SeeHearSpeak Podcast

00:12 Tiffany Hogan: Welcome to See Hear Speak Podcast Episode 18. In this Episode I talk with Sean Redmond with co-host Norma Craffey. We discuss Sean’s work on Developmental Language Disorder, Specific Language Impairment, and ADHD.
This conversation is 1 in a 5 part series on Developmental Language Disorder (known as DLD) released this week in honor of DLD Awareness Day, which this year is on Friday Oct 18th.
Thank you for listening! And don’t forget to check out www.seehearspeakpodcast.com to sign up for email alerts for new episodes and content, read a transcript of this podcast, access articles and resources that we discussed, and find more information about our guests. Also don’t forget to subscribe to this podcast and leave a positive rating in apple podcast or wherever you are listening.
01:13 Tiffany Hogan: Well, welcome Sean and Norma to SeeHearSpeak Podcast. I'll start out by having you introduce yourself first, Sean.

01:25 Sean Redmond: Hi, I'm Sean Redmond from the University of Utah. I have a doctorate in Child Language, and I teach courses in child language disorders, and do research in that area also. And I'm a certified speech-language pathologist.

01:48 TH: Awesome. And Norma. First, I have to say happy birthday to Norma. She is recording on her birthday, [chuckle] a birthday podcast for you. But Norma, please introduce yourself.

0:01:57 Norma Craffey: Hi everyone, Norma Craffey here. I am a reading specialist with a background in public education K-12. I'm also a now second-year doc student that studies with Dr. Hogan over at the IHP (MGH Institute of Health Professionals) in the SAiL lab. My primary interest is the overlap between disorders of language and literacy. I look at dyslexia and DLD, but also the comorbidity of disorders, such as ADHD. So we'll be talking about that today! Excited.

02:30 TH: Fantastic. Well, Sean, you study DLD and ADHD. I've had the good fortune of working with you. Several years ago we worked on a paper in LSHSS, and we're currently working on a paper together with Norma right now. Stay tuned for that one! So I want the listeners to understand more about this. Why study these two populations together? If you could tell us more about what defines each. Tell us how they're similar and how they're different.

02:58 SR: Yeah, so in some ways, developmental language disorders and ADHD is a study in contrast. So one of the disorders is one of the most widely recognized conditions worldwide. ADHD doesn't have a problem with name recognition. It's on the thoughts and concerns of parents when they start noticing their children aren't developing in line with their expectations, or what they are observing in other children. In contrast, developmental language disorder is a condition which often doesn't cross people's minds as a possibility for explaining why children might be out of sync with what our expectations in terms of their development. From a teacher's perspective, a child with ADHD and a child with DLD might behave the same in the classroom. Children from both groups might have difficulties following directions, for example. But the source of those problems are probably very different, and would require different kinds of responses to help.

04:24 SR: The other reason to study these two conditions is that they are both very common, not just what the epidemiological evidence is telling us. In terms of identification, the contrast between those two conditions is we have concerns with under-identification with developmental language disorders, and have at different times had concerns over over-identification of ADHD. So for those reasons, we're taking a look from a practitioner perspective. I think it's where teachers and parents and speech pathologists live; these people regularly encounter children from both groups. Sometimes they encounter children who have both conditions. What has gone underdeveloped in our field, is two things. First, a way of identifying or differentiating the two conditions. And second, establishing cross-communication between clinical psychologists, school psychologists, and speech language pathologists on how to manage these two conditions.

05:48 TH: I've heard you talk also about some of the theoretical nuances between studying them related to processing speed. Is that correct, and how does that play out?

06:00 SR: Yes, so the other reason beyond those sort of practical considerations is to use the two conditions as a way of testing different hypotheses we might have about how things like attention and language abilities link. When you only compare a clinical group to a group of kids who are typically developing, you're likely to find differences at the group level on any number of dimensions. But some of that's gonna be due to ascertainment by us, and some of that's gonna be due to measurement confounds. You really need the cross-clinical comparison to test the necessity and sufficiency of different mechanisms. So for example, if it's the case that something like sustained attention compromises children's grammatical development, then we look at a group of kids with ADHD that have problems with sustained attention. Then we should be able to find evidence of limited grammatical proficiencies. So those kinds of predictions can really only be tested when we have a two-group or a three-group design that brings in those two clinical groups.

07:18 TH: Yeah, that makes a lot of sense, so practically and clinically speaking. When you've studied these two impairments, you've spoken about three presuppositions associated with the study of these two. So can you tell us about those presuppositions. I knew I would stumble on that word. And [chuckle] how you examine them in your research? I'm very curious to hear about these three different approaches, and what they've told you.

07:46 SR: So when I started getting interested in what comorbidity could tell us about how language disorders develop, it started to become apparent that in order to do that, I needed to establish some assumptions or presuppositions. These were about where we were as a field and where the literature had developed to. So one of the presuppositions is that there's enough clarity in the reports of co-occurrence that allows us to rule out the possibility that we're getting a referral ascertainment or measurement bias. If it's the case that children with behavior problems are more likely to be referred for language evaluations, then the rate of comorbidity in a clinical sample is going to be elevated.

09:07 SR: If the way we're measuring language or the way we're measuring ADHD introduces measurement error by virtue of requiring proficiency in the other domain. For example, if you're doing a language test that requires a lot of planning for children with ADHD. Because of their ADHD, they’re gonna have problems completing that language task, but not because they have a primary deficit in language processing or semantics or syntax.

09:48 SR: On the other side, if how we're identifying inattention or hyperactivity or impulsivity is dependent upon symptoms that overlap with a problem with understanding words or sentences, then we're gonna have some problems in the measurement on that side. A lot of what I've been working on over the past few years has been looking at the content of behavioral writing skills. This represents the dominant assessment modality for identifying risk for ADHD in kids, and looking at the items that are included into a scale. Either the inattention scale, the impulsivity scale, hyperactivity scale, or some composite ADHD measure. What I've found regularly, we just recently updated this with a new report looking at new measures. It shows that there's a lot of items there that would be identified by speech-language pathologists as being more or less in the language realm, especially in the areas of receptive language. And these instruments are typically designed to differentiate those conditions. So it's almost as if a child, the language impairment, is already at a penalty when a parent or a teacher is asked to fill out one of these scales.

11:24 TH: Yeah. I remember, Sean, when I first started working with you several years ago, I remember having this discussion with you and being very surprised. At that time, I hadn't really spent much time thinking about what was on those rating scales. Then I remember you pulled one up, and for instance, it was one of the ways to identify ADHD was “couldn't understand directions,” or even more mind blowing to me, one of them was “couldn't spell words correctly.” So I'm thinking, "Huh." I also remember reading a lot about scholars making the argument that there shouldn't be this measurement issue in ADHD because, on one hand, it's parent and teacher rating scales. While, with language and other communication disorders, you see that it's based on clinician direct assessment. So this person was trying to argue there shouldn't be as much overlap, but when you looked at the actual items, especially on the ADHD rating scales, my mind was blown. I know clinicians are seeing this every day, and I think you've seen this too, Norma, in terms of the scales.

12:31 NC: Yeah, yeah, the scales. Actually, I'm taking Advanced Measurement right now. So as Dr. Alan Jette would say is that the scales are not biased in and of themselves or the people aren't filling them out. It’s the scales and how they're constructed, that might be. I was actually asking about this last week. But it is something within the schools that we see a lot, and I think that it gives a lot of difficulty, number one, as you said, to identify kids or even talk about children with developmental language disorder and having any language difficulty that is not expressive. But also to differentiate between children that, the severity of whether or not it is truly ADHD or whether or not there's a behavioral difficulty at the time that hasn't been worked through. That's something we see a lot. I think that it gives a stigmatism to ADHD that, as you said earlier, there's potential for over-diagnosing it. That definitely is impairing to the children who truly do have ADHD, and who really have a difficulty getting a diagnosis at all. This is especially common in the schools, because that's not a diagnosis we provide, although we do fill out the scales.

13:47 NC: I was just interested in the paper that you were talking, Dr. Redmond, earlier in 2002. You did that evaluation of the scales, and to see the difference, and that the best scale that you had come up with, the one was most sensitive to that language piece, was a scale that we don't even use in schools. The Conners or the Vanderbilts are really the most assigned. So I thought that was really interesting, and also problematic for clinicians.

14:14 NC: The other thing that I've noticed in the schools, even within the evaluations of SLPs working with kids with attentional deficits. So frequently, when I would send kids from a reading perspective to an evaluation, and they would have a language evaluation, the speech and language pathologist would often make assumptions about why kids did poorly. They would think it was due to inattention on tasks of the CTOPP, for instance, nonword rep, or on the CELF. There was always an an element of, "Well, he or she was distracted, that's why they're doing poorly on this." Whereas, from my practitioner's perspective and working with the child every day, I could truly see that there was a difficulty there. So I can see how it can be a barrier, and I'm really interested to hear more about how we can try to bridge that barrier.

15:03 SR: Yes, so going back to the list of assumptions, or presuppositions, that Tiffany was talking about. Some of the things that you were talking about there, Norma, highlight some of these same challenges. If we aren't positioning ourselves in a way that something like differential diagnosis is gonna be part of the assessment process, then it leaves those possibilities open to our imaginations about what is motivating children's poor performance in different areas. What we do in the lab is we assess our participants with ADHD when they've had washout, meaning their medications have been suspended. When you do that, you realize that there's a lot of behavioral management issues that you need to attend to. And by attending, I mean you relax some of the ideas that children have to have quiet hands. You relax the criteria that children have to stay in their chair. You relax the criteria that children have to complete a task from beginning to end, and can't go off-task for a while and come back. So what we have typically noticed in our assessments is that, for the children with ADHD, their verbal abilities line up pretty nicely with their nonverbal abilities. If there really was a big discrepancy between what they could perform if they were paying more attention, or couldn't perform, doesn't seem to be supported by a discrepancy in that dimension.

17:05 SR: Now, having said that, it's also true that in our literature, we don't have any studies that have looked at how children perform on language tasks within a particular participant, on and off medication. To have gotten this far in our field, and not have had that established, is kinda remarkable. I mentioned that embracing the idea that differential diagnosis is part of our task. It is an important one. If you go into our pre-professional textbooks, for example, I've only been able to find one that even has differential diagnosis as an index item in the back of the book.

17:46 TH: Wow.

17:46 SR: This is a text that's supposed to be for a clinical profession, and yet it doesn't have differential diagnosis as a topic. There's a number of reasons why I think that's the case. Part of it has to do with the way we're situated to treat child language disorders most commonly in the school context. In the school context, the idea of diagnosis or labeling is really only mentioned as a negative. It is perceived as the thing that we want to avoid. So we're in this weird space where we're trying to apply principles of good clinical practice, and yet we're not allowed to do one of the most fundamental aspects of clinical practice, and that's differential diagnosis. At least we perceive that we're not allowed to do that.

18:46 TH: Absolutely, and I think that's a nice parallel to what's happening in dyslexia, too. You have the whole movement. There’s this whole hashtag, say dyslexia, say it in the schools, diagnose it. But its still, correct me if I'm wrong, Norma, I think all the states now have some law on the books about dyslexia. Is that correct?

19:08 NC: I don't think it's all yet, but there are more than... I don't know the numbers, but a lot.

19:14 TH: Yeah. The last time I checked it was 42, but I was thinking it might be more. But even with all those laws on the books, there’s this variability across the states with what the law says. We still see when we go into schools that there's this resistance to label a child at all. It’s seen as this negative, like you said, Sean. So it is very difficult to think about using differential diagnosis in a system that doesn't even want to acknowledge diagnosis.

19:47 SR: That's... Yeah. I think that will represent a barrier as we move forward with trying to elevate public awareness of language disorders. And, well, I'll let you talk.

[laughter]

20:13 TH: Well, I was just going to say...

20:13 SR: I lost my train of thought.

20:15 TH: Oh, that's okay. I was just going to say that I think that was probably the biggest difference that I encountered moving from clinical practice to a research career. In clinical practice I do think I did thorough evaluations as much as possible. I definitely didn't have the training in measurement that I wish I would have had. But I don't think I necessarily thought about the comprehensive nature of my evaluation in the sense of trying to think about all the different possibilities, and that one could influence the other. I didn't have that level of specificity, but part of it was because I was never encouraged to. In the system itself, it was always like, "Don't worry about that, just work on what they need." I do think that there’s a mistake because the more specific we can understand, and more comprehensively we can evaluate, all of the different components and not make these assumptions about, oh, the child has ADHD. So that's probably why they score poor on language, that kind of thing. We would have a better way to tackle the true issues that are going on for that child.

21:29 SR: Another perspective that's been missing in the assessment of language disorders in children has been a consideration of how the kinds of evaluations, information that we present to families, is received by families. So one of the projects that we've been involved in here in the lab has been to conduct semi-structured, relatively open-ended conversations with parents about the experiences they've had working with different professions, and talking about their child's difficulties. To a person in our study sample... These were the moms of kids who we had already assessed for research purposes, and each child fit the classic presentation of specific language impairments. So these were kids with normal nonverbal abilities, and no concomitant disorders like ADHD that would be part of the equation. Every person expressed frustration with how people were talking about their child's difficulties. And nobody could, with certainty, explain what their child's difficulty was. That was a source of continuing suffering, and confusion, and anger. So on more than a couple occasions, mothers expressed anger and hostility towards the speech-language pathologist, because they didn't feel like they were getting a straight answer.

23:25 SR: Part of what's going on here is that what goes on in the schools. It is an eligibility audit to make sure the child meets the criteria, whatever's in place, to receive interventions for the child's difficulties. So the speech-language pathologist thinks they're doing their job by identifying strengths and weaknesses within language, and then moving on to intervention as quickly as possible. But from the parent's perspective, this is supposed to be where a diagnosis takes place. And that is what happens for those families who get a diagnosis of ADHD that's made outside of the school context. There is no parallel place, except if families sought out, and they rarely do, an assessment from a university clinic or private practice. That is how they would get that diagnostic moment. So what they're left with is a description, a rephrasing of the problems that they already know their child has. It'd be like if you went to a doctor and you were complaining of stomach pains, and you were concerned that you might have something serious going on like gallstones or cancer. And the doctor responds back with, "Well, you have a moderate to severe thoracicitis."

24:55 TH: Yeah, right.

24:55 NC: Yeah.

24:56 SR: It's just another description of your problem. We do that when we tell families that your child has moderate to severe deficit in grammar, and then we launch into a discussion on what standard scores mean. But none of this is making sense to them. So what parents want you to do is tell them that it isn't autism, tell them that it isn't ADHD, tell them that it isn't apraxia, tell them that it isn't auditory processing disorder. It's kinda interesting how those all start with the letter A, but...

[laughter]

25:37 SR: We... That's differential diagnosis.

25:42 TH: They also want you to tell them it's not their fault, and that it is something that is biological. I think that's something they don't get.

25:53 SR: They can't get there if you don't give them a diagnosis.

25:58 TH: Right. I agree. I think we come from a very similar place of advocacy, Sean, for labeling kids. Because in working in research, that's been the biggest struggle. I had a family, for example, they were in one of my studies. The mom said, "What's going on?" And I said, "Oh, he's fitting the criteria for developmental language disorder." "Oh, I've never heard of that. You know, he's been in treatment in the school for years." She goes, "Who diagnoses that?" I said, "Well, a speech-language pathologist." So she goes back to her speech-language pathologist, and the speech-language pathologist says, "Well, I can't really diagnose that, but I can tell you he's got language problems." So then she comes back, and she's like, "Well, what... " It's really frustrating.

26:43 TH: And then prior to getting some resources out there like RADLD and DLD and Me, which Sean and I are founding members of, for that website. There was nothing to even send them to. I really felt like I almost looked like a quack, to be honest, because I was basically saying, "Your child has this,” but no one they talked to would confirm it. There were no resources on the web. So the parents were in angst. What I noticed is that they would start to just kind of ignore what I've said, because it's like, "Well, I don't know, we don't know what they have."

27:25 SR: Part of that is recognizing that speech-language pathology is in its own little universe. It has to engage with other clinical categories if we're going to make sense to families. The tradition in our textbooks has been to encourage clinicians to treat language disorders arriving from different sources as basically the same thing. They respond to the same interventions, so why bother getting into ideology, ideology schmideology. Now we're starting to see some of the consequences of that. So it's really hard for the public to understand what speech-language pathology is, and why it is any different from regular tutoring. They've got a point. So if you're working on strengths and weaknesses, and you're not characterizing these things as deficits that are significant enough to become a clinical disorder, then you are tutoring in the way that the Kumon facilities do.

28:48 TH: I think that you make such a good point, it's not... For the clinicians listening to the podcast, it's not the clinician's fault per se. This is our training. This is how we've trained clinicians as a field for years, and it has to come as a concerted effort to change that in our field. We should change this lack of differential diagnosis. It has to be a groundswell of reasons why we need to change it, as opposed to, "Oh, I should have known that. Oh, why am I doing this?" Well, it's not a blame game. It's really just let's change it now, let's make a difference and move forward in a different way.

29:26 SR: So that would be the second presupposition, that there is. In both clinical psychology, and speech-language pathology, the second presupposition is a strong tradition of differential diagnosis. That seems to be true for clinical psychology, and less true for speech-language pathology. Now, to kind of add a silver lining or maybe a hopeful note here, the third presupposition that I've talked about in various capacities is the extent to which we can identify clinical markers in both areas that are capable of differentiating typical from atypical performance, which is what most of the considerations have been directed at, and as well as differentiating between different types of atypical performance. One of the consequences of a couple decades of research focusing on the phenotype of specific language impairment, has been to identify some relatively robust clinical markers of the condition. This is especially in children in their early elementary grades, preschool to early elementary grades. When we have taken those measures, which are nonword repetition, sentence recall, and tense marking, and assess children with ADHD, we find no difference in performance between kids with ADHD and typically developing kids.

31:11 SR: Then, as you know, Tiffany, because you were a co-author on that paper, we looked at comorbidity. Kids who had both ADHD and language impairment based on experimental criteria, not necessarily seeking services in both areas. We showed that there wasn't an additive effect such that kids who had both ADHD and language impairment were demonstrably worse on those measures than kids with specific language impairment alone. So, to me, that's a signal that should be looked at more closely and replicated in other samples, but it suggests the possibility that our language measures might be suitable to the task. So if you use one of those measures and you don't know the child's status, their ADHD status, it probably wouldn't have impacted their performance, if they had ADHD you didn't know it. It also suggests that trying to improve language skills by improving executive function, or attention, or these other elements that are associated with ADHD is not likely to yield big dividends unless something drastically different is used compared to what we've done with samples of kids with ADHD in the past. So that's encouraging.

32:24 SR: We've also been able to show that if you take out those language items from those ADHD scales and we score them so that they're more language neutral, that it doesn't diminish the capacity of those ADHD scales to differentiate kids with ADHD from kids with typical development. However it does improve their capacity to differentiate a specific language impairment from ADHD. I'm using the term specific language impairment to identify that sub-group of kids with development language disorders that the more strict criteria of average performance and nonverbal ability. The extent to which things get different when you relax the nonverbal ability criteria is still open to question. It could be the case that things are different on that side.

33:56 TH: I think these results have such clear clinical implications in my mind, because one of the implications I know you've talked about, Sean, is the idea of screening and universal screening to try to catch these kids who have problems in language. What do you think about universal screening for developmental language disorders, and what have you studied in that realm?

34:20 SR: Well, we just came out with a recent report looking at a screening of a community sample. We did something a little bit different than what's typically done with these kinds of studies. We introduced multiple reference standards for language impairment. So, what typically happens in a diagnostic integrity study is you look at one reference. You settle on a reference standard. Then you take a look at different measures to see which one has the highest sensitivity and specificity relative to that standard. What we did was we used the standard of a performance on a standardized test, we used the CELF. We looked at two cutoffs, 85 and 80. We looked at performance on tests of early grammatical impairment. We looked at nonword repetition. We looked at parental report of communication difficulties that was captured by the Children's Communication Checklist.

35:31 SR: Then we also included, as a criterion, the children were receiving services for speech or language impairment. In the past, people have offered that as a strong, ecologically valid measure of language impairment because it's a functional deficit that is strong enough to evoke enough concern to get referred, assessed, and then treated. The potential problem with using receipt of services is that we know that there's great disparities in access to speech-language pathology services as they're delivered by the schools. So we know that, for example, families that are Caucasian and whose children who have mothers who have college educations are more likely to get services. We also have some evidence to suggest that boys might be squeezing out services relative to girls, even when you look at children who have equal levels of performance on standardized tests. There's ethnic and racial disparities. And so there's a lot of reasons to maybe not be too enthusiastic about the functional ecological validity of de facto receipt of services.

36:59 SR: Then we also know from reports from epidemiological and longitudinal studies, most notably the Iowa study sample followed by Bruce Tomblin in '90s and early 2000s, that the majority of children that met research criteria for language impairment didn't get services throughout their academic career even though they were at clear elevated risk for academic and socioemotional problems.

37:29 TH: Yeah, it wasn't even a severity issue. I remember reading that. So that was really interesting, too. It wasn't like they had less severe language issues.

37:38 SR: Yes, so going back to our study... [chuckle]

37:42 TH: Yeah.

37:54 SR: What we found was that our screening measures did reasonably well with most of our behavioral assessment criteria, but less well with receipt of services. So there's children with language impairments that weren't picked up. When we looked at the kids who were getting services, it was also true that a not insignificant number of those kids, that were getting services, didn't have a measurable language impairment by other criteria. So there are children who are enrolled in services that may not be impaired. We then looked at pragmatics as a potential component, something that's difficult to capture. You can get to that by the Children's Communication Checklist. And that didn't seem to be contributing to this group of kids that were getting services without a language impairment either on one of the other criteria that we were using.

38:55 TH: What do you think it was?

38:57 SR: Well, it was true that they were more likely to have college-educated moms, and... I'm blanking on some of the other ones. We found what everyone else has reported.

39:12 TH: Yeah, right.

39:12 SR: So the racial disparity, you got. Her sample wasn't very heterogeneous. Boys were getting more services, and then mom's education was one we came across. So it could be a number of things. One possibility is that you can have, in different clinical areas, a hothousing phenomenon. This is where parents of above-average abilities who have a child with average to low-average abilities interpret that as a deficit. So they feel they need to receive clinical attention. Depending on how strongly positioned they are for advocating for services, they might be able to get them in the way things are set up now. If we had a universal screening, and I'm not suggesting that we've figured it out… It's a solvable problem, what is the best screening measure for whatever language impairment definition you want to use? That's an empirical question we can solve.

40:30 SR: The other thing that we've encountered when we've been engaged in some focus groups with teachers, is that teachers don't like being put into the position to make these kinds of referrals. They don't feel equipped to do so. And when we pose the question, "Well, how much support would you have behind universal screening?" the support from teachers was higher than the support from speech pathologists. Because SLPS are worried that this is going to crash their case loads.

41:08 TH: Right, that makes sense. I actually feel really positive, I feel more positive about this possibility because as you know, Sean, I wrote a piece for DLD and Me called A Call for Universal Screening of Language. One thing I've recently added to that was a spreadsheet, an open Google Doc spreadsheet to try to list off all the screening data that's out there. Your paper is listed in there, but to try to think about this. I've actually had several people email me, speech pathologists, and special educators, to say, "Yeah, I want to do this. What do you think it would look like?" They are very interested, and I'm hoping we can benefit from the movement to screen for dyslexia. You know, if we're screening in general, maybe we could also tie together and screen for language. Do you agree, Norma?

42:00 NC: Yeah, no, I definitely do. I think that it would be interesting within the schools. We spoke earlier, the system itself is inherently not set up to diagnose children. Through the whole process of how you're evaluated, and what your identification is. If and when, perhaps that screening both for dyslexia and language impairment, maybe even throwing ADHD in there, maybe that would force the system to change. But how it's set up now, I can see that there might be a lot of pushback, because in the same way with dyslexia, they're saying, "Well, we don't have professionals that are trained for this. We don't know how to handle it, and that's why we don't wanna identify it." I can see very similar pushback happening in the schools for screening for language as well.

42:51 NC: Although, I will say that there are some elements of kindergarten screening, that certainly they look for articulation and do a lot of the expressive receptive quick checks. But we are very hesitant, like you said before, to... There is no diagnosis, we're hesitant to label children. So it will be interesting to see how that plays out in the schools, but I think that screening might be that piece that breaks the camel's back in getting more training into the schools. Then we can appropriately identify all kids because every child deserves access to that label.

43:29 SR: And what you do with the screen doesn't necessarily lead inevitably to diagnosis.

43:34 NC: Absolutely, absolutely.

43:36 SR: The RTI model allows us to have different places to land after we identify an individual that is at risk for having a difficulty.

43:48 TH: Yeah, I wrote a paper recently with Suzanne Adlof where we talked about calling for language screens within the RTI system. I think that there's room for thinking about a better Tier 2 model for language stimulation that doesn't necessarily have to always be driven by the speech pathologist, but can be driven within general education where, if they have a risk maybe they get some support, and that is a way to kind of move through the rank through RTI. I've had better luck in thinking about screening when I work with a full district, not just the speech pathologist, but work at the district level. My argument is that districts are very concerned about their reading scores. And we know from the Iowa study, and other longitudinal studies, that children who have DLD in kindergarten are at risk. This means they are very likely to be poor comprehenders in the future, and this is a big piece that the schools are missing for their reading comprehension scores. So that's kind of the way I've pitched it more within that RTI realm, and within the idea of improving not only language scores, but also reading scores along the way.

45:01 SR: Yeah, there is the sense that things are shifting on multiple fronts. And one thing that could happen with the renewed interest, and elevating the visibility of developmental language disorder, is that the identification of DLD is gonna require a diagnosis. You are kind of engaging in a bit of malpractice if you are just calling something a disorder, and not following it through with official disclosure processes. You tell the families, "This is what's going on." One of the challenges with incorporating that into RTI, is that moment when you tell the family "Your child has a disorder. It's called developmental language disorder," could come relatively late when it could have been identified. So we're kind of in an interesting trap.

46:22 SR: We can certainly find kids who are at risk in preschool for what we're going to call specific language impairment or developmental language disorder, but there are some kids that seem to use those following couple of years to catch up and seem to be doing okay. So the fact that those kids exist has prevented us from getting too excited about making a diagnosis early. But waiting until the child is 8, 9, 10, 11 years old before we tell the families that there is a disorder here is not going to be received well. It’s going to make us look like we don't know what we're doing, even though our research literature provides us with some pretty good measurement systems for identifying kids at risk.

47:18 SR: One of the things that I came to appreciate looking at the assessment systems in speech language pathology, relative to the assessment systems in clinical psychology for ADHD and other behavioral disorders, is that our measures are very robust. They're very reliable. They measure behavior first-hand symptoms we're after are usually literally falling out of the child's mouth. There’s no interpretation about why they're saying the things they're doing. Whereas most of the time when people are being assessed for ADHD, this is being collected through informant rating scales. It's a widely recognized limitation that informants have biases, and one of the things we know about language impairments and kids who have language impairments is that adults are very quick to assign negative attributions to kids who sound dumb, or different, or delayed, or young. Those are even present in speech-language pathologists. So one of the cool things that's available on some of the newer scales to assess children, is that there's actually validity checks to make sure that there isn't an overly negative bias or positive bias brought in by the informant.

48:55 TH: Well, that's really interesting. I do think that this idea of thinking about how other fields approach diagnosis, it interesting. I know that's something that really informed to your work, Sean, and it definitely has me with dyslexia. Back to the measurement issue, I do find it kind of interesting to think about RTI, because what I see is that there's this big movement for dyslexia, to screen and diagnose early. But truthfully, in the research literature you see, that the stability of diagnosis of dyslexia is much lower in kindergarten than DLD, for instance. The stability of diagnosis of DLD in kindergarten is actually very high. So if a child has language problems in kindergarten, you see that that stability over time is high.

49:41 SR: It's good to get a relative comparisons because nothing's perfect, and you can focus on the limitations of what's available to you and not really appreciate that all clinical fields are struggling with these issues, and in some areas, we're actually doing pretty well.

49:59 NC: Right.

50:01 TH: Right. I think we're in a very hopeful time, as you said, especially, knowing this podcast is being released on DLD Awareness Week, that we're bringing so much awareness, that we're actually starting to think more about these issues that tie clinical practice and research. Sean, your work is such a nice example of that, of tying what's really happening in the schools, to what's happening with clinicians, and tying that to the research work. I truly appreciate that. I'm looking at our time, and I'm realizing we probably need to wrap up a bit. I always ask two questions of my guests. So I want to ask you, Sean. The first one is, what are you working on now that you're most excited about?

50:42 SR: So we just started a longitudinal study looking at symptom progression in kids with language impairments that would fit the SLI profile or the sub-group there, children with ADHD, children with both, and then children with neither. We're following their development on language, we're looking at vocabulary, verbal memory, and grammar. We're using grammaticality judgement for the grammar. On the ADHD measurement side, we're looking at inattention, impulsivity, hyperactivity, and executive function. So we're following those four groups over time. We're looking at the age span between 7-12, which I think it's an interesting one for these two conditions because that's when a lot of kids get identified for ADHD. It’s also a time when kids with language impairments start to peel out of services, because people have decided that things look reasonably well, and we don't need to attend here, even though the longitudinal studies suggest that these symptoms are very stable.

52:12 SR: So one of the things we're interested in is how often do children who start off in one group drift into the other group. And then what sort of variables predict that transmission? So we're trying to capture cases where comorbidity occurs and identify what precedes what, do the language symptoms come first, and then they get considered to be into the orbit of ADHD later on or vice versa? The other thing I'm really excited about is looking at protective or resilience factors that prevent kids. So the kids in the comorbid group, there's a possibility that they will resolve in one of those domains, and what is behind that.

53:09 TH: That's cool.

53:12 SR: It is cool.

53:12 TH: That's so cool. [chuckle]

53:14 SR: The last really super cool bit is we're gonna collect measurements on siblings, so the idea being that there might be family-level risk between these two disorders that occurs across siblings. Maybe kids with specific language impairment are more likely than typically developing kids to have siblings with ADHD, and maybe the siblings with ADHD might have more siblings with language impairments. I would like to be able to give a progress report, but it's way too early. We don't have anything to say at the moment except, as you said, I think this is pretty cool.

54:03 TH: And we'll be following that, for sure, because Norma will say comorbidity is one of my favorite words [chuckle]. I think it represents where we need to go in our field because what struck me as a clinician, is that I took all these courses on individual disorders. Then when I went out to see one child, I realized, "Whoa, there's a lot more going on," so I really think that's very cool. I love the risk resilience aspect as well. I think that's also an area we have to move towards to better understand changes over time. So my last final question for you is, if you would share with the audience, what is your favorite book from childhood or now? So it can be childhood or now or both, whatever you'd like.

54:46 SR: So I'm going to cheat [chuckle] and make it a set of books.

54:53 TH: Oh, that works!

54:58 SR: This is going to be the set of books that I have identified as sort of formative in childhood. I must have read D'Aulaires' Books of Greek Myths and Norse Myths cover to cover hundreds of times. It sort of sparked an ongoing interest I've had even as an adult with sort of that magical realism genre. So I made sure that both of my kids got copies of those books, and they reacted in the same way that I did. And the artwork is incredible. They were out of print for a while, which made me sad, but now they're back.

55:52 TH: Oh, that's good, I'll link it to the podcast website, because listeners often like to take a look at the books. It opens up a new avenue for them, so I'll make sure I link that through Amazon or whatnot.

56:04 SR: So that was one set of work, and then the other one that I think as a child, and as a parent, the Ed Emberley books on how to draw…

56:28 NC: I loved those as a kid. [chuckle]

56:33 SR: There is something there about creating a composite out of decomposed little bits that you're able to give a child at a stage when they really can't draw. Starting off with the big picture, I think has some parallels with some interests I have with how language builds up from little bits.

56:57 NC: Awesome.

56:58 SR: So there we go.

57:00 TH: That's fantastic. Well, I have to tell you that my two and four-year-old often have to hear podcasts playing in the background, and sometimes they're like, "Turn off those stories," especially if I'm editing and different things. But they do know that when I do a podcast, I often go get new books for them, because I like to get the books for them that the guests have recommended. So I think they will quite appreciate that, especially my four year-old, because he... I forgot about those books and he loves to draw. That's awesome! And it's such a great parallel, like you said.

57:33 TH: Well Norma, I've had you say your favorite book before so I don't know if you wanna say it again. I know I won't say mine again, so we'll just have the listeners check back to episode four if they want to see. I think it's four, maybe, I can't remember now. Check back to another episode if you want to hear about my favorite book and Norma's. I just wanna thank you so much, Sean, for speaking with me today. Norma, and I'm excited to release this podcast during DLD Awareness Day and get the word out, so thank you so much.

58:04 SR: Yes, thanks for having me, this was fun.


58:08 Tiffany Hogan: Check out www.seehearspeakpodcast.com for helpful resources associated with this podcast including, for example, the podcast transcript, research articles, & speakers bios. You can also sign up for email alerts on the website or subscribe to the podcast on apple podcasts or any other listening platform, so you will be the first to hear about new episodes.

Thank you for listening and good luck to you, making the world a better place by helping one child at a time.