Advances in Speech-Language Pathology Volume 4, Number 1, pp. 65-67 Copyright © 2002 by The Speech Pathology Association of Australia Limited

Having Your Cake and Eating It: The Apparent Paradox of

Long-Term Outcomes of SLI

James Law City University

London, United Kingdom

The research on specific language impairment (SLI) is very messy. It is full of apparently contradictory findings. For example, on the one hand, the article by Nippold and Schwarz discusses the negative out- comes of SLI presenting in the preschool years. They reach the conclusion that if these children have marked difficulties at school entry, they do not tend to grow out of them. Of course, this is a useful mes- sage to convey to medical practitioners who are still saying to parents "Don't worry he'll grow out of it." It is a position that, in many ways, suits the needs of the speech and language therapist because it em- phasises the potential "health (and educational) bur- den" and thus the clinical importance of SLI.

On the other hand, there is good evidence from sophisticated meta-analyses of respectable treatment effect sizes following speech and language interven- tions (Nye, Foster, & Seaman, 1987; Law, Boyle, Har- ris, Harkness, & Nye, 1998), a position supported by a number of narrative reviews (Enderby & Emerson, 1995; Snyder-McLean & Mclean, 1987; McLean & Woods Cripe, 1997; Olswang, 1998). The second of these reviews demonstrates significant effects for clinical interventions targeting delays/disorders in expressive language, receptive language, and speech. Furthermore, the evidence is convincing that direct therapist-administered intervention works better than parent intervention for speech-focused work but that parent-focused interventions, for ex- ample, of the type characterised by the Hanen Early Language Parent Programme (Manolson, 1992), can

Address for correspondence: Prof. James Law Ph.D., FRCSLT, Head of Department, Department of Language and Communication Science, City University, Northamp- ton Square, London ECIV OHB, United Kingdom. Emaih J.C.Law@city.ac.uk

be at least as effective as clinician-directed interven- tions for promoting language skills. This position al- so suits the speech-language therapist because it demonstrates the efficacy of the interventions of- fered. However, at face value, it is difficult to see how the two positions can be reconciled. If interven- tion works, the trajectory of the language impair- ment should be affected and the prognosis im- proved for some, if not all, the children.

One of the factors that makes interpretation prob- lematic is the categorical use of "quasi-diagnostic" terminology. It is appealing to reify diagnostic cate- gories as if they were diseases and, in many ways, this reflects the historical antecedents of our under- standing of these conditions. However, it has be- come increasing clear over the past 10 or more years that SLI is a relative concept. As far back as 1981, Stark and Tallal, in trying to operationalise SLI in a group of referred cases, found that a substantial pro- portion of children did not meet their own criteria (Stark & Tallal, 1981). This is a function of the cut points on the tests used, the specific tests and the profile of different tests, and finally the fact that there appears to be little difference in the way SLI and, for example, children with moderate learning difficulties are treated by speech and language ther- apists, especially in the early years (Plant, 1998).

These problems of definition are accentuated in the preschool period and have resulted in many re- searchers trying to identify a subgroup of children, often known as late talkers, on the grounds that this is the group whose difficulties resolve sponta- neously (Kelly, 1998), even though it is notoriously difficult to distinguish late talkers from children who continue to have difficulties (Rescorla, Roberts, & Dahlsgaard, 1997). As Thal and Katich (1996) comment:

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66 ADVANCES IN SPEECH-LANGUAGE PATHOLOGY, VOL. 4, NO. 1

The longitudinal studies of late talkers all suggest that the majority of children who have expressive language delay prior to 3 years of age are not at seri- ous risk for language or language-learning disorders in the school years, even without intervention. (p. 20)

Much probably depends on how much verbal comprehension is included in the definition of late talkers. Nippold and Schwarz make extensive use of the interpretations taken from the Bishop and Ed- mundson cohort (Bishop & Edmundson, 1987), which was initially identified as having receptive difficulties. Interestingly much of the U.S. literature has tended to emphasise expressive language diffi- culties either with normal receptive language skills or with no reference to comprehension at all.

It is sometimes suggested that this inconsistency in the pattern of language impairment is a function of the age of the children studied. The younger the child, the less easy it is to predict outcomes and the less confident we can be of the prognosis; the older the child, the more consistent the pattern of difficul- ties and the stronger the prediction. Unfortunately, although there is ample evidence to support Nip- pold and Schwarz's position that children continue to have difficulties well into their teenage years (Stothard, Snowling, Bishop, Chipchase, & Kaplan, 1998) and beyond (Johnson et al., 1999; Beitchman, Wilson, Brownlie, Waiters, & Lancee, 1996), sensitive analyses of the children's profiles show quite clearly that the presenting symptomatology of language impairment continues to change through the pri- mary school years (Conti-Ramsden, Botting, Simkin, & Knox, 2001). The answer to this problem is proba- bly that we should stop trying to reduce SLI to cate- gories intended to have some sort of psychological reality but see it in terms of risk and resilience.

Part of the problem is a heavy overreliance on the use of standardised measures as our benchmarks for including children in one group or another. Obvi- ously the judgments that arise out of the application of these measures are only as good as the measures themselves. There is plenty of hterature which em- phasises how difficult the apphcation of standard- ised measures can be. Even with adequate standard- isation there is clearly considerable inconsistency between measures purporting to access the same construct. Interestingly, speech-language therapists in the United Kingdom have largely moved away from an overreliance on standardised measurement for all but audit and research. This practice is the re- sult of their lack of faith in the absolute nature of standardised scores, but also because such measure- ments have little ecological validity in the sense they do not reflect the child's learning environment. In- stead, therapists in the United Kingdom make far greater use of context-sensitive measures---Individ- ual Education Plans, teacher reports of adaptive and

social behaviour, and so forth. The World Health Or- ganisation's term "participation" incorporates as- pects of the child's performance which are unlikely to be captured by a static assessment but which would be much more meaningful to the classroom teacher or the therapist. How a child adapts to his or her peers or how the child accesses the curriculum are far more meaningful for a 10 year old than his or her performance on a standardised test.

Another issue which is not covered in the article but which is of considerable concern to practitioners is that of social class. The historical understanding of SLI is that children who have language difficulties as a result of extreme deprivation cannot reasonably be classified as SLI. Indeed, most clients with SLI are essentially middle class. Although this may prevent children who have been severely neglected or abused from being categorised as SLI, the fact is there are different profiles of interaction across social class, and this situation has a direct bearing on the language development of the children in the early years (Hart & Risley, 1995). Clinical experience would suggest that many of these children are likely to present with early language problems, may be classified as SLI, and are likely to go on to have diffi- culties managing in school. Now, if these children are included in the analysis of outcomes, as they must surely be once large scale studies (rather than studies of half a dozen children) are used as the main source of evidence, we may have to revisit the negative pictures of outcomes painted by Nippold and Schwarz. Recent data from the Abecedarian Head Start project have shown marked long-term effects of intervention following intensive preschool intervention (Campbell, Pungello, Miller-Johnson, Burchinal, & Ramey, 2001). This poses a challenge for the negative long-term outcome model and in- deed a challenge for speech and language interven- tions generally. It may be that the children have such poor long-term outcomes because they simply do not experience enough intervention. Nippold and Schwarz rightly make this point about the negative short- term outcomes of the recent U.K. study, which provided an average of 6 hours intervention per year per child (Glogowska, Roulstone, Enderby, & Peters, 2000). If children with SLI received the sort of "dosage" found in the Abecedarian project, it may be that their outcomes would be different.

In conclusion, then, what Nippold and Schwarz say may be true. For a substantial proportion of chil- dren with pronounced expressive-receptive difficul- ties, there is a high risk they will have difficulties with all sorts of language and language-related tasks throughout their school careers. This difficulty may even extend into adulthood, but there is httle in the literature that discusses the outcomes in early adult- hood and beyond. We need to be careful in assum- ing that the primary outcomes of intervention are

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HAVING YOUR CAKE AND EATING IT 67

tested language performance. Clearly the standard- ised language scores of these children do not readily change. If different measures were used, for exam- ple, relating to the child's ability to access the educa- tional curriculum, it may be that the outcomes re- ported for the group as a whole might be different. Throughout childhood, speech and language thera- pists and early childhood educators need to search for the best me thods of document ing change in a valid and reliable way. It may be that the psychome- tric measures on which so much of N ippo ld and Schwarz's argument is based and which have done so much to increase the understanding of language development do not serve us well as measurements of meaningful change in the children. Finally, it is not enough to say that we need to intervene as early as possible with all these children rather than watch- ing and waiting. If the prevalence estimates are ac- cepted, there are too many of these children to rea- sonably receive remedial help from speech and language therapists, and it is not clear that interven- tion is what they need anyway. What is needed is a systematic evidence-based approach to intervention with properly controlled large-scale studies. Many of the difficulties of interpretation have arisen be- cause the sample sizes are simply too small for ther- apists to have confidence in the results.

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