neurobiology of the condition
(Gottesman and Gould 2003).
Another point emerging from genetic studies is that
heritability of language impairment can vary depending
on how it is defined. Bishop and Hayiou-Thomas (2008)
found that alternative ways of identifying language dis-
ordergaveverydifferentresultsinanalysisofatwin
sample. Genetic influence on impairment was marked
only for children who attracted parental or professional
concern. For children who had low scores on language
tests but no clinical referral, there was little evidence
of genetic influence. This suggests that overt problems
with speech production and/or expressive language—
which tend to be readily noticed and so lead to clini-
cal referral—are more heritable than weak vocabulary,
which does not attract concern unless accompanied by
other difficulties.
5. Does it make sense to focus on ‘specific’
problems with language?
It is often assumed that we should distinguish children
whose language difficulties can be attributed to a known
cause from those who have unexpected, unexplained lan-
guage problems. The notion of a ‘specific’ impairment
has been operationalized by requiring a discrepancy be-
tween impaired language function and normal nonver-
bal ability—something which was part of diagnostic
criteria for specific learning disabilities for many years.
The discrepancy criterion captured the notion that the
impairment was unexpected and unexplained: whereas
there was an assumption that language deficits were un-
surprising in a child who had more global intellectual
difficulties. However, this rationale has not been sup-
ported by evidence in either language or literacy prob-
lems. While it is true that verbal and nonverbal impair-
ments often co-occur, it is not the case that nonverbal
ability sets a limit on language development (Bishop
2004, Tomblin et al. 1996). Indeed, it is possible to find
children whose performance on language tests is much
better than their performance on nonverbal tests—the
opposite pattern to what is seen in SLI. Furthermore,
inclusion of discrepancy criteria in diagnostic formula-
tions can be a barrier to progress in studies of aetiology.
For instance, Bishop (1994) found that twin data were
more interpretable if children were categorized accord-
ing to language deficits, regardless of nonverbal ability,
than if a conventional diagnosis of SLI were used. In
short, where low nonverbal ability accompanies poor
language skills, it should be seen as a correlate rather
than an explanation.
One setting where use of nonverbal IQ criteria can
sometimes be justified is in research contexts where the
goal is to identify specific correlates of poor language
learning. For instance, poor phonological awareness is
a well-established correlate of poor reading, regardless
of IQ level. If, however, this had been discovered in
children whose poor reading was accompanied by low
nonverbal IQ, it is unlikely its significance for reading
would have been appreciated. It would instead have been
regarded as part of general developmental delay. In the
field of oral language impairments, demonstration of
problems with procedural learning (Lum et al. 2013),
grammatical morphology (Bishop 2013, Rice 2000) or
nonword repetition (Graf Estes et al. 2007) are far more
striking when seen in language-impaired children of nor-
mal nonverbal ability, than if demonstrated in those with
more general learning difficulties.
6. Are language problems distinct from
other neurodevelopmental disorders?
In the past, research on different neurodevelopmental
disorders proceeded largely independently, but there is
growing awareness of considerable overlap between dif-
ferent conditions. First, it is evident that many children
with SLI meet criteria for developmental dyslexia and
vice versa (Bishop and Snowling 2004). The overlap
was for many years not appreciated, because reading
and oral language problems are usually dealt with by
different professional groups: psychologists or educators
Terminology for children with language problems 389
for reading problems, and speech–language therapists
for language problems. As the evidence grew for close
relationships between disorders of written and spoken
language, people started to ask whether SLI and dyslexia
were the same condition presenting at different points
in development. Bishop and Snowling (2004) con-
cluded that the reality was more complex, with different
children showing different combinations of underlying
problems, which may be restricted to phonological pro-
cessing in some cases, or extend to broader aspects of
oral language in others. The message, however, is clear:
it does not make sense to create a sharp division between
oral and written language in any diagnostic system, be-
cause the two go hand in hand (Snowling and Hulme
2012).
There are also high rates of co-occurrence between
language problems and a range of other neurodevel-
opmental disorders, notably speech sound disorder,
ADHD, developmental dyscalculia, and developmental
coordination disorder (DCD: more informally termed
‘developmental dyspraxia’) (Bishop and Rutter 2008).
We still do not know the reason for these overlaps, but it
seems likely that they occur because the same environ-
mental or genetic factors that increase risk for language
problems also increase risk for other neurodevelopmen-
tal disorders. Should we refer to language impairments
as ‘specific’ when they occur together with these other
conditions (Hill 2001)? It comes down to how words are
used. If by ‘specific’ we mean that the child has no prob-
lems other than with language, then this is clearly an
inappropriate term if ADHD or DCD is also present.
If, however, we take ‘specific’ to mean ‘idiopathic’ or
‘functional’, i.e. with no known cause, then the term
is still applicable, because the co-occurring condition is
not an explanation for the language problems.
Autism spectrum disorder (ASD) is of particular in-
terest, because traditional diagnostic criteria exclude a
diagnosis of SLI when ASD is present, yet it is clear
that a subset of children with ASD also have language
difficulties that are similar to those seen in SLI (Tager-
Flusberg and Caronna 2007). This has led researchers
to subdivide children with ASD into those with and
without additional language impairments (Lindgren et
al. 2009). Even more complex for any diagnostic sys-
tem are children who appear to occupy a position that
is half-way between ASD and SLI. These are children
who have problems with pragmatic aspects of commu-
nication, yet do not have the repetitive behaviours and
restricted interests characteristic of autism. In some cases
they also have the kinds of grammatical and phonologi-
cal difficulties typical of SLI. The solution in DSM-5 has
been to create a new category of social communication
(pragmatic) disorder (SCD) for these children (figure 3).
Norbury (2014) has pointed out a number of problems
with this solution: it treats SLI and SCD as different con-
Figure 3. Relationship between social communication disorder
(SCD), specific language impairment (SLI) and autism spectrum
disorder (ASD) in DSM-5. Unlabelled regions of the Venn diagram
do not correspond to specific diagnostic labels, though it is likely
that some children would fall in these regions.
ditions, though often there are overlapping impairments
in the two groups; it bases diagnosis on aspects of social
communication for which reliable and valid assessments
are lacking; and there is a risk that children may end up
with no suitable intervention if no professional group
feels responsible for meeting their needs.
7. What labels have been used for
unexplained language problems?
The diagnostic mayhem affecting the field of chil-
dren’s speech and language impairments is illustrated in
figure 4. Most labels consist of some permutation of
the terms shown in the figure, i.e. an optional prefix
(specific, primary, or developmental), a reference to the
language domain, and a noun that indicates we are iden-
tifying a child with a problem. A search on Google
Scholar for each phrase for the period 1994–2013 re-
vealed that 130 of 168 possible combinations had at least
one return. Two additional terms that were counted
were ‘developmental aphasia’ and ‘developmental dys-
phasia’. Terms with more than 600 returns are shown
in table 2. This reveals a massive problem: not only
are there numerous possible terms, but also they can
have different meanings. By far the commonest terms
were ones with no prefix, but their use was not re-
stricted to children with unexplained language prob-
lems. Indeed, the terms, ‘communication delay’ and
‘communication problems’ were widely used to refer
to electronic systems. ‘Communication disorder’ identi-
fied papers on language or communication difficulties of
adults with Parkinson’s disease or acquired aphasia, and
children with Down syndrome. ‘Language needs’ often
referred to second-language learners. It is of concern that
‘language disorder’ is the term used in DSM-5 to refer
390 D. V. M. Bishop
Figure 4. Possible terminology for children with unexplained language problems: 130 of the 168 possible combinations of a prefix, descriptor
and noun were found on a literature search using Google Scholar.
to children with unexplained language problems, yet is
effectively useless in a literature search because it is far
too general.
If we focus just on terms that have a prefix that dis-
tinguishes childhood language problems of unknown
origin, then table 2 shows that the term ‘specific lan-
guage impairment’ is the most commonly used: five
times more common than the next in the list, ‘develop-
mental language disorder’. As noted, however, there are
objections to the label SLI, centring around the word
‘specific’. This implies that the language problems occur
in the context of otherwise typical development and,
this is only rarely the case.
Further confusion surrounds the use of terms such
as ‘speech and language’ or ‘speech/language’, because
they are ambiguous. They could be used to group to-
gether children with speech or language difficulties, or
to refer to those who had problems in both domains.
Indeed, ‘speech’ is a term used with various meanings,
and can include those who have articulatory difficulties
for structural or neurological reasons (e.g., cleft palate
or cerebral palsy), or for cases of ‘speech sound disor-
der’ which are not attributable to sensori-motor causes,
and may be better characterized as language problems
affecting the phonological domain. ‘Communication’ is
another alternative which seems too broad to be useful:
although sometimes used with more specific meanings,
it potentially includes nonverbal communication and
social interaction, as well as language and speech.
Another part of terminology that can be controver-
sial is the third column in figure 4: how problems are
referred to. Should we talk about language impairment,
disorder, disability, difficulties, needs or delay? In prac-
tice, these are often treated as synonyms, yet they have
different connotations and political implications. The
term ‘disability’ was introduced as part of ‘specific learn-
ing disability’ in the United States in the 1960s to refer
to children who had difficulties learning despite being
of normal intellectual capacity. As Waber (2010) noted,
there were legal ramifications in the choice of termi-
nology. ‘Learning disability’ drew parallels with other
disability conditions, and led to provisions being made
in law for federal funding for education and research for
affected children. ‘Disorder’ is widely used in medical
contexts to refer to neurodevelopmental problems of no
known cause, including autistic spectrum disorder and
developmental coordination disorder. ‘Language disor-
der’ is the term used in DSM-5. However, both ‘dis-
ability’ and ‘disorder’ are disliked by some practition-
ers because they are seen as emphasizing abnormality
rather than quantitative differences between children,
and they focus attention on problems within the child.
The acronym LD is also ambiguous, being used for
learning disability (which means intellectual disability in
the UK but specific learning disability in other English-
speaking countries).
The term ‘delay’ is fairly common but highly am-
biguous. A parent who is told that their child’s devel-
opment is delayed might reasonably assume that it will
follow a normal course but at a later age than usual.
‘Language delay’ is indeed sometimes used this way, to
refer to late-talking toddlers who subsequently catch up
with their peer group. However, another use is to draw an
implicit contrast with ‘language disorder’, but agreed cri-
teria for making this distinction do not exist. One view
is that a child with language delay will have language
that in all respects resembles that of a younger, typically
developing child, whereas a child with language disorder
Terminology for children with language problems 391
Table 2. Number of returns for terms with at least 600 returns
on Google Scholar, search date range 1994–2013
Label Number of hits
∗Communication problemsa56 739
∗Communication needs 40 632
∗Language problems 40 427
∗Language difficulties 32 610
∗Communication difficulties 32 530
∗Language needs 21 139
Specific language impairment 18 850
∗Communication delaya17 594
∗Language impairment 16 663
∗Language disorder 16 208
∗Language delay 14 786
∗Communication disorder 7061
∗Communication impairment 4611
∗Language disability 3738
Developmental language disorder 3509
∗Speech and language difficulties 2602
∗Speech and language disorder 2584
∗Speech and language problems 2486
∗Communication disability 2376
Developmental aphasia 2097
∗Speech and language impairment 2081
∗Speech and language delay 1781
Developmental dysphasia 1772
∗Language learning needs 1758
∗Speech/language impairment 1718
∗Language learning difficulties 1595
∗Language learning problems 1328
Developmental language delay 1310
Developmental language impairment 1105
∗Language learning disability 783
∗Speech/language disorder 685
∗Speech, language and communication needs 673
∗Speech/language problems 646
Notes: ∗Counts for these terms after subtracting cases preceded by ‘specific’, ‘primary’
or ‘developmental’, which are counted separately.
aFrequently used to refer to electronics systems.
will have an abnormal profile. Yet in practice, children
who have selective problems with specific components
of language (potentially cases of ‘disorder’) have a better
prognosis than those with a more even depression of
language skills (Bishop and Edmundson 1987), which
seems counterintuitive. And in addition, it is clear that,
at least in the research literature, ‘delay’ is seldom used
with such a distinctive meaning: more often, it is just
another synonym for below-age-level language skills.
The term ‘impairment’ has a clear definition in the
World Health Organization’s (1980) classification of im-
pairments, disabilities and handicaps, but in the context
of children’s language problems it is used with a rather
different meaning. It does not refer to physical impair-
ment, but rather to poor performance on a measure of
language skill. Bishop (2004) suggested that, in con-
trast to ‘disability’, ‘impairment’ can be used without
any implication that there is an impact on functioning
in everyday life. For instance, some children who do
poorly on a test of nonword repetition do not have evi-
dent problems in everyday communication or academic
achievement. Nevertheless, an impairment in nonword
repetition can run in families, and may put the child
at risk for language or literacy problems if it occurs
in combination with other risk factors (Bishop 2006a,
Snowling 2008).
In the UK, ‘needs’ began to be used in educational
contexts after the Warnock Report (Warnock 1978),
which introduced the term ‘special educational needs’
(SEN) to break away from dichotomizing children into
the ‘handicapped’ and everyone else. The report noted
that up to one in five children were likely to require some
form of special educational provision at some point,
and children with language difficulties were explicitly
included in this group. The term ‘needs’ represented a
move away from a focus on deficit—what the child or
young person could not do—to what was required to
provide learning opportunities and support academic
progress. It seems, though, too weak a term to convey
the major, long-term language deficits that affect some
children. Similar criticisms may be made of the terms
‘problems’ and ‘difficulties’: everyone has ‘needs’ and
encounters ‘problems’ and ‘difficulties’ in life, but other
people may feel little obligation to do anything about
this if they are just regarded as normal challenges of
everyday existence.
8. What are the consequences of the lack of
agreed terminology?
In many respects, diagnostic dilemmas in the field of
children’s language problems are similar to those for
other conditions such as reading or attentional difficul-
ties: In all cases, there are questions about the appro-
priateness of a medical model, difficulties in specifying
cut-offs to define disorder, and overlaps between dif-
ferent conditions. However, there is one problem that
is particular to the domain of language, and that con-
cerns the lack of an agreed label. In this regard, SLI
is very different from developmental dyslexia. Just as
with SLI, children with a diagnosis of developmental
dyslexia are quite variable in both the severity and the
profile of their literacy problems, there is no clear di-
viding line between dyslexia and normal variation, the
aetiology is complex and multifactorial, and there is
no good biomarker of the condition. Accordingly, the
label ‘developmental dyslexia’ has been repeatedly at-
tacked over the years by those who have pointed out
how misleading it is in implying that we are dealing
with a homogeneous syndrome with a neurological ba-
sis. This case has been made again with renewed vigour
in a recent review of evidence by Elliott and Grigorenko
(2014). They argue that ‘developmental dyslexia’ has no
392 D. V. M. Bishop
validity, and they make the case that persistent use of
the term does a disservice to other poor readers who
are denied the extra resources and legal protection that
are afforded to those with this label. Nevertheless, the
term is likely to weather this attack, just as it has with-
stood previous assaults (Rutter and Yule 1975, Stanovich
1994). The evidence comes again from bibliometrics,
where one can trace changing terminology used at dif-
ferent points in history. Attempts to introduce alterna-
tive terms such as ‘specific reading retardation’ (Rutter
and Yule 1975), ‘reading disorder’ (American Psychiatric
Association 1994) or ‘language-based learning disabili-
ties’ (American Speech–Language–Hearing Association
n.d.) have been ignored by the majority of people: In the
bibliometric database used by Bishop, the term ‘dyslexia’
accounted for 93% of research papers on children’s read-
ing problems in 1985–89, rising to 99% from 2000 on-
wards. Quite simply, in spite of its poor validity, the term
is a successful meme (Kamhi 2004). One reason for this
success may be that ‘dyslexia’ emphasizes the positive
consequences listed in the second column of table 1,
with some children and young people talking of a sense
of relief at receiving the diagnosis (Ingesson 2007) and
some claiming that dyslexia has positive attributes—but
see Seidenberg (2013).
There is nothing comparable for children with un-
explained language problems. If they are provided with
a label, it will probably be one that most people have not
heard of, and it is unlikely to have any positive connota-
tions. The lack of agreement about terminology means
that many will either misunderstand the condition or
doubt its reality.
The terminological confusion also has a detrimental
effect on research (Bishop 2010). It is very difficult to
assemble information from the research literature be-
cause one must search using multiple different terms,
some of which will capture a large amount of irrelevant
material. Any attempt to apply for research funding is
hampered by the need to first explain to funders what
the condition is that one is researching: it cannot be
assumed that they will have any notion of the nature,
prevalence, personal implications or social impact of
children’s language difficulties. The amount of research
funding, and the number of published papers on unex-
plained language problems is considerably less than one
would predict from knowledge of the frequency and
impact of such problems (Bishop 2010): It seems likely
that lack of agreed terminology plays a significant role
in this deficit.
9. How might we enhance positive
consequences, and avoid negative
consequences, of labelling?
I have argued in favour of an agreed label to refer to chil-
dren with unexplained language problems, but noted
too that there can be unintended negative consequences
of using labels. How can these be averted? First, a child
who receives such a label should automatically qual-
ify for an evaluation by a language specialist—usually a
speech and language therapist—who would aim to iden-
tify barriers to language learning and put intervention
in place to counteract or compensate for these. Note the
mention of compensation: there are rather few kinds
of language intervention that have been validated as ef-
fective in clinical trials for improving serious language
deficits, especially those involving comprehension (Law
et al. 2004). This does not mean that we should stop try-
ing to develop interventions, but it does imply that one
role of the therapist will be to work with children and
their teachers to develop effective strategies for coping
with problems and accommodating to them. The sec-
ond recommendation is more radical: it is that any child
identified with unexplained language problems should
also undergo an evaluation to identify areas of strength:
activities they enjoy and have the possibility of succeed-
ing at. These could, for instance, involve sports, art,
cookery, graphic design, horticulture, working with ani-
mals or music. Realistically, we would not expect all chil-
dren to have hidden talents, but we should move from
a frame of mind that is solely focused on deficits, and
attempting to ‘fix’ these so the child can gain academic
credentials. We have ample evidence that most children
with language learning impairments (LLIs) have dif-
ficulties that persist into adolescence (Conti-Ramsden
and Durkin 2008, Stothard et al. 1998) and beyond
(Clegg et al. 2005, Johnson et al. 2010, Whitehouse
et al. 2009a). We should therefore be thinking more
about how to enable children to be successful citizens,
and this may require us to move away from narrowly
conceived academic ideas of success.
10. What terminology should we adopt?
I have argued that we need an agreed terminology to de-
scribe children whose language is well behind age level
for no obvious reason. As Tomblin (2008: 95) put it:
‘language disorder represents a situation in which the
child is unlikely to be able to meet the socially defined
functional expectations either currently or in the future
because of his or her current or future language abili-
ties’. We know that when language problems persist into
school age, the outcomes for children are usually poor.
While they may benefit from school-based programmes
designed to foster language development in all children
(Law et al. 2013), this is unlikely to be sufficient to
overcome the academic and social difficulties that en-
sue when language expression and/or comprehension
are well behind that of the peer group.
Labels can have negative consequences, but the con-
sequences of avoiding labels can be worse. Without
agreed criteria for identifying children in need of addi-
tional help, and without agreed labels for talking about
Terminology for children with language problems 393
them, we cannot improve our understanding of why
some children fail, or evaluate the efficacy of attempts
to help them. The fact that language difficulties do not
constitute a specific syndrome is not a sufficient reason
to abandon labels.
The current situation, with myriad different defi-
nitions and labels, is unsustainable. Having an uncon-
strained set of descriptive terms is just as bad as having no
labels at all. It hinders communication, prevents cumu-
lative research, and introduces ambiguity into decisions
about who merits intervention—ambiguity that can eas-
ily be exploited when it is politically expedient to do so.
Although I have argued that the purpose of diagnosis
will determine the ideal diagnostic system, there needs
to be contact between different approaches: those work-
ing in education, in speech–language therapy and in
research need to have a common vocabulary that allows
information to be exchanged between these disciplines.
One point that is often overlooked when devising
classification systems is the importance of having a label
that is a good term for use with internet search engines.
In this regard, general terms, such as ‘language disorder’
are too nonspecific to be useful; although they can be
applied to unexplained language problems, they are also
used descriptively for adults as well as children with a
wide range of aetiologies. The term ‘speech, language
and communication needs’ (SLCN), which is widely
used in the UK in educational contexts, is also too gen-
eral, as it includes both speech and language difficulties,
and fails to distinguish unexplained language problems
from those that can be attributed to a known cause.
While there may be situations when it is not necessary
to distinguish problems by type or by aetiology, very
often this distinction is of practical importance in edu-
cation, as well as being crucial for research.
Of the less general terms in current use, SLI is by
far the most common in academic settings, though it is
less widely used in clinical and educational practice in
the UK. A case could be made for retaining this term,
to maintain continuity with the past. It has, however,
one drawback, which is that the ‘specific’ part of the
label has been criticized for being too exclusive. If we
take ‘specific’ to mean that the child (1) has a substantial
discrepancy between language and nonverbal ability and
(2) has no other neurodevelopmental difficulties, then a
vanishingly small proportion of language-impaired chil-
dren would be included as cases of SLI. In practice, the
criteria have loosened over the years, and it is no longer
common to interpret SLI as requiring a large mismatch
between verbal and nonverbal skills: rather children are
included if they have notable language difficulties in
the context of broadly normal-range nonverbal ability—
usually interpreted as having a nonverbal IQ of at least
80 (though some use other cut-offs, ranging from 70 to
85) (Tomblin et al. 1996). Furthermore, the presence
of other conditions such as dyslexia, ADHD, or DCD
would not usually be regarded as precluding the diagno-
sis of SLI. So we could just agree to keep the term SLI,
but to adopt laxer criteria that did not specify an ab-
sence of other neurodevelopmental problems, and that
require only that nonverbal IQ should be broadly within
normal limits. This corresponds to usage by the Amer-
ican Speech–Language–Hearing Association (2008). In
addition, we might want to restrict the use of SLI to
children who have a functional impairment affecting
everyday communication, social interaction, behaviour,
and/or academic attainment.
We also need to reach agreement about a common
set of language components that should be included
in a language assessment for SLI. In clinical practice,
the choice of measures can be quite arbitrary, but is
of potential importance: it could, for instance, deter-
mine whether children meeting DSM-5 criteria for so-
cial communication disorder are included or not. One
approach would be to include those aspects of language
that reliably have emerged as good ‘markers’ of SLI
(Bishop 2004, Conti-Ramsden 2003, Redmond et al.
2011). These mainly involve aspects of language struc-
ture and verbal memory, rather than language content
or use.
SLI is not, however, the only terminological option
open to us. An alternative term that would be precise
enough to be useful, without having unwanted con-
notations of specificity is primary language impairment
(PLI). This term is not in widespread circulation—it had
only 362 returns on my Google Scholar search—but it
has been used in two contexts: first, when identifying
language impairments that are not accounted for by
bilingualism (Kohnert 2010) and second as a more in-
clusive term to refer to language difficulties that are not
secondary to another condition, without requiring a dis-
crepancy with nonverbal ability (Boyle et al. 2007). One
drawback is that the acronym PLI has potential for con-
fusion with ‘pragmatic language impairment’ (Bishop
2000), though it could be argued that this is not impor-
tant, given that ‘pragmatic language impairment’ was
never part of any official diagnostic framework, and
DSM-5 has now coined ‘social communication disor-
der’ which covers the same territory.
Another option would be to revert to a term such
as ‘developmental language disorder’, which was more
commonly used some 20–30 years ago. As noted above,
‘disorder’ is disliked by some because it has medical over-
tones and implies qualitative rather than quantitative
differences between children. ‘Developmental language
impairment’ would be another possibility, which is al-
ready in circulation (table 2).
Finally, another option would be the term ‘language
learning impairment’ (LLI). Like PLI or developmental
language disorder, this avoids confusion with more gen-
eral language problems from known aetiologies, without
implying that the language problems occur in isolation.
394 D. V. M. Bishop
It also emphasizes that this is a kind of learning difficulty,
rather than reflecting a lack of progress due to inade-
quate stimulation. This is the term that we settled upon
when considering how to refer to unexpected language
difficulties in an internet campaign to raise awareness:
Raising Awareness of Language Learning Impairments
(RALLI) (Bishop et al. 2012). However, only time will
tell whether it becomes more widely accepted, or joins
the long list of possible labels that serve only to add
to confusion in this field. Changing a label should not
be undertaken lightly, as it can break links with previ-
ous knowledge: this is why in the RALLI campaign we
still use ‘specific language impairment’ in many of our
videos, as this is a better-known label, and more likely
to be used as a search term. Only by having discussions
with a wide range of stakeholders can we hope to reach
a consensus on terminology.
Many of the points made by Frances (2013) in his
DSM-5 critique would apply equally to our delibera-
tions about a label such as SLI. We should heed his
warnings about unintended consequences of diagnos-
tic inflation and medicalization of normality. But we
should note too his comments about the importance
of diagnostic labels for those whose problems are severe,
clear-cut, and unlikely to go away on their own. We must
accept that we will never have an ideal nomenclature,
suitable for all purposes: As Frances noted, diagnosis has
a necessary place in every evaluation, but never tells the
whole story. We must not reify our labels, but recognize
they are a collection of ‘temporarily useful diagnostic
constructs, not a catalogue of “real” diseases’ (Frances
2013: 73).
Acknowledgements
The author is most grateful to Becky Clark, Kate Nation and Caro-
line Bowen for insightful comments on an earlier draft of this paper.
This research was supported by a Wellcome Trust Principal Research
Fellowship and programme (Grant Number 082498/Z/07/Z). Dec-
laration of interest: The author reports no conflicts of interest. The
author alone is responsible for the content and writing of the paper.
References
AMERICAN PSYCHIATRIC ASSOCIATION, 1994, Diagnostic and Statis-
tical Manual of Mental Disorders, 4th Edition (Washington,
DC: American Psychiatric Association).
AMERICAN PSYCHIATRIC ASSOCIATION, 2013, Diagnostic and Statisti-
cal Manual of Mental Disorders (5th ed.): DSM-5 (Arlington,
VA: American Psychiatric Publ.).
AMERICAN SPEECH–LANGUAGE–HEARING ASSOCIATION, 2008, Inci-
dence and Prevalence of Communication Disorders and Hear-
ing Loss in Children—2008 Edition (available at: http://
www.asha.org/research/reports/children.htm).
AMERICAN SPEECH–LANGUAGE–HEARING ASSOCIATION, n.d.,
Language-Based Learning Disabilities (available at: http://
www.asha.org/public/speech/disorders/lbld.htm).
BARRY,J.G.,YASIN,I.andBISHOP, D. V. M., 2007, Heritable risk
factors associated with language impairments. Genes, Brain
and Behavior,6, 66–76.
BISHOP, D. V. M., 1983, Comprehension of English syntax by pro-
foundly deaf children. Journal of Child Psychology and Psychi-
atry,24, 415–434.
BISHOP, D. V. M., 1994, Is specific language impairment a valid
diagnostic category? Genetic and psycholinguistic evidence.
Philosophical Transactions of the Royal Society, Series B,346,
105–111.
BISHOP, D. V. M., 2000, Pragmatic language impairment: a corre-
late of SLI, a distinct subgroup, or part of the autistic con-
tinuum? In D. V. M. Bishop and L. B. Leonard (eds), Speech
and Language Impairments in Children: Causes, Characteris-
tics, Intervention and Outcome (Hove: Psychology Press), pp.
99–113.
BISHOP, D. V. M., 2004, Specific language impairment: diagnostic
dilemmas. In L Verhoeven and H. van Balkom (eds), Clas-
sification of Developmental Language Disorders (Mahwah, NJ:
Erlbaum), pp. 309–326.
BISHOP, D. V. M., 2006a, Developmental cognitive genetics: how
psychology can inform genetics and vice versa. Quarterly Jour-
nal of Experimental Psychology,59, 1153–1168.
BISHOP, D. V. M., 2006b, What causes specific language impairment
in children? Current Directions in Psychological Science,15,
217–221.
BISHOP, D. V. M., 2009, Genes, cognition and communication: in-
sights from neurodevelopmental disorders. The Year in Cogni-
tive Neuroscience: Annals of the New York Academy of Sciences,
1156, 1–18.
BISHOP, D. V. M., 2010, Which neurodevelopmental disorders get
researched and why? PLOS One,5, e15112.
BISHOP, D. V. M., 2013, Problems with tense-marking in children
with specific language impairment (SLI): not how but when.
Philosophical Transactions of the Royal Society B: Biological Sci-
ences,369, 20120401.
BISHOP,D.V.M.,CLARK,B.,CONTI-RAMSDEN,G.,NORBURY,C.
F. a n d S NOWLING, M. J., 2012, RALLI: an internet campaign
for raising awareness of language learning impairments. Child
Language Teaching and Therapy,28, 259–262.
BISHOP,D.V.M.andEDMUNDSON, A., 1987, Language-impaired
four-year-olds: distinguishing transient from persistent im-
pairment. Journal of Speech and Hearing Disorders,52, 156–
173.
BISHOP,D.V.M.andHAY IOU-THOMAS, M. E., 2008, Heritability of
specific language impairment depends on diagnostic criteria.
Genes, Brain and Behavior,7, 365–372.
BISHOP,D.V.M.andMCDONALD, D., 2009, Identifying language
impairment in children: combining language test scores with
parental report. International Journal of Language and Com-
munication Disorders,44, 600–615.
BISHOP,D.V.M.,NORTH,T.andDONLAN, C., 1995, Genetic basis
of specific language impairment: evidence from a twin study.
Developmental Medicine and Child Neurology,37, 56–71.
BISHOP, D. and RUTTER, M., 2008, Neurodevelopmental disorders:
conceptual issues. In M. Rutter, D. Bishop, D. Pine, S. Scott,
J. Stevenson, E. Taylor and A. Thapar (eds), Rutter’s Child
and Adolescent Psychiatry (Oxford: Blackwell), pp. 32–41.
BISHOP,D.V.M.andSCERIF, G., 2011, Klinefelter syndrome as
a window on the etiology of language and communication
impairments in children. Acta Paediatrica,100, 903–907.
BISHOP,D.V.M.andSNOWLING, M. J., 2004, Developmental
dyslexia and specific language impairment: same or different?
Psychological Bulletin,130, 858–886.
BOYLE,J.,MCCARTNEY,E.,FORBES, J. and O’HARE, A., 2007, A
randomised controlled trial and economic evaluation of direct
versus indirect and individual versus group modes of speech
and language therapy for children with primary language
impairment. Health Technology Assessment,11, iii–iv, xi.
Terminology for children with language problems 395
CLEGG,J.,HOLLIS,C.,MAW HO O D ,L.andRUTTER, M., 2005,
Developmental language disorders—a follow-up in later life.
Cognitive, language and psychosocial outcomes. Journal of
Child Psychology and Psychiatry,46, 128–149.
COHEN,N.J.,MENNA,R.,VALLANCE, D. D., BARWICK,M.A.,IM,
N. and HORODEZKY, N. B., 1998, Language, social cognitive
processing, and behavioral characteristics of psychiatrically
disturbed children with previously identified and unsuspected
language impairments. Journal of Child Psychology and Psychi-
atry,39, 853–864.
COLE,K.N.andFEY, M. E., 1997, Cognitive referencing in language
assessment. In K. N. Cole, P. S. Dale and D. J. Thal (eds),
Assessment of Communication and Language (Baltimore, MD:
Paul H. Brookes), pp. 143–160.
CONTI-RAMSDEN, G., 2003, Processing and linguistic markers in
young children with specific language impairment. Journal of
Speech, Language and Hearing Research,46, 1029–1037.
CONTI-RAMSDEN,G.,BOTTING, N. and FARAGHER, B., 2001, Psy-
cholinguistic markers for specific language impairment (SLI).
Journal of Child Psychology and Psychiatry,42, 741–748.
CONTI-RAMSDEN,G.andDURKIN, K., 2008, Language and inde-
pendence in adolescents with and without a history of specific
language impairment (SLI). Journal of Speech, Language and
Hearing Research,51, 70–83.
CONTI-RAMSDEN,G.,MOK,P.L.H.,PICKLES, A. and DURKIN,K.,
2013, Adolescents with a history of specific language impair-
ment (SLI): strengths and difficulties in social, emotional and
behavioral functioning. Research in Developmental Disabilities,
34, 4161–4169.
DEVASCONCELOS HAGE,S.R.,CENDES,F.,MONTENEGRO,M.
A., ABRAMIDES,D.V.,GUIMAR˜
AES,C.A.andGUERREIRO,
M. M., 2006, Specific language impairment: linguistic and
neurobiological aspects. Arquivos de Neuro-Psiquiatria,64,
173–180.
DURKIN,K.,CONTI-RAMSDEN, G. and SIMKIN, Z., 2012, Functional
outcomes of adolescents with a history of specific language
impairment (SLI) with and without autistic symptomatology.
Journal of Autism and Developmental Disorders,42, 123–138.
DYCK,M.J.,PIEK,J.P.andPATRI CK, J., 2011, The validity of psychi-
atric diagnoses: the case of ‘specific’ developmental disorders.
Research in Developmental Disabilities,32, 2704–2713.
ELLIOTT,J.G.andGRIGORENKO, E. L., 2014, The Dyslexia Debate
(Cambridge: Cambridge University Press).
FLETCHER, J. M., 1992, The validity of distinguishing children with
language and learning disabilities according to discrepancies
with IQ. Journal of Learning Disabilities,25, 546–548.
FRANCES, A., 2013, Saving Normal: An Insider’s Revolt against Out-
of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and
the Medicalization of Ordinary Life (New York, NY: Harper-
Collins).
GOTTESMAN,I.I.andGOULD, T. D., 2003, The endophenotype
concept in psychiatry: etymology and strategic intentions.
American Journal of Psychiatry,160, 636–645.
GRAF ESTES,K.,EVANS ,J.L.andELSE-QUEST, N. M., 2007, Differ-
ences in the nonword repetition performance of children with
and without specific language impairment: a meta-analysis.
Journal of Speech, Language and Hearing Research,50, 177–
195.
GRAHAM,S.A.andFISHER, S. E., 2013, Decoding the genetics of
speech and language. Current Opinion in Neurobiology,23,
43–51.
HAWKER,K.,RAMIREZ-INSCOE,J.,BISHOP,D.V.M.,TWOMEY,T.,
O’DONOGHUE,G.M.andMOORE, D. R., 2008, Dispropor-
tionate language impairment in some children using cochlear
implants. Ear and Hearing,29, 467–471.
HILL, E. L., 2001, Non-specific nature of specific language impair-
ment: a review of the literature with regard to concomitant
motor impairments. International Journal of Language and
Communication Disorders,36, 149–171.
HYMAN, S. E., 2010, The diagnosis of mental disorders: the problem
of reification. Annual Review of Clinical Psychology,6, 155–
179.
INGESSON, S. G., 2007, Growing up with dyslexia: interviews with
teenagers and young adults. School Psychology International,
28, 574–591.
JOHNSON,C.J.,BEITCHMAN,J.H.andBROWNLIE, E. B., 2010,
Twenty-year follow-up of children with and without speech–
language impairments: family, educational, occupational, and
quality of life outcomes. American Journal of Speech–Language
Pathology,19, 51–65.
KAMHI, A. G., 2004, A meme’s eye view of speech–language pathol-
ogy. Language, Speech and Hearing Services in Schools,35,
105–111.
KOHNERT, K., 2010, Bilingual children with primary language im-
pairment: issues, evidence and implications for clinical ac-
tions. Journal of Communication Disorders,43, 456–473.
LAUCHLAN, F. and BOY LE, C., 2007, Is the use of labels in special
education helpful? Support for Learning,22, 36–42.
LAW,J.,GARRETT, Z. and NYE, C., 2004, The efficacy of treat-
ment for children with developmental speech and language
delay/disorder: a meta-analysis. Journal of Speech, Language,
and Hearing Research,47, 924–943.
LAW,J.,MCBEAN, K. and RUSH, R., 2011, Communication skills
in a population of primary school-aged children raised in an
area of pronounced social disadvantage. International Journal
of Language and Communication Disorders,46, 657–664.
LAW,J.,REILLY, S. and SNOW, P. C., 2013, Child speech, language
and communication need re-examined in a public health con-
text: a new direction for the speech and language therapy pro-
fession. International Journal of Language and Communication
Disorders,48, 486–496.
LAW,J.,RUSH,R.,SCHOON,I.andPARSONS, S., 2009, Model-
ing developmental language difficulties from school entry
into adulthood: literacy, mental health, and employment out-
comes. Journal of Speech, Language and Hearing Research,52,
1401–1416.
LAWS , G. and BISHOP, D. V. M., 2004, Verbal deficits in Down’s
syndrome and specific language impairment: a comparison.
International Journal of Language and Communication Disor-
ders,39, 423–451.
LEFFEL, K. and SUSKIND, D., 2013, Parent-directed approaches to
enrich the early language environments of children living in
poverty. Seminars in Speech and Language,34, 267–277.
LEONARD,C.M.,MARON,L.,BENGTSON,M.,KULDAU,J.M.,
RICCIUTI, N., MAHONEY,B.andDEBOSE, C., 2008, Identical
neural risk factors predict cognitive deficit in dyslexia and
schizophrenia. Neuropsychology,22, 147–158.
LEPP¨
ANEN,P.H.T.,LYYTINEN,H.,CHOUDHURY, N. and BENASICH,
A., 2004, Neuroimaging measures in the study of specific lan-
guage impairment. In L. Verhoeven and H. van Balkom (eds),
Classification of Developmental Language Disorders (Mahwah,
NJ: Erlbaum), pp. 99–136.
LETTS,C.,EDWARDS,S.,SINKA,I.,SCHAEFER,B.andGIBBONS,
W., 2013, Socio-economic status and language acquisition:
children’s performance on the new Reynell Developmental
Language Scales. International Journal of Language and Com-
munication Disorders,48, 131–143.
LEWIS,B.A.,SHRIBERG, L. D., FREEBAIRN,L.A.,HANSEN,A.J.,
STEIN,C.M.,TAYL OR ,H.G.andIYENGAR, S. K., 2006,
The genetic bases of speech sound disorders: Evidence from
396 D. V. M. Bishop
spoken and written language. Journal of Speech, Language and
Hearing Research,49, 1294–1312.
LINDGREN,K.A.,FOLSTEIN,S.E.,TOMBLIN,J.B.andTAGER-
FLUSBERG, H., 2009, Language and reading abilities of chil-
dren with autism spectrum disorders and specific language
impairment and their first-degree relatives. Autism Research,
2, 22–38.
LUM,J.A.G.,CONTI-RAMSDEN,G.M.,MORGAN,A.T.andULL-
MAN, M. T., 2013, Procedural learning deficits in specific
language impairment (SLI): a meta-analysis of serial reaction
time task performance. Cortex,51, 1–10.
LYYTINEN,P.,EKLUND, K. and LYYTINEN, H., 2005, Language de-
velopment and literacy skills in late-talking toddlers with and
without familial risk for dyslexia. Annals of dyslexia,55, 166–
192.
MASON,K.,ROWLEY,K.,MARSHALL,C.R.,ATKINSON,J.R.,HER-
MAN,R.,WOLL, B. and MORGAN, G., 2010, Identifying spe-
cific language impairment in deaf children acquiring British
Sign Language: implications for theory and practice. British
Journal of Developmental Psychology,28, 33–49.
NEWBURY,D.F.,PARACCHINI,S.,SCERRI,T.S.,WINCHESTER,L.,
ADDIS,L.,RICHARDSON,A.J.,WALTER,J.,STEIN,J.F.,TAL-
COTT,J.B.andMONACO, A. P., 2011, Investigation of dyslexia
and SLI risk variants in reading- and language-impaired sub-
jects. Behavior Genetics,41, 90–104.
NORBURY, C. F., 2014, Practitioner review: Social (pragmatic) com-
munication disorder conceptualization, evidence and clinical
implications. Journal of Child Psychology and Psychiatry,55,
204–216.
OFFICE FOR STAN DA RD S IN EDUCATION,CHILDREN’SSERVICES AND
SKILLS, 2010, The Special Educational Needs and Disability
Review: A Statement is Not Enough (Manchester: Office for
Standards in Education, Children’s Services and Skills).
PARSONS,S.,SCHOON,I.,RUSH, R. and LAW, J., 2011, Long-term
outcomes for children with early language problems: beating
the odds. Children and Society,25, 202–214.
PICKSTONE,C.,GOLDBART,J.,MARSHALL,J.,REES, A. and ROUL-
STONE, S., 2009, A systematic review of environmental in-
terventions to improve child language outcomes for children
with or at risk of primary language impairment. Journal of
Research in Special Educational Needs,9, 66–79.
RAMIREZ-INSCOE,J.andMOORE, D. R., 2011, Processes that
influence communicative impairments in deaf children
using cochlear implants. Ear and Hearing,32, 690–
698.
REDMOND,S.M.,THOMPSON,H.L.andGOLDSTEIN, S., 2011,
Psycholinguistic profiling differentiates specific language im-
pairment from typical development and from attention-
deficit/hyperactivity disorder. Journal of Speech, Language and
Hearing Research,54, 99–117.
REILLY,S.,WAKE,M.,UKOUMUNNE,O.C.,BAVIN ,E.,PRIOR,M.,
CINI,E.,CONWAY,L.,EADIE,P.andBRETHERTON, L., 2010,
Predicting language outcomes at 4 years of age: findings from
Early Language in Victoria Study. Pediatrics,126, E1530–
E1537.
RICE, M. L., 2000, Grammatical symptoms of specific language im-
pairment. In D. V. M. Bishop and L. B. Leonard (eds), Speech
and Language Impairments in Children: Causes, Characteris-
tics, Intervention and Outcome (Hove: Psychology Press), pp.
17–34.
ROY, P. and CHIAT, S., 2013, Teasing apart disadvantage from dis-
order: the case of poor language. In C. R. Marshall (ed.),
Current Issues in Developmental Disorders (Hove: Psychology
Press), pp. 125–150.
RUTTER, M. and YULE, W., 1975, The concept of specific reading
retardation. Journal of Child Psychology and Psychiatry,16,
181–197.
SCHOON,I.,PARSONS,S.,RUSH, R. and LAW , J., 2010, Childhood
language skills and adult literacy: a 29-year follow-up study.
Pediatrics,125, E459–E466.
SEIDENBERG, M., 2013, The Gladwell Pivot (available at:
http://languagelog.ldc.upenn.edu/nll/?p=8123) (accessed on
24 November 2013).
SNOWLING, M. J., 2008, Specific disorders and broader phenotypes;
the case of dyslexia. In D. V. M. Bishop, M. J. Snowling and
S.-J. Blakemore (eds), Neurocognitive Approaches to Develop-
mental Disorders: A Festschrift for Uta Frith (Hove: Psychology
Press), pp. 142–156.
SNOWLING,M.J.,BISHOP,D.V.M.,STOT HARD,S.E.,CHIPCHASE,
B. and KAPLAN, C., 2006, Psychosocial outcomes at 15 years
of children with a preschool history of speech–language im-
pairment. Journal of Child Psychology and Psychiatry,47, 759–
765.
SNOWLING, M. J. and HULME, C., 2012, Annual Research Review:
The nature and classification of reading disorders—a com-
mentary on proposals for DSM-5. Journal of Child Psychology
and Psychiatry,53, 593–607.
STANOVICH, K. E., 1994, Annotation: does dyslexia exist? Journal of
Child Psychology and Psychiatry,35, 579–595.
STOTHAR D,S.E.,SNOWLING,M.J.,BISHOP,D.V.M.,CHIPCHASE,
B. B. and KAPLAN, C. A., 1998, Language impaired preschool-
ers: a follow-up into adolescence. Journal of Speech, Language
and Hearing Research,41, 407–418.
TAGER-FLUSBERG,H.andCARONNA, E., 2007, Language disorders:
autism and other pervasive developmental disorders. Pediatric
Clinics of North America,54, 469–481.
TAYLOR , E. and RUTTER, M. L., 2008, Classification. In M. Rutter,
D.Bishop,D.Pine,S.Scott,J.Stevenson,E.TaylorandA.
Thapar (eds), Rutter’s Child and Adolescent Psychiatry (Oxford:
Blackwell), pp. 18–41.
TOMBLIN, J. B., 2008, Validating diagnostic standards for SLI using
adolescent outcomes. In C. F. Norbury, J. B. Tomblin and D.
V. M. Bishop (eds), Understanding Developmental Language
Disorders (Hove: Psychology Press), 93–114.
TOMBLIN,J.B.,RECORDS, N. and ZHANG, X., 1996, A system for
the diagnosis of specific language impairment in kindergarten
children. Journal of Speech and Hearing Research,39, 1284–
1294.
TOMBLIN,J.B.,RECORDS,N.L.,BUCKWALTER,P.,ZHANG,X.,
SMITH, E. and O’BRIEN, M., 1997, Prevalence of specific lan-
guage impairment in kindergarten children. Journal of Speech
and Hearing Research,40, 1245–1260.
TOMBLIN,J.B.,ZHANG,X.,BUCKWALTER, P. and O’BRIEN,M.,
2003, The stability of primary language disorder: four years
after kindergarten diagnosis. Journal of Speech, Language and
Hearing Research,46, 1283–1296.
WABER, D. P., 2010, Rethinking Learning Disabilities: Understanding
Children who Struggle in School (New York, NY: Guilford).
WARNOCK, H. M., 1978, Special Educational Needs: Report of the
Committee of Enquiry into the Education of Handicapped Chil-
dren and Young People (London: HMSO).
WASHINGTON,K.N.,WARR-LEEPER, G. and THOMAS-STON ELL,N.,
2011, Exploring the outcomes of a novel computer-assisted
treatment program targeting expressive-grammar deficits in
preschoolers with SLI. Journal of Communication Disorders,
44, 315–330.
WHITEHOUSE,A.J.O.,LINE,E.A.,WATT ,H.J.andBISHOP,D.
V. M., 2009a, Qualitative aspects of developmental language
impairment relates to language and literacy outcome in adult-
hood. International Journal of Language and Communication
Disorders,44, 489–510.
WHITEHOUSE,A.J.O.,WATT ,H.J.,LINE,E.A.andBISHOP,
D. V. M., 2009b, Adult psychosocial outcomes of chil-
dren with specific language impairment, pragmatic language
Commentary 397
impairment and autism. International Journal of Language and
Communication Disorders,44, 511–528.
WORLD HEALTH ORGANIZATION, 1980, International Classification
of Impairments, Disabilities, and Handicaps (Geneva: World
Health Organization).
WORLD HEALTH ORGANIZATION, 1992, The ICD-10 Classifica-
tion for Mental and Behavioural Disorders: Clinical De-
scriptions and Diagnostic Guidelines (Geneva: World Health
Organization).
ZAMBRANA,I.M.,PONS,F.,EADIE,P.andYSTROM, E., 2014, Trajec-
tories of language delay from age 3 to 5: persistence, recovery
and late onset. International Journal of Language and Commu-
nication Disorders,49, 304–316.
How to cite Commentary articles
Please use the following style:
Baird G., 2014, Lumping, splitting, drawing lines, statistical cutoffs and impairment. Commentary on Bishop,
D.V.M., 2014, Ten questions about terminology for children with unexplained language problems. International
Journal of Language and Communication Disorders,49, 381–415. doi: 10.1111/1460-6984.12101
Commentary
Lumping, splitting, drawing lines, statistical cut-offs and impairment: a com-
mentary on ‘Ten questions about terminology for children with unexplained
language problems’
Gillian Baird
Professor of Paediatric Neurodisability and Consultant Paediatrician, Guy’s & St Thomas NHS Foundation Trust and King’s
Health Partners, London, UK
Abstract
There is an agreed need for some classification system of language problems, but the varying views about inclu-
sion/exclusion criteria, the lack of biomarkers and the similar problems affecting all neurodevelopmental disorders
are explored.
Main text
There have long been debates about whether some chil-
dren learn language differently or are simply at the lower
end of a normal continuum of language development
(Leonard 1991). Much research has suggested that there
is a group of children who have a real problem in learn-
ing language and that this is lifelong, that the effects
are initially on understanding and speaking language,
and subsequently on reading and understanding writ-
ten language. Persistent deficits have been shown in as-
pects of language processing, such as non-word repeti-
tion and reading non-words, leading to suggestions that
such skills are markers for language learning and reading
problems.
The hypothesis of a developmental learning disorder
affecting language is recognized in the current classifica-
tion systems (ICD and DSM) alongside similar learning
difficulties in motor coordination, attentional develop-
ment and academic skills. For each of these the same
debate has occurred over whether these disorders repre-
sent the extreme end of a normal continuum or a specific
learning impairment which is different and can be sep-
arated by specific tests. Therein lies the difficulty—an
absence of specific tests that clearly differentiate a dis-
order from a normal continuum. In all these develop-
mental areas it becomes a matter of clinical judgement
about where ‘lines’ are drawn. However, this problem
is not confined to neurodevelopmental disorders and is
much the same in measures of physiology such as high
blood pressure, a topic in which debate over what is nor-
mal and what is a case needing intervention is equally
vigorous. As Bishop points out, many of the disorders
are multifactorial in aetiology. The problem with clas-
sification systems is that they impose categories upon
dimensions and in the absence of biomarkers are based
on surface features of behaviour, which include measures
that are standardized, norm-based, etc. Bishop draws at-
tention to the limitations of a statistical approach to
defining language problems (favoured by Reilly et al.
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online C2014 Royal College of Speech and Language Therapists
DOI: 10.1111/1460-6984.12101
398 Commentary
2014) and also the likely inconsistency of using im-
pairment (or concern by teacher or parent) alone as a
defining feature. What is lacking are agreed inclusion
criteria.
Professor Bishop has been at the forefront of research
into language disorders, the reasons for them and the
links with literacy, and thereby has contributed to our
understanding of both the immediate and long-term
problems that are experienced by children and young
people with language-learning difficulties. As always,
she writes lucidly. The opening vignette summarizes the
dilemma for the individual child and also the perspec-
tives of those from various services inevitably involved,
whether it be speech and language, other members of
the health service, the education service, and parents
struggling to understand what the problem is with their
child.
The fourth section, in which Bishop outlines the cri-
teria for identifying children with language problems, is
particularly helpful, highlighting the difficulties of dif-
ferentiating from typical development, the problems of
using cognitive ability as separating those with language
impairments from those with additional learning prob-
lems; whether or not genetic syndromes should be ex-
cluded and, very importantly, the influence of language
environment and/or social deprivation on language de-
velopment. Bishop makes a very good case for her own
view that genetic risk factors play a far larger part than
is generally understood by those writing about social
deprivation.
IamgladthatBishopgoesontodefendtheuse
of diagnostic classification and hence ‘labels’. The diag-
nostic approach has been criticized as over-medicalizing
normal variation or for placing a problem within the
person rather than society.
However, at its best it prompts a problem-based ap-
proach that leads the parent and then the professional
to seek an answer to the question: ‘Why has my child
got this problem? Is there a treatable cause?’. A classi-
fication system should have clinical, public health and
research utility. It provides a language for communi-
cation with the individual and parents/carers/families
and with others (health, education etc.) who will be
responding to that individual’s problems. It provides a
framework for research and access to specific evidence-
based treatments. As Bishop emphasizes in her second
section, identifying specific deficits, evaluating inter-
ventions and giving parents a prognosis are all help-
ful correlates of taking a diagnostic classification based
approach.
One danger, of course, of classification systems is
that labels are reified and both clinicians and researchers
stop thinking about whether this is the best way of
classifying a problem. Researchers need continually to
challenge the existing categories and definitions. An ob-
vious example is the change from DSM-IV to DSM-5 in
autism spectrum disorders where subgrouping into atyp-
ical autism, Asperger’s syndrome etc. was found not to be
consistently applied. There were no really clear distinc-
tions between the subgroups that met critical evaluation,
there were no genetic factors distinguishing subgroups.
They have now been abandoned in DSM-5 and included
under the more general title of autism spectrum disor-
ders, a lumping rather than a splitting approach. This
does not mean that a splitting approach may not be-
come appropriate again, but on a different basis rather
than the current DSM-IV and ICD-10 one. Reilly et
al. (2014), I think, seek to do the same with language
impairment.
Bishop’s views about the ‘label’ used for those with
language-learning problems are particularly pertinent to
current discussions, especially her strictures about the
DSM-5 label of language disorder and the need for a
‘searchable’ term. There are many problems with the
term ‘specific’ which she (and Reilly et al.) outline, par-
ticularly given the increasing recognition of coexistence
with other developmental disorders and the fact that us-
ing a non-verbal reference point is increasingly regarded
as not helpful. ‘Disorder’ is the term used throughout
DSM and ICD for conditions without obvious aeti-
ology and is intended to separate any condition from
its functional effect as described separately in the In-
ternational Classification of Function, Disability and
Health.
In conclusion, the elusive goal in language-learning
problems, as in other developmental conditions, re-
mains finding underlying neurobiological factors with
the aim of selecting those who need particular inter-
ventions and compensatory strategies, rather than mea-
suring surface features and arguing about statistical cut-
offs. The biomarkers proposed have not been clearly
tested in population samples. Language learning is het-
erogeneous, so one marker such as non-word repetition
may be too simplistic and has, in any case, been more
strongly linked to reading decoding with language im-
pairment rather than being universally impaired in those
with language-learning impairments. Agreed inclusion
criteria for developmental language disorder recogniz-
ing heterogeneity and potential subgroups, rather than
exclusion criteria, would help the clinical and research
community. In the absence of biomarkers and underly-
ing process impairment markers, the child that a parent
or a teacher is concerned about is, as Bishop points out,
as important to pay attention to as the child who fails
test scores.
Gillian Baird was a member of the DSM-5 Neu-
rodevelopmental Work Group and is a member of
the ICD-11 Neurodevelopmental Work Group; e-mail:
gillian.baird@gstt.nhs.uk.
Commentary 399
To label or not to label: is this the question?
Fraser Lauchlan∗and Christopher Boyle†
∗University of Strathclyde, Glasgow, UK
†University of New England, Armidale, NSW, Australia
Abstract
We consider whether the use of labels is an inevitable consequence of the world of limited and finite resources in
which we live and work, or whether there could be other positive reasons for using labels. We argue that it may be
more worthwhile expending time and energy on intervention for children with language difficulties rather than
on the diagnosis itself.
Main text
Seven years ago, while working as educational psychol-
ogists (EPs) for a local education authority in Scotland,
we wrote a paper on the advantages and disadvantages
of labelling (Lauchlan and Boyle 2007). We did not
expect the level of interest that would result, not only
amongst the academic and professional community, but
also in the media (Times Educational Supplement (TES)
2007). Seven years on, the labelling debate is still rife and
we have been invited to comment on Dorothy Bishop’s
paper which outlines the arguments for the use of dif-
ferent terminology (or labels) for children who have
unexplained language problems.
We tend to agree with Bishop’s comments that the
removal of labels could unfortunately lead to the removal
of support for many children, and this is a consequence
that no caring professional could tolerate. We certainly
do not condone the stance that some may make, as a pro-
fessional, not to label a child solely to make a sociological
point if the consequence was that there could be no ac-
cess to services for the person and family that required
it. A question then: Do we accept (perhaps reluctantly)
that we use labels only because the educational/health
system in which we work demands it, or do we use them
for other reasons? This is at the heart of Bishop’s pa-
per in our view, i.e. that there are other positive reasons
for using labels. However, there are counter-arguments
that could be made to some of the points made. Let us
consider some of these.
Bishop raises the need to have clear and objective
criteria that should be used to determine which chil-
dren might benefit from support. Again, we agree with
Bishop’s statement. However, the difficulty is that there
do not currently exist any clear and objective criteria for
the myriad of labels that exist in education, whether it
be SLI, emotional and behavioural difficulties (EBD),
autism, attention deficit hyperactivity disorder (ADHD)
and dyslexia, to name but a few. And that, in itself, causes
major problems for parents, teachers and other profes-
sionals working in schools, such as EPs and SLTs, and
it raises the question as to whether we should be using
labels at all if there is not clear agreement about how
they should be applied. For example, the discussion in
Bishop’s paper about ‘cognitive referencing’ (a mismatch
between language and non-verbal skills) would appear
to be an area that has the potential for various misun-
derstandings and misdiagnoses.
According to Bishop, the ‘discrepancy model’ ap-
pears to have been discredited now, and instead it seems
that, for a diagnosis to be made, a child only has to
achieve some minimum level of non-verbal ability, al-
though the exact level that is required and which tests
should be used are, as yet, unspecified. It reminds us of
a similar debate that took place in the 1990s in educa-
tional psychology (and still now, amongst some) regard-
ing the diagnosis of dyslexia. It is generally considered
to have been an unhelpful and damaging debate and
it could be argued (Elliott and Gibbs 2008) that if the
same amount of time and resources were put into how to
intervene with children with reading difficulties rather
than on how to make a diagnosis of dyslexia (including
whether there should be a ‘discrepancy’ between liter-
acy and other areas of the curriculum), then we might
have considerably fewer children with reading and writ-
ing difficulties across the UK. Could the same case be
made about the diagnosis of children with unexplained
language problems?
Taking this point further, Bishop outlines some ar-
guments for separating those children for whom there
is a known cause for the language problems from those
that are unexplained (see the discussion on exclusionary
criteria). We ask the question: Does it matter? Maybe it
does, maybe it does not. We are unsure. However, we
are more sure that by expending our limited resources
on exploring the different possible reasons for children’s
language problems, we are inevitably taking away re-
sources from what can be spent on the intervention, i.e.
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400 Commentary
what to do about it. Bishop writes that the distinction
of problems by type or by aetiology is ‘very often [ ...]
of practical importance in education’. We disagree. We
would welcome some practical examples as to when this
has been the case, as it is our view that, while it may be
important in some cases, it is not true ‘very often’.
The problems are there and must be tackled, re-
gardless of the cause. In some respects we argue for
the theoretical approach put forward by advocates of
the solution-focused method (Rees 2008), namely that
more time should be placed looking to resolve the prob-
lem rather than spending too much time exploring the
problem itself.
Bishop discusses research on the feelings of relief
that some children have experienced upon receiving a
diagnostic label, especially dyslexia, which is undeniable,
but did this relief lead to improved opportunities for the
child? Did his/her literacy skills improve? Did the child
work harder with additional vigour upon receiving the
diagnosis, or did it lead to feelings of helplessness and
inevitability about their difficulties that made the child
try less and less? In other words, research needs to be
carried out looking at these questions, in our view, not
whether the diagnostic label brought some relief to the
child concerned and/or their parents.
Bishop writes that when applying labels it is not
assumed that all children so labelled are the same. We
would hope not, however the reality is that this is indeed
what happens. While there may be numerous profes-
sionals (and academics) who do not believe that chil-
dren who have the same label are the same, or should
be treated the same, there are countless others who do,
and this is a problem with the continued blanket use of
labels, and one that needs to be tackled (see Lauchlan
and Boyle 2007, for further discussion).
The overarching question that we feel should be
asked when considering the use of labels is the following:
‘Will the label change the child’s life for the better?’. If
the answer to this question is an emphatic ‘yes’, then
there is little argument that can be made against the
use of the label. However, if the answer, as can quite
often be the case, is ‘well, perhaps, but I’m not sure,
actually maybe for this particular child, no’, then we
must be extremely careful to continue to attach labels
in our daily working lives in our respective professions.
Let us hope that labels, if deemed necessary, are applied
appropriately and always to the benefit of any recipient.
e-mails: fraser.lauchlan@strath.ac.uk; cboyle7@une.
edu.au
Can any label work for both intervention and research purposes?
Jude Bellair, Sara Clark and Stephanie Lynham
Central London Community Healthcare NHS Trust, London, UK
Abstract
Discussion of the issues surrounding the current specific language impairment (SLI) label identified another perti-
nent question: Can any label be useful for both research and intervention purposes? In exploring the relationship
between a label’s purpose, parameters and terminology, we conclude that no single label is suited to both purposes,
but having a clear, workable label for research purposes is vital.
Main text
The ideas in Dorothy Bishop’s article prompted much
debate amongst colleagues, the questions raised being
both pertinent and central to everyday practice. How-
ever, discussions continually reverted to one question
not raised: Can any label be useful for both research and
intervention purposes? While reflecting our response to
this article, our commentary also explores this additional
question.
We are speech and language therapists working in
Central London who have a component of time allo-
cated to working in specialist speech and language pro-
visions, and who both diagnose and provide intervention
to children identified as having SLI. The opinions and
ideas stated are our individual views and conclusions,
arrived at following discussions with colleagues.
Some questions the article raised were less contro-
versial than others, resulting in unanimous agreement.
Yes, we should be concerned about children’s language
problems; a group of children have unresolved language
difficulties that impact on their educational attainment
and social relationships. No, we should not abandon
diagnostic labels; the positive outcomes of using labels
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Commentary 401
for intervention and research outweigh the negatives
which can be mitigated by our practice. Yes, the medical
model is appropriate for unexplained language problems
in children; accepting that environmental factors impact
on language development, children identified as having
SLI are those where purely environmental causes are ex-
cluded, meaning language difficulties have a significant
‘within child’ (biological) component.
The issues around criteria for inclusion in the cur-
rently called SLI group were more contentious. It be-
came clear that the purpose of a label influences not
only the criteria applied, but also the choice of the label
itself. This lead to our central question: Is there a label
that works for both research and intervention purposes?
Regarding criteria, for both purposes we agreed the
requirement for evidence of significant language impair-
ment, including elements of disordered language devel-
opment or such extreme delay as to be disordered. Ide-
ally, evidence of difficulty with language learning would
be observed or dynamically assessed. Working predomi-
nately with children exposed to more than one language,
we cannot rely on standardized scores, so when making
a diagnosis performance on formal testing is interpreted
carefully and considered alongside the impact on in-
teractions and access to the curriculum. Having rigid
cut-off scores as inclusion or exclusion criteria is not
functional for our client population.
However, some criteria important for placement on
an intervention pathway were not thought important
for research purposes, and vice versa. While for research
purposes, excluding or including based on the cause of
language-learning disorders is important to eliminate
variables, this is not necessarily important for alloca-
tion to a care pathway. Conversely, whether a child’s
language-learning difficulties were the primary area of
difficulty for the child would be important for allocation
to care pathways, but not useful for research purposes.
In our view, the presence of additional difficul-
ties such as hearing impairment, learning difficulties
or ASD should not bar children from an SLI label,
assuming these additional difficulties are excluded as
causing the language-learning impairment (while ac-
knowledging research may initially need to be con-
ducted using a restricted group of SLI children). How-
ever, for a child with learning difficulty and SLI, iden-
tifying the learning impairment as the primary need
would affect the choice of intervention offered, and
conversely, children who had known causes for their
language-learning difficulties, such as Landau-Kleffner
or extreme environmental deprivation while not hav-
ing SLI, may benefit from access to the same care
pathway.
When thinking about interventions and care path-
ways, the descriptive term ‘primary language impair-
ment’ is useful, as it incorporates children who have
language-learning impairments regardless of cause, as
long as language learning is their primary need, which
reflects current practice. However, as a label, it has lim-
ited use for research purposes as it encompasses too
broad a group for results to be valid or useful, and
is reliant on somewhat subjective decisions based on
function. While intervention pathways may be similar
for children with language-learning difficulties whether
they are idiopathic or not, research cannot be carried
out on such a disparate group, and ongoing research in
this area is essential.
In conclusion, we believe that keeping the term ‘spe-
cific language impairment’ is the best option, where ‘spe-
cific’ refers to ‘idiopathic’, ‘language’ encompasses the
idea of ‘language learning’, and ‘impairment’ allows for
variability in functional impact. By using ‘specific’ in this
way, children with co-occurring difficulties or disorders
can still be identified as having SLI. As a label it would be
more useful for research purposes than intervention pur-
poses, however having a label that can work for research
purposes is of paramount importance. Maintaining the
link with previous research into SLI is also essential,
and although current research is conducted on clini-
cal populations that are narrower than those we see in
practice (i.e. only IQ above 85, or not EAL, etc.), this
would be best rectified with more research and repeat-
ing successful trials on a broader group of SLI children
or those with non-idiopathic language-learning difficul-
ties. Additionally, changing the label carries a risk of
children not being referred for assessment and access to
specialist services, and the consequent risk to losing cur-
rent funding particularly at a time of cost savings being
required.
The potential negative outcomes of retaining the
SLI label are within our control to manage. Instead
of using diagnostic labels for care pathways, thereby
excluding children without the label from a partic-
ular level or type of support, descriptions of a phe-
notype such as ‘primary language impairment’ could
be used instead. A label, such as SLI, can be ap-
plied to an individual’s impairment but does not neces-
sarily dictate the support and interventions required:
children with SLI need differing types and levels of
support. Phenotype descriptions may be more use-
ful when writing care pathways as they group chil-
dren by presenting needs rather than cause or purely a
label.
In recommending retention of the label SLI, we
acknowledge the work needed to build consensus within
our profession as to exactly what this term means, and
also in increasing awareness within other professional
groups and the wider community. As a profession we
need to become more precise and deliberate in our use
402 Commentary
of labels versus descriptions of difficulties. The range
of terms in use on electronic media is problematic, and
as professionals we need to improve our awareness and
ability to guide others in their search for information.
However, we feel that as a profession we are up to these
challenges.
e-mails: jbellair@nhs.net, saraclark1@nhs.net and
stephanie.lynham@clch.nhs.uk
Advocating for SLI
MabelL.Rice
University of Kansas, Lawrence, KS, USA
Abstract
The label of specific language impairment (SLI) has inspired substantive advances in our knowledge of previously
overlooked but clinically (and theoretically) significant language impairments. Advocacy is needed to sustain the
scientific gains, do a better job of identifying and providing services for persons with SLI, and build better screening
and assessment tools suited for diverse clinical and research purposes.
Main text
My charge is to provide commentary on the paper by
Bishop. I am in general accord with her perspectives and
wish to use this opportunity to expand an advocacy for
the label of specific language impairment (SLI). I have
three main points:
rSLI, a term coined only about 30 years ago
(Leonard 1981), has inspired substantive advances
in our knowledge of previously overlooked but
clinically (and theoretically) significant language
impairments.
rAs a clinical label SLI has yet to receive widespread
adoption in clinical practice, in spite of the great
need for it. From toddlers to young adults, the
condition is likely to go undetected, untreated
and be poorly understood by the general public,
teachers and physicians (cf. Bishop’s overview).
rRemoval of barriers to services for children and
adults with SLI requires informed advocacy and
the development of accurate and time-efficient
methods of identification, as well as population-
based studies and continued high-level experi-
mental and longitudinal studies.
The SLI diagnostic category helped change views
of typical and atypical language acquisition. Consider
that in 1984 Steven Pinker wrote: ‘In general, language
acquisition is a stubbornly robust process; from what
we can tell there is virtually no way to prevent it from
happening short of raising a child in a barrel’ (Pinker
1984: 29). In contrast, now the National Institute of
Deafness and Communicative Disorders (NIDCD) in-
cludes research about SLI as a priority area for scientific
studies and includes a definition on its website (see
https://www.nidcd.nih.gov/health/voice/pages/specific-
language-impairment.aspx). This shift in perspective
was accomplished by dedicated scientists meeting high
empirical standards of validity and replication across
studies, evaluating well-motivated and competing
theoretical interpretations, carrying out population-
based epidemiological studies as well as decades-long
longitudinal studies, and introducing genetic and
family-based programmes of investigation. In effect,
a significant knowledge base has accumulated and
provides a foundation for further advances (Leonard
1998).
Let me highlight a few noteworthy advances, with
selective, not exhaustive, references:
rValid estimates of population prevalence in young
children reveal a relatively high rate, about 7%, of
children with SLI (Tomblin et al. 1997).
rFor children identified with SLI in a population-
based study, speech disorders appear in approxi-
mately 5–8% of the children, a much lower over-
lap than expected (Shriberg et al. 1999).
rThe relationship between language impair-
ments and nonverbal cognitive abilities is not
straightforward—nonverbal cognitive deficits are
neither necessary nor sufficient for language im-
pairments (Rice et al. 2004, Tomblin et al. 1997).
rEmpirical advances include new methods of lan-
guage assessment that meet high standards of sen-
sitivity and specificity (Rice and Wexler 2001,
Spaulding et al. 2006).
rLanguage impairments of children with SLI
are likely to persist throughout childhood and
adolescence (Conti-Ramsden et al. 2012, John-
son et al. 1999, Rice 2013).
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Commentary 403
rThe grammatical property of finiteness marking
in English and other languages is a linguistic re-
quirement likely to pose problems for children
with SLI, a finding that informs theories of chil-
dren’s language acquisition and has led to ways
to identify children with SLI (Rice 2000, Rice
and Wexler 1996), develop theoretically coherent
empirical measures of progress toward the adult
grammar from toddlers to adolescents (Hadley
and Holt 2006, Hadley et al. 2014, Rice 2012,
2013, Rispoli et al. 2012), differentiate dialec-
tal differences from language disorders (Oetting
and McDonald 2001), differentiate children with
SLI from children with ADHD (Redmond et al.
2011), differentiate bilingualism from SLI (Par-
adis et al. 2008), and identify remarkable strengths
as well as limitations in growth trajectories across
a very wide age range (causing us to rethink our
notions of ‘impairment’) (Rice 2012, 2013).
rSignificant advances in our understanding of
causal pathways, with illumination of previously
unknown genetic influences as well as clarification
of prenatal, perinatal, and environmental contri-
butions (Rice et al. 2008, 2009, 2014).
With these remarkable accomplishments in a rela-
tively short time, why are we now debating the value of
SLI as a diagnostic category? The dialogue is inspired in
part by the editorial decisions of the recent revision of
the Diagnostic and Statistical Manual of Mental Disor-
ders (DSM-5) (2013), compiled by the American Psy-
chiatric Association. DSM-5 serves as an official nosol-
ogy for mental disorders, meant to be implemented by
physicians/clinicians in medical settings. Prominent in
the development of the DSM-5 were physicians, psy-
chologists, social workers, nurses, counsellors, epidemi-
ologists, statisticians, neuroscientists and neuropsychol-
ogists. The point here is that the vetting process involves
diverse professional perspectives.
Communication disorders were considered in the
context of neurodevelopmental disorders, including in-
tellectual disabilities, autism spectrum disorder, atten-
tion deficit hyperactivity disorder, specific learning dis-
order and motor disorders. Because the category of SLI
met rigorous scientific standards after more than a year of
internal editorial reviews, it was included in the nosol-
ogy that proceeded to the phase of public comments,
where it received mixed reviews but not as heatedly
mixed as for other proposed categories. As it turned
out, the diagnostic language categories of DSM-5 were
relevant to controversial changes in the diagnostic cat-
egory of autism spectrum disorders. Ultimately, a new
category of social communication disorder (SCD) was
coined, for which, as Bishop observes, reliable and valid
assessments are lacking. In short, the empirically well-
researched category of SLI was not included and the
newly coined category of SCD, with a minimal research
base, was included.
My conclusion is that the DSM-5 outcome does
not constitute reason to step away from the enormous
scientific gains accrued from studies of SLI as currently
defined, especially in a world where, as Bishop notes, the
term has generated almost 20 000 citations in the sci-
entific literature, an impact that will require a long time
for an alternative label to achieve. In the meantime,
children (and families) in need of identification remain
at high risk of being undetected. One potentially help-
ful legacy of the DSM-5 is the notion of ‘specifiers’,
used, for example, to clarify subgroups within the cat-
egory, ‘Autism Spectrum Disorder’. For example, one
‘specifier’ is whether ASD appears with or without ac-
companying language impairment; another is whether
ASD appears with or without accompanying intellectual
impairment. DSM-5 kept the broadly inclusive term
‘Language Disorders’ (LD) without specifiers. One po-
tentially valuable approach would be to consider SLI
as a ‘specifier’ or subgroup of children identified with
language disorders, an approach in need of thoughtful
consideration. Another lesson from the DSM-5 expe-
rience is the need to recognize that among the barri-
ers to utilization of this diagnostic category is the need
for cost-effective, time-efficient screening tools for SLI
that can be used in doctors’ and psychologists’ offices,
large population-based epidemiological or genetic stud-
ies, and in the daily activities of school-based practi-
tioners where there are many cost-related pressures to
reduce the number of children identified in need of
services. Some progress has been made, in the form of
10-min grammar assessments in the relatively narrow
age range of 3–9 years (Rice and Wexler ), now avail-
able free online (see www2.ku.edu/cldp/MabelRice/)
and found to show high heritability in twin studies
(Bishop et al. 2005). Yet much more is needed. Ulti-
mately, parental access to screening tools could be a key
asset for breaking down the barriers to access to clinical
services.
All things considered, the risk of advocacy for SLI
seems very small compared with the risk of derailing
a very productive line of scientific enquiry with high
relevance for clinical services and the likelihood that,
without the label, services for individuals with SLI will
be reduced even further.
In the interest of full disclosure, I served as an advi-
sor to the Neurodevelopmental Disorders Work Group
forDSM-5,asreportedinthemanual.Inthatcapac-
ity I worked on a panel charged with the development
of the categories for communication disorders. Advi-
sors signed confidentiality agreements as part of the
process.
e-mail: mabel@ku.edu
404 Commentary
The SLI construct is a crucial link to the past and a bridge to the future
Catherine L. Taylor
Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
Abstract
Language impairment constructs are not the province of one discipline, profession, political portfolio, service
system or programme of research. What brings different perspectives together is the shared purpose of improving
language outcomes and life choices and opportunities for children with language impairments. We will need to
define and measure language impairments differently for different purposes and in ways that foster the exchange
of knowledge.
Main text
It is paramount that we have agreed taxonomies and
nomenclature to describe children with language im-
pairments. It is clear from the issues that Bishop dis-
cusses that this will not be a trivial exercise. She invites
us to think about the evidence and counter-evidence
for current language impairment terms and constructs,
with a main focus on SLI. This is a valuable exercise for
proponents and opponents of the SLI construct. Bishop
is not opposed to the term ‘specific language impair-
ment’ (SLI) or the SLI construct and points out that it
is a widely used term even though it is not understood
well enough. SLI describes a prevalent developmental
disability that is under-identified in the general popula-
tion. Changing the term ‘SLI’ is unlikely to resolve this
issue, which is one of measurement rather than nomen-
clature.
Bishop lays out the measurement challenges for us
very clearly. Not the least of these challenges is pene-
trating conventional disciplinary boundaries and inte-
grating across them. She provides an excellent example
of the divide between health and education, that unless
bridged, leaves children with SLI under-identified and
under-serviced. In Australia, the Australian Early Devel-
opment Index (AEDI) is a new and potentially powerful
lever for bridging this divide. Introduced nationwide in
2009, the AEDI is a population-wide measure of child
development in the first year of formal school. It covers
five developmental domains: physical health and well-
being, social competence, emotional maturity, language
and cognitive skills, and communication skills and gen-
eral knowledge. It is completed by a teacher on indi-
vidual children, but the data are not used to identify
individuals. Rather, the data are aggregated at the com-
munity level to show the proportion of children who are
developmentally on track, at risk and vulnerable. This
is a radically different approach to monitoring children’s
development through screening for clinical assessment
and clinical services. The AEDI is not a substitute for
speech pathology assessment and speech pathology ser-
vices: it has a different purpose. The speech pathology
profession has an increasing public health role and this
will require us to embrace different ways of thinking
about children with vulnerable language development.
Our clinical services are overstretched and social gradi-
ents in access to these services mean that the families
who need the services most are statistically least likely to
access them. AEDI results for vulnerable language and
cognitive skills revealed a clear social gradient, with the
highest proportion (18.3%) of vulnerable children living
in the most disadvantaged communities and the small-
est proportion of vulnerable children (5.4%) living in
the least disadvantaged communities. However, extrapo-
lated to the entire Australian population of 250 000 five-
year-olds, this equates to 9150 vulnerable children living
in communities in the bottom (i.e., most disadvantaged)
quintile of socio-economic area disadvantage and 17 350
vulnerable children spread across the other four quintiles
of socio-economic area disadvantage. These and other
data support a proportionate universalism approach to
policies and programmes for children with vulnerable
language and cognitive skills (Christensen et al. 2014,
Taylor et al. 2013a). Proportionate universalism is pro-
vision of services for all, delivered on a scale and with
an intensity proportionate to the level of disadvantage
(Marmot 2010). The logic, as illustrated in the AEDI
example, is that policies and programmes targeting only
the most disadvantaged groups will miss large numbers
of vulnerable children.
Advances in knowledge about human development
have widened the lens through which we view indi-
vidual differences in children’s language development.
Invariably, consideration of the full range of individual
differences in children’s language abilities makes it dif-
ficult to draw boundaries between typical and atypical
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DOI: 10.1111/1460-6984.12101
Commentary 405
development. This challenge is not confined to child-
hood and Bishop draws lessons from chronic diseases
such as hypertension and obesity to illustrate this. Per-
haps the greatest challenge lies in the temporal dimen-
sion of health. As contemporary definitions of health
evolve to include health trajectories and transitions, the
boundaries between health and disease are becoming
even less clear-cut.
Contemporary definitions of language impairment
will also need to describe patterns of stability, change,
improvement and decline in children’s language devel-
opment. Increasingly childhood is front and centre of
public health policy (Taylor et al. 2013b). Bishop en-
courages us to think beyond the language domain to
the overarching goal of childhood which is to develop
human capability, defined as our capacity to participate
economically, socially and civically and to live lives we
value (Zubrick et al. 2009). The new DisabilityCare
Australia national insurance scheme emphasizes the im-
portance of a person’s abilities, interests, goals and as-
pirations in the provision of support services for people
with disabilities (Disabilitycare Australia 2013).
Bishop poses the question of whether to keep the
term SLI or to change it. From her article we know
that the definition of SLI is not fixed and that it has
evolved with the science. She illustrates this using the
example of how the criterion for nonverbal ability has
changed from an outmoded discrepancy criterion (i.e.,
language ability substantially less than nonverbal abil-
ity) to the criterion that nonverbal ability that is broadly
within the normal range. She points out that the use
of the term ‘specific’ to mean ‘exclusive’ is at odds with
the evidence that SLI can co-occur with developmental
vulnerabilities in other domains (e.g., social–emotional
development). 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. This does mean
that the term ‘specific language impairment’ cannot be
interpreted literally; however, this is also true for other
developmental impairments, such as cerebral palsy. Per-
haps, somewhat surprisingly, cerebral palsy is a quali-
tative trait beset with similar definitional issues to SLI.
Like SLI, it is an umbrella term for a heterogeneous
group of impairments, in this case motor impairments,
with largely uncharted aetiologies. The risk factors for
SLI, and most cases of cerebral palsy, are essentially un-
remarkable, in that most children with these risk factors
(i.e., preterm birth, intrauterine growth restriction) have
normal development. As we confront definitional chal-
lenges in relation to language impairments, we can learn
from how these challenges are being met in relation to
other developmental disorders. For example, the term
‘cerebral palsy’, while not perfect, has been kept because
it provides an important link to the past. Like SLI, the
definition of cerebral palsy has been updated as new
evidence has emerged (Stanley et al. 2000).
On balance, there is a strong argument for keeping
the term SLI (Rice 2009), and as Bishop suggests, up-
dating the definition as our knowledge advances. Keep-
ing the term SLI maintains our link to the past and is
a bridge to the future. It is paramount that children,
whose most conspicuous individual difference is in the
domain of language, are conspicuous in our policies
and practice. Research reported in this publication was
supported by the National Institute On Deafness and
Other Communication Disorders of the National Insti-
tutes of Health under Award Number R01DC005226.
The content is solely the responsibility of the authors
and does not necessarily represent the official views of
the National Institutes of Health.
e-mail: Cate.Taylor@telethonkids.org.au
What should we call children who struggle to talk? Taking a developmental,
global perspective on diagnostic labels—reflections on Bishop
Gina Conti-Ramsden
School of Psychological Sciences, University of Manchester, Manchester, UK
Abstract
This commentary takes four alternative diagnostic labels discussed by Bishop and highlights issues that arise from
each of the choices. It reflects on the need to have a global, developmental perspective in tackling complex issues
of diagnosis and terminology and in moving the field forward.
Main text
Language learning can be challenging for some children
at different times in their lives. Despite the recognized
importance of language to children’s healthy develop-
ment, professionals and academics working in speech
and language therapy, psychology and education have
struggled to find a common language to refer to these
children. Currently, we do not have a label that fosters in-
formation exchange and collaboration across disciplines
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406 Commentary
and across different stages of children’s development.
But there is more to this situation. As professionals and
academics, we find ourselves dissatisfied and in turmoil:
there is terminological confusion, a long list of different
labels and different definitions. In terms of diagnosis
and terminology we are in the eye of the storm.
Thus, Bishop’s article is a particularly welcomed,
timely contribution. It provides a very useful, insightful
and systematic review of the issues. Bishop not only
mapsoutwhereweareatbutalsohowwemaymove
forward. In terms of diagnostic labels, in essence, she
puts four options for consideration:
rRetain specific language impairment (SLI) and
adopt laxer criteria.
rAdopt the diagnostic label PLI.
rAdopt the diagnostic label developmental lan-
guage disorders (DLD).
rAdopt the diagnostic label language learning im-
pairments (LLI).
Bishop presents a considered discussion of her pro-
posed diagnostic label alternatives. What other consid-
erations may we take into account? In terms of the di-
agnostic label SLI there are further issues that counter
the benefits of retention. First, it is difficult to foster
change of criteria for an existing diagnostic label (SLI)
particularly when another label is in use and has already
taken that semantic space, so to speak. I am referring
to the diagnostic label of language impairment (LI) as
there are studies that specifically differentiate SLI from
LI on the basis of performance IQ criteria being more
lax for LI (Weismer et al. 2000). Second, Bishop is right
in pointing out that SLI is by far the most common label
used in academic settings. However, I would like to add
the proviso ‘in English’. An examination of number of
returns for terms on Google Scholar search for Spanish
labels suggests a different picture. In Spanish LI (Span-
ish: Trastornos del Lenguaje) is by far the most common
label with 68 000 hits, LLI (Trastornos del Aprendizaje del
Lenguaje) is next with 36 000 hits; and SLI (Tras to r no s
Espec´
ıficos del Lenguaje) produces 16 000 hits. Taking
into consideration professionals and academics working
with languages other than English affords a more global
perspective on the terminological and diagnostic issues
we are facing.
There is also the issue of labels that highlight a par-
ticular feature, e.g. ‘primary’ or ‘developmental’. The
difficulties with the qualifier ‘specific’ have been well re-
hearsed so I will not repeat them here. But how about the
qualifier ‘primary’? I don’t think the change from specific
to primary gets rid of enough unwarranted implications.
The term ‘primary language impairment’ does not fos-
ter a global, developmental way forward. By global this
time I mean taking into consideration the perspectives
of other disciplines and services.
Take Bishop’s case of 8-year-old George. This time
George had his first point of contact with clinical psy-
chological services given his temper tantrums as a young
pre-schooler, his lack of regular sleeping patterns and
his aggression towards his baby sister. The psychologist
in consultation with the psychiatrist has diagnosed him
as having emotional behavioural difficulties (EBD). At
school entry his teacher notices he has a weak vocab-
ulary and he seems to have a hard time following ver-
bal instructions. So she asks her speech and language
therapy colleague to undertake an assessment. The di-
agnosis comes back: George has a primary language im-
pairment. This vignette illustrates some further tensions
that may be worth considering. Should we infer that
George’s primary problem is his language and his EBD
is secondary to this previously unidentified difficulty?
If the evidence suggests George has co-morbid PLI and
EBD, what is the use of the ‘primary’ in the PLI label?
One could say that we are identifying a language im-
pairment that is not accounted for by bilingualism so
the term PLI is still informative. Would we change our
minds if I told you George’s mother speaks only Span-
ish in the home although her English is virtually native-
like?
The term ‘primary language impairment’ may also
invite a static view of language difficulties across develop-
ment. Do adolescents who have received speech therapy
throughout their childhood and elementary schooling
who struggle to understand long, complex sentences in
everyday rapid conversations with peers have a primary
language problem at this stage in their development?
Evidence from the Manchester Language Study would
suggest this is not the case, hence our terminology ‘with
a history of SLI’ which, in all frankness, is a mouthful
(Conti-Ramsden et al. 2012).
Leaving aside the issues of the term ‘disorder’ that,
as Bishop suggests, could be replaced with ‘impairment’,
how about the label developmental language disorder?
In this label we have ‘developmental’ clearly highlighted.
But does ‘developmental’ here mean what we have been
talking about above? Bishop underlines the difficulty of
the same term having different meanings in our field and
this I would argue is one of the drawbacks for the di-
agnostic label developmental language disorder. In this
context, the term ‘developmental’ is usually interpreted
as ‘not acquired’ and ‘in childhood’. This has conse-
quences for young people with language impairment in
adolescence and young adulthood. Indeed, one of the
challenges in our field is the provision of language sup-
port for secondary school pupils and for post-school-age
young people. They are at risk of falling off the radar
from childhood and receiving child services to their of-
ficial classification as ‘adults’ and being eligible to access
adult services.
Wheredoesthisleaveus?Ontheonehandwehave
the proposal from Bishop for LLI and the proposal from
Commentary 407
Reilly et al. (2014) for LI. Each has its merits that have
been described by the authors. I will not add to these
but instead underline the need for due process in under-
taking further discussions to reach agreement. I would
join Reilly and colleagues in calling for an International
Consensus Panel; an international and global panel that
includes voices from different languages, and the voices
of those affected and their families. I would add to the
remit of the panel and all those working with language
impairment Bishop’s call for enhancing positive aspects
of development. We need to discuss the inclusion of
different areas of functioning in our assessments. We re-
quire this information in order to identify the strengths
of children and young people with language (learning)
impairments. In this respect, we could take a page from
the field of autism. If asked, academics and profes-
sionals working with autism can tell us what are the
most common strengths (Baron-Cohen and Belmonte
2005). Could we answer this question now, today for
SLI?
We cannot go on with the current situation. Our
mission is much more than reaching agreement on an
appropriate label. We are ready to have an open discus-
sion and harness existing goodwill and energy and not
only tackle complex issues of diagnosis and terminology
but also move the field forward. We can all live with
what Bishop and others have highlighted: labels have a
necessary place in diagnostic evaluation, but they never
tell the whole story.
By a name I know not how to tell thee who I am.
(William Shakespeare, Romeo and Juliet,Act2,
Scene 2)
e-mail: gina.conti-ramsden@manchester.ac.uk
Changing labels for a concept in change
Kristina Hansson, Olof Sandgren and Birgitta Sahl´
en
Department of Logopedics, Phoniatrics, and Audiology, Lund University, Lund, Sweden
Abstract
In this commentary we reflect on current labels and criteria for child language impairment from a Swedish
perspective. We call for a new label highlighting the developmental, changeable and dynamic characteristics of the
impairment and discuss implications for diagnosis, assessment and research. Conceptual coherence will promote
the professional identity and status necessary for much needed communicability.
Main text
First of all, this initiative is laudable and we hope that
this issue of the journal will mark an important point
within research and clinical management of child lan-
guage impairments. The arguments for diagnosing are
strong and we need a research label to match the diag-
nosis.
Descriptions of a child’s strengths and weaknesses
and/or an identification of their ‘needs’ are not sufficient
but provide the necessary foundation for the diagnosis.
We agree with Bishop that the lack of explanation of
the problems of children with language impairment is
not a reason for not having a label. Labels and diagnoses
facilitate communication with other professionals, fam-
ilies and policy-makers but require acknowledgment of
the large amount of heterogeneity that is characteristic
of all neurodevelopmental conditions. Within the field
of SLI this raises the question of the specificity of the
impairment, an issue that has for a long time caused de-
bate among child language researchers in our country.
The strong influence of Stark and Tallal (1981) has been
challenged by almost 35 years’ of intense exploration of
the neurobiological, genetic and social underpinnings of
child language impairments. This has altered the picture
and today we prefer the label ‘language impairment’,
which, in our view, shows potential to better unite re-
search and clinical interests.
Language impairment is elusive in the sense that the
constellation of strengths and weaknesses within a child
is not static but changes with both time and context.
We cannot predict what problems or skills will persist
or even emerge. We need to remind ourselves that lan-
guage processing involves interaction in two senses: an
interaction between cognition, language and sensori-
motor systems within the individual as well as between
individuals involved in interpersonal communication.
A deficient or reduced functioning in any of these sys-
tems may result in limitations in communicative choices
and use of compensatory strategies. This complex inter-
action of systems within and between individuals gen-
erates unique effects for each individual and for each
communicative event. This also opens up the possibility
for the emergence of new skills and abilities through
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408 Commentary
compensatory adaptation and choices (Perkins 2007).
The highly contextual nature of language processing
calls into question our standardized assessment proce-
dures. The influence of non-verbal aspects of the com-
municative setting, e.g. the partner’s gaze, gestures and
voice characteristics, are often overlooked. We have re-
cently shown that both the examiner’s speech rate and
voice quality interact in interesting ways with item com-
plexity and cognitive factors to affect children’s perfor-
mance in a language comprehension test (Haake et al.
2014, Lyberg- ˚
Ahlander et al. 2014). Applying the frame-
work of the International Classification of Functioning,
Disability and Health (ICF) when deciding on a new
label to be used for both research and clinical purposes
would be useful. This will give clinicians a better under-
standing of the functional consequences for the affected
child and will help determine appropriate goals for in-
tervention and research (McLeod and Bleile 2004).
Similarly to colleagues in English-speaking coun-
tries, diagnoses available for Swedish clinicians, de-
scribed within the ICD-10, do not map neatly onto
the research label. Whereas SLI gives the impression
of enabling clear-cut distinctions between affected and
unaffected children, clinicians struggle to find similar
delineations. This results in frustration from researchers
hoping to recruit participants, and frustration from clin-
icians turning to research in search of answers to manage
their everyday caseloads. Due to lack of alternatives, clin-
icians agree on less than optimal diagnostic codes, with
F80.2B (mixed receptive–expressive language disorder)
providing the closest match for the research label SLI.
As for the question of cognitive referencing, most
research in our country (articles published during the
last 10 years) apply a cut-off for non-verbal IQ at 70.
This cut-off point has never been officially discussed
in the research community, only gradually adopted by
researchers.
Support for the convention is provided by results
showing similar benefits of intervention for children
with language impairment with IQ between 70 and 80
and those above 80 (e.g., Tomblin 2008).
In Sweden, phonological difficulties have been con-
sidered part of language impairment since the early
1980s (Nettelbladt 1983). At least at pre-school age,
children with grammatical/lexical problems almost in-
variably also present with some degree and type of
phonological difficulties. There seems to be less agree-
ment on including social communicative problems in
language impairment. According to our experience, in-
dividuals with such deficits emerging from structural
language problems (i.e., problems at different levels of
language production and comprehension) qualify for in-
clusion even with apparently restored language abilities.
Thus, it is our opinion that children who have not had
any structural problems should not be included.
A growing body of research points to co-occurrence
of language impairment and other conditions. In our
own research comparing children with mild to moder-
ate sensorineural hearing impairment and children with
language impairment (e.g., Sahl´
en and Hansson 2006,
Sandgren et al. 2013) the findings are consistent with
those of other authors (e.g., Briscoe et al. 2001, Gilbert-
son and Kamhi 1995). A considerable proportion of
children with hearing impairment have similar prob-
lems as children with language impairment, but their
problems are generally not as pervasive and persistent.
The lack of proportionality between degree of hearing
impairment and degree of language deficits suggests that
hearing and language impairments co-occur.
We should recognize and take pride in the contribu-
tions of SLI theory to the research on language impair-
ments in a range of disability groups. Although much
remains to be explained, the development of SLI theory
has informed us on both typical and atypical language
development, and how language relates to and interacts
with other cognitive and social skills. The urge to in-
crease the theoretical and methodological depth should
not prevent us from taking a stance on the label and
diagnostic criteria and to advance the field.
The time has come for a new label and a golden
standard for definition, criteria and assessment of chil-
dren with language impairment. Conceptual coherence
will enable and facilitate communication between re-
searchers, clinicians, families, educational systems and
policy-makers. This will strengthen the identity of re-
searchers and clinicians working in the field of child lan-
guage disorders. This, in turn, will better the chances of
communicating the message. In our opinion, language
learning impairment and developmental language dis-
order are both likely to accomplish these objectives since
the labels highlight the dynamic, changeable nature of
the condition.
e-mails: kristina.hansson@med.lu.se, olof.
sandgren@med.lu.se and birgitta.sahlen@med.lu.se
Commentary 409
What should we call children with unexplained language difficulties? A
practical perspective
Ann Clark†∗and Glenn Carter†
∗Queen Margaret University, Musselburgh, UK
†NHS Forth Valley, UK
Abstract
This commentary reflects on Bishop’s discussion of possible diagnostic terms for children with unexplained
language problems. We discuss each of her four proposed terms in turn, commenting on their potential use in
clinical and educational contexts by speech and language therapists and other professionals.
Main text
Bishop’s article is a timely and welcome discussion, gath-
ering together the main issues around the terminology
used to describe children who have unexplained lan-
guage problems.
There are many UK-wide examples of excellent SLT
practice working with children with unexplained lan-
guage problems in increasingly challenging professional
environments, often with reduced resources. Although
SLTs appear to have a consistent approach to interven-
tions with children with unexplained language prob-
lems, there is no consistent practice either in what we
call these children or in the pathways to their diagno-
sis. In our survey of SLTs working in Scotland (Clark et
al. 2013), we found 85% used ‘specific language impair-
ment’ in line with Bishop’s finding with Google Scholar.
However, although SLI is the term used most often by
SLTs, 45% also used ‘language disorder’, 27% ‘language
delay’ and 21% ‘specific language disorder’. This adds
further weight to Bishop’s view that the current system
is in mayhem. Some SLTs report they have moved away
from the term SLI when discussing these difficulties with
parents and education colleagues and use it only with
SLT colleagues.
In terms of pathways to diagnosis, we have increas-
ingly moved away from traditional exclusionary criteria
and towards measuring and defining inclusionary crite-
ria that best represent difficulties these children present
with. In the survey, 6% said diagnosis was a joint pro-
cess between SLTs and educational psychologists, 12%
said this took place between SLTs and specialist language
teachers. However, 82% said there was either no official
pathway of diagnosis (59%) or they did not know/were
not sure what it was (23%). Despite the fact, as Bishop
discusses, that cognitive referencing is now largely dis-
credited, this information can be slow to disseminate
onto the ground. SLTs may be reluctant to change their
practice because there has been no clear message about
alternative and evidence-based pathways in which to
make a diagnosis. However, one thing is clear. SLTs
have a key role in diagnosis and we need sharper tools
to achieve this, while working with education colleagues
to identify the impact for each child.
Bishop presents a vignette to illustrate her argu-
ments. At present it is difficult to give George a di-
agnosis that is consistently understood or valued by the
team around him including his parents. The lack of a
consistent, known label is likely to lead to confusion and
indeed anger for George’s parents who are trying to come
to terms with his difficulties, but are unable to qualify in-
formation with a consistent message from professionals
and the internet. The internet is the most powerful tool
parents, clinicians and young people have for accessing
information that can inform and help them understand
the nature of these difficulties. Without agreement on a
label, accessing this information is frustrating or worse
misleading. One of the positive consequences of diag-
nostic labels, to which Bishop alludes, warrants further
comment. That is, the fact that a ‘reason’ or label for a
child’s difficulties can help to ‘remove the blame from
the child’. This will be particularly salient for George as
he gets older. Anecdotal evidence and experience work-
ing with teenagers and adults shows that they feel dis-
empowered by not understanding the nature of their
difficulty and believe the feedback from their peers or
others that they are ‘stupid’ or ‘useless’. A clear diagnosis
and label would help to reduce George’s anxiety.
Bishop presents four terms as potential candidates to
describe unexplained language problems, economically
and persuasively outlining their pros and cons, as well
as possible ways forward. Here, we hope to add to the
debate by discussing some other issues around these four
suggestions in the context of SLT practice.
With respect to SLI, the fact that there are so many
different labels used in the literature and in practice
suggests that this term has not met the mark. One
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DOI: 10.1111/1460-6984.12101
410 Commentary
suggestion is to change the understood meaning of ‘spe-
cific’ to ‘idiopathic’. While keeping the term SLI is ap-
pealing, as it is so widely used it would be challenging,
and arguably it is too late, to redefine a term which, for
so long, has meant something different.
Another challenge is differentiating between chil-
dren who may have transient language difficulties and
those who have an atypical/disordered language profile.
Transient language difficulties is a term that well de-
scribes children with delayed language presentation that
responds to generalized language interventions such as
vocabulary development or narrative techniques. One
possibility would be to hold onto SLI for the small
group of children who actually have very specific diffi-
culties and further build on the term ‘transient language
difficulties’ for children who have delayed language dif-
ficulties related to environmental deprivation, for exam-
ple. We would only know which group a child falls into
after we have seen how they respond to intervention.
Reilly et al. (2014) recommend waiting a minimum of
a year before making a diagnosis, which seems a sensible
guideline.
Moving on to the term ‘primary language impair-
ment’, ‘primary’ has the advantage of narrowing down
‘language impairment’ while neatly avoiding the prob-
lems of ‘specific’. However, ‘primary’ could lead to con-
fusion with parents and education staff as it potentially
implies these difficulties are relevant to children who are
of ‘primary’ school age. It excludes the reality that that
this is a developmental difficulty, which for the majority
of affected children first manifests in the early years and
in many cases continues into adolescence.
‘Language learning impairment’ is the most educa-
tion friendly term suggested by Bishop. A benefit of this
term is that it ties ‘language’ with ‘learning’ to emphasize
the impact of these difficulties on educational success.
One potential problem is that ‘learning’ may suggest that
difficulties are associated with formal learning at school
only, rather than language learning in other contexts as
well.
Considering the term ‘developmental language dis-
order’, the addition ‘developmental’ to the DSM-V term
‘Language Disorder’ is helpful, as it focuses on the con-
genital aspect of these difficulties. Within the context
of education colleagues it is still useful within the early
and primary school years. It may be more problematic
as adolescence approaches. However, adults with ‘devel-
opmental dyslexia’ diagnosis commonly drop the ‘de-
velopmental’ and we perhaps need to take a pragmatic
approach in adopting a term that reflects at what stage
we most commonly provide support.
When we weigh up Bishop’s arguments about the
positive and negative consequences of a consistent la-
bel, we are in absolute agreement with Bishop’s state-
ment that ‘labels can have negative consequences, but
the consequence of avoiding labels can we worse’.
Where do we go from here? We need an urgent,
strategic and international debate to come to an in-
formed and ideally a consensus decision on what term
we adopt. It needs to be precise enough to describe
the difficulties these children face and understandable
to those outside of our profession. However, that said,
no matter what we call it, we need to use the term to
increase awareness of the difficulties faced by these chil-
dren. If we can do that and the profile is high enough,
we can help the general population attach meaning to a
particular term, as we have seen with autism spectrum
disorder. Then we will be in a much stronger position to
campaign for resources to support these children and for
research funding to increase our knowledge of both un-
derlying causes and effective interventions. The adopted
term needs to be integrated into SLT pre- and post-
registration training, as well into training of education
staff including educational psychologists.
This debate is timely, needed and welcome. Let us
continue with the momentum we now have and aim
to ensure we will not be having the same discussion 10
years from now.
e-mails: aclark@qmu.ac.uk and glenn.carter@nhs.
net
Terminology mayhem: why it matters—the ramifications for parents and
families
Alison H¨
uneke and Linda Lascelles
Afasic, UK
Abstract
Parents take the view that the term ‘SLI’ has not been a successful diagnostic label. Its lack of credibility and market
recognition has made it vulnerable to political and economic pressures. Parents would welcome a term that helps
ensure their children’s difficulties are recognized, taken seriously and adequately supported. Alternatives are briefly
considered and improvements suggested.
International Journal of Language & Communication Disorders
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DOI: 10.1111/1460-6984.12101
Commentary 411
Main text
Afasic is the UK charity representing parents of children
who might be described as having SLI as well as other
forms of speech and language difficulty. As such, we
are well placed to reflect parents’ views about diagnostic
terms.
Any debate about SLI must take account of the pre-
vailing political and social context. Until comparatively
recently, SLI was generally regarded as a relatively rare
condition requiring a high level of specialist interven-
tion; however in recent years there has been more em-
phasis on the need for a ‘mass intervention’ approach to
address the substantial minority of children now recog-
nized to have what has more frequently come to be called
‘speech language and communication needs’ (SLCN).
Why this shift in how language difficulties are per-
ceived? Firstly, the focus on underachievement among
young people from low socioeconomic backgrounds has
identified speech and language difficulties in the early
years as one of the main causative factors. Secondly, fi-
nancial constraints imposed on the NHS have meant
considerable cuts to speech and language therapy ser-
vices, including the loss of many specialist therapists,
and a shift away from personalized therapy towards gen-
eralized, low-dosage packages of support, often delivered
by early years or support staff.
However, the use of ordinary English words in terms
such as SLI or language delay/disorder has probably not
helped either. It is hard to imagine such a dramatic
change happening to a more ‘medical’ sounding label,
such as autism or ADHD. Even some medical profes-
sionals are struggling. Paediatricians, for instance, in-
creasingly seem to consider SLI to be an ‘educational’
issue rather than a medical condition.
Another issue is that the underlying concept does not
really resonate. We seem to be hardwired to assume that
young children will learn to talk in due course, and there
do not seem to be enough children with visibly serious
but unexplained problems to change this perception.
Clearly, then, SLI has not been a very successful
term. Both Bishop and Reilly et al. (2014) argue that it
is not helpful to retain it as it is currently understood.
Their view is that SLI cannot be distinguished clearly
from non-specific language impairment, which they sug-
gest has in the past been regarded as less serious. They
argue that, in fact, children with low non-verbal IQ re-
spond equally well to speech and language therapy and
have similarly poor, or in some cases even worse, adult
outcomes. Bishop also adds that the term ‘language dis-
order’ can be misleading as it may be interpreted as a
more severe condition than a broader delay whereas the
evidence points to a much better prognosis.
Parents would argue that this is precisely the point.
They are happy to concede that, compared with many
other disabilities, their child’s difficulty is relatively mild.
The difference is that, given the right support, these
children have the potential to do as well as their non-
impaired peers, achieving good GCSEs, securing mean-
ingful employment and even going on to university.
The authors of the lead articles in this special is-
sue may take the view that removing the distinction
between specific and non-specific language impairment
will mean that both groups of children receive the higher
level of help that parents of children with SLI currently
(sometimes) secure. This is optimistic. In the current
climate, where both education and health services are
reluctant to fund speech and language therapy, there
is a high risk that they will instead offer only a very
basic level of support to everyone, with the result that
the concept of language impairment as a specific need
will effectively disappear, and instead be subsumed into
general low ability/mild learning difficulty.
Nevertheless, it is possible that all these concerns
could be addressed by the adoption of a more viable
alternative label. Bishop does suggest a number of possi-
bilities, none of which is likely to be any more successful
than SLI has been. Of the various options, parents would
probably favour the term ‘disorder’, which, they feel, in-
dicates a specific problem. We recently consulted a small
group of parents about the term ‘language learning im-
pairment’, but they felt it implied a learning difficulty
and would be equated with low ability.
The best option would be something like ‘(devel-
opmental) dysphasia’: it is clearly a medical term; it
equates SLI with other specific learning difficulties such
as dyslexia and dyspraxia; and it meets the ‘Google test’
outlined by Bishop. It is also the standard term in other
European countries, including France.
An alternative option, as Bishop suggests, is to revise
the definition of language impairment. Criteria that de-
pend on language scores require children to have a full
speech and language therapy assessment, and only a very
small number do so. Classifying it instead in terms of
specific abnormalities in children’s language would have
a number of advantages:
rIt would be easier for teachers and other non-
specialists to recognize.
rIt could also be applied to brighter children who
may be struggling with some aspect of compre-
hension or expressive language, but whose scores
are too high to meet current criteria. Their inclu-
sion would also, as with dyslexia, help to shift the
perception of the condition more positively.
rIt would make it easier to identify children with
social communication disorders who often score
quite well on formal language assessments and so
struggle to have their needs recognized and met.
412 Commentary
rThe identifying characteristics could be adapted
for a range of ages. This would help to remove
the perception that language deficits relate solely
to a difficulty with the basic language skills young
children normally acquire during their pre-school
years and raise awareness that they can affect peo-
ple of any age.
Initially, parents often worry that having a label
might adversely affect their children as they grow up,
but they do welcome something that helps them un-
derstand their children’s difficulties and validates their
concerns. What they would like, above all, is a diag-
nostic label that other people recognize and understand,
and which delivers the help their children need.
e-mails: hlmgr@afasic.org.uk and lindal@afasic.
org.uk
Getting behind the label: practitioners’ points of view
Marion Strudwick†∗and Ann Bauer†
∗Parent advocate SOS!SEN, the special needs helpline
†Head of Language Resource, mainstream secondary school
Abstract
Dorothy Bishop’s article concerning the labelling of language impairments is discussed in the context of educational
provision. We discuss labelling from our perspectives as parent advocate and specialist teacher. We support the
need for labels and for a more universal definition of terms. We suggest the label becomes a starting point to
describe the child’s language needs within a holistic profile.
Main text
We welcome the debate on precise labelling of speech
and language needs. Labels have a use as they provide a
reference to need, in this case in relation to speech and
language, and also a foundation for provision, ‘we could
then gather evidence to determine which children actu-
ally benefit from support and services’ (Bishop). They
are also a basis upon which specialist teaching, therapy
and mainstream teaching can develop (McCartney et
al. 2009: 80–90). The name attached to this need is
significant with Bishop explaining the possible impacts
on pupils’ education arising from attitudes towards the
condition. Reilly et al. go further in suggesting cut-off
data to form criteria for inclusion into whatever label is
chosen. We hesitate about the use of cut-off data and ar-
gue that the child’s language needs should be considered
in the context of the whole child’s profile.
‘Language impairment’ (LI) (Reilly et al. 2014) or
‘language learning impairment’ (LLI) (Bishop) are both
acceptable titles and we welcome Bishop’s warning that
the label is not the construct. We contend that labels
are open to misunderstanding and misinterpretation by
some professionals. In our experience, misinterpretation
leads to inappropriate provision for an individual child,
whether determined within school, local authority or
special educational needs tribunal. Therefore, any uni-
versal label should have enough depth to be understood
by all.
We have experienced the difficulties facing those
determining a child’s provision to understand the im-
plications and differences in terminology relating to im-
pairments described variously as ‘delayed’, ‘disordered’,
‘difficulties’, ‘needs’ (Bishop). For instance, a teacher de-
scribing all pupils as having ‘individual needs’ gives this
as a reason why a pupil’s language ‘needs’, described in
a statement of SEN, do not need to be addressed differ-
ently, or a tribunal member claiming all speech and lan-
guage therapists have their own interpretation of what
is disordered and what is delayed. This can have serious
consequences for the outcomes for the child (Bishop) if
it leads to failure to address the impairment.
We suggest that either LI or LLI are valid labels, but
if a child’s needs are to be fully understood and met, the
label is just the starting point. The label is not necessarily
helpful unless two things are addressed: (1) the nature of
the impairment(s); and (2) the whole profile of the child
covering the range of needs, how they impact upon each
other and the holistic outcome. Bishop shows there are
very few pupils who have language impairment as their
only special educational need.
We contend that the broad label ‘language impair-
ment’ is only useful if the nature of the impairment
is clearly set out to indicate whether the language is
delayed, disordered or both, whether it relates to fun-
damentals such as pragmatics, semantics, auditory pro-
cessing, short-term memory or combinations of difficul-
ties. The language impairment should also be set out in
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online C2014 Royal College of Speech and Language Therapists
DOI: 10.1111/1460-6984.12101
Commentary 413
the context of the child’s developmental history as well
as other defined needs, for instance cognition, attain-
ment, emotional and sensory. B