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Clinical Decision Making in Developmental Language Disorders

Clinical Decision Making in Developmental Language Disorders

Volume Editor: Alan G. Kamhi

ISBN: 978-1-55766-882-0
Pages: 416
Copyright: 2007
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SLPs—get ready to work effectively with children and adolescents who have developmental language disorders with this indispensable resource. Highly respected editors Alan G. Kamhi, Julie J. Masterson, and Kenn Apel have developed a comprehensive, one-of-a-kind text that

  • Teaches assessment and intervention. The book's first half shows SLPs how to assess spoken and written communication skills and select targets for intervention, and the second half is an extensive guide to interventions for specific areas of language development.

  • Covers the widest range of topics. Current and future practitioners will get clear, explicit guidance on all the practical issues they'll face on a daily basis.

  • Addresses a broad age span. Readers will discover how to manage the specific issues they'll encounter when assessing and intervening with infants, toddlers, preschool children, school-age children, and adolescents.

  • Incorporates both scientific evidence and clinical insight. More than two dozen expert contributors lay out the latest research and add their own wisdom from years of practice—showing readers how to use sound clinical judgment to fill the gaps in available evidence.

The most complete treatment of this critical subject area, this essential text will prepare SLPs to make the best possible clinical decisions—and improve the communication and overall quality of life for children and adolescents with developmental language disorders.

Clinical Decision Making in Developmental Language Disorders is a part of the Communication and Language Intervention Series
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Review by: Johanna Price, Assistant Professor, Mississippi University for Women
"An invaluable resource for both students and clinicians."
Review by: Judy Montgomery, Board Recognized Specialist in Child Language, Professor, Chapman University School of Education
Excellent clinical decisions are now within our grasp.
Review by: Jenny Roberts, Department of Speech-Language-Hearing Sciences, Hofstra University
"A wonderful book . . . using first-person accounts from leaders in the field."
Series Preface
Editorial Advisory Board
About the Editors
Laurence Leonard


I. Assessment, Diagnosis, and Target Selection

  1. Considerations for Family-Guided Communication Assessment of Infants and Toddlers in Natural Environments
    Juliann Woods and Amy M. Wetherby

  2. Assessment of Prelinguistic & Emerging Language Skills of Children with Developmental Language Disorders
    Shari A. Robertson

  3. Assessment of Preschool & Early School-Age Children with Developmental Language Disorders
    Shari A. Robertson

  4. Assessment and Diagnosis of Adolescents and Young Adults: Spoken Language Disorders
    Julie Wolter

  5. Assessment of Reading Comprehension and Written Expression in Adolescents and Adults
    Bonnie D. Singer

  6. Language Variation, Assessment, and Intervention
    Elizabeth D. Peña, Connie Summers, & Maria Resendiz
II. Intervention and Service Delivery

  1. Facilitation of Early Communicative Behaviors
    Carla Wood Jackson

  2. Syntax-Morphology
    Catherine H. Balthazar and Cheryl M. Scott

  3. Semantic Intervention: Enhancing Vocabulary Knowledge in Children with Language Impairment
    Gail T. Gillon, Catherine A. Moran, & Felicity Page

  4. Addressing the Social Concomitants of Developmental Language Impairments
    Sean M. Redmond & Geralyn R. Timler

  5. Supporting the Development of Spoken Narrative Skills in Children with Language Impairment
    Donna Boudreau

  6. Early Literacy Development
    Joan Kaderavek

  7. Spelling and Word-Level Reading: A Multilinguistic Approach
    Julie J. Masterson and Kenn Apel

  8. Understanding and Remediating Text Comprehension Problems in School-Age Children
    Sandra Laing Gillam

  9. The Right to Write: Composition Instruction for Students with Language/Learning Disabilities
    Laura Green

  10. Serving Secondary Students
    Kevin N. Cole

  11. Facilitating Language Skills in Individuals Who Use Augmentative and Alternative Communication
    Lisa A. Wood & Pamela Hart

  12. Legal Mandates: Impetus for Improving Assessment, Diagnosis, and Treatment of School-Age Children and Adolescents with Developmental Language Disorders
    Tom C. Ehren & Barbara J. Ehren

III. Future Directions

  1. Thoughts and Reflections on Developmental Language Disorders
    Alan Kamhi

Excerpted from Chapter 4 of Clinical Decision Making in Developmental Langugage Disorders, by Alan G. Kamhi, Ph.D., Julie J. Masterson, Ph.D., & Kenn Apel, Ph.D.

Copyright © 2007 by Paul H. Brookes Publishing Co. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.

Charlie, a 16&#ndash;year–old high school sophomore, was recently referred to me by his parents, who were concerned about his academic progress and limited ability to communicate. Charlie had a history of speech and language delays and had received treatment services focused on syntactic and semantic development until third grade, at which time he was discharged from therapy given his ageappropriate speech and language. In addition, Charlie had always struggled in school and received special education services for his reading and writing since his early elementary school years. At the time of the referral, Charlie was still receiving special education literacy services


Charlie's case may be similar to those referrals with which speech–language pathologists (SLPs) working with adolescents and young adults are confronted on a consistent basis. Adolescence—defined as the stage from age 12 to 20—is a time when students are faced with increasing language demands, and students such as Charlie, with literacy deficits and a history of spoken language delays, may experience difficulties comprehending and producing complex language. Charlie may face increased language pressures in his school curriculum, where he is expected to use formal language in both spoken and written forms. In addition to the demands of the school curriculum, older students, such as Charlie, face challenges in their social environment. At this age, skills such as the mastery of figurative language and the use of slang are an important part of developing a sense of self–identity and fitting in with one's peer group. Another important part of forming a self–identity is to negotiate for independence with one's parents, which requires structured and planned spoken language (Whitmire, 2000). Thus, the language demands on adolescents and young adults are quite high and should be considered within a functional context.

When faced with a case such as Charlie's, I consider several different factors and language areas. First, I considered Charlie's cognitive functioning. A previous 55 psychoeducational evaluation revealed that Charlie's IQ was well within the average range. This testing, however, revealed that he had difficulties with listening comprehension and his ability to retain information in memory, such as the details of a story. Next I wanted to know more about the kinds of communication difficulties that Charlie was experiencing and the contexts and settings in which these difficulties occurred. Charlie was having word–finding problems and difficulty explaining himself when expressing his opinion or answering questions that required planned and lengthy responses in both spoken and written contexts. These difficulties arose in the academic setting when talking to his teachers or participating in group discussions, as well as when he was making a point or negotiating with his parents. In addition, Charlie was having difficulty organizing and producing language when he was expected to give an oral presentation or write a paper on a specified topic in school.

Beyond this background information, I was interested in learning more about Charlie's performance in the areas of semantics, syntax, morphology, pragmatics, narratives, and executive functioning. Moreover, I wanted to personally assess whether Charlie experienced language difficulties in certain linguistic contexts such as expository or conversational discourse. I also wanted to determine whether specific language breakdowns occurred in certain settings (e.g., school, home) and what might be contributing toward these respective breakdowns. Furthermore, I wanted to evaluate Charlie's language use in both the spoken and written modes.

Charlie's case will be revisited at the conclusion of this chapter, but for now, let us consider the process of assessing language in an adolescent or young adult. When I complete a comprehensive assessment, I consider my own clinical knowledge and expertise, as well as the research regarding developmental expectations and appropriate assessment measures. My assessment includes standardized tests along with nonstandardized measures such as observations and criterion–referenced tasks. Standardized measures may be required to qualify a student for services and help narrow my focus on where I want to proceed with specific criterion–referenced measures. Clinical observation and criterion–referenced measures then may be conducted to provide me with an in–depth picture of how language is used in context and where I will begin treatment. This chapter discusses how to apply these components in an assessment of an adolescent's spoken language. It should be noted that although a comprehensive language assessment should include evaluations of both spoken and written language, the assessment description is limited to the spoken language domain. The assessment of written language in adolescents and young adults is discussed in Chapter 5.


Different linguistic contexts may result in varying working memory demands. Adolescents with specific language impairments have been found to have limited working memory (Gillam, 1998; Weismer, Plante, Jones, & Tomblin, 2005) and thus, working memory is an important component to be considered when assessing language in adolescents and young adults. Working memory corresponds to that of which one is conscious at any given moment, and in language production, "it serves the role of 56 Wolter maintaining information while planning happens" (Cowen, 1998, p. 3). Success in language comprehension and production comes from the ability to maintain and integrate linguistic information in working memory (Weismer, 1998). Simply put, many researchers believe that the processing of language breaks down when demands on a system exceed the available resources.

To illustrate how working memory affects language processing, consider the student interacting with friends versus the same student giving a presentation in class. When the student is speaking to his peers, he most likely uses common vocabulary and simple syntax in relation to highly familiar topics; moreover, he can anticipate what his friends are thinking and build on their utterances in the give and take of conversation. In this context, the student may use little of his working memory resources to maintain and integrate the language expressed and comprehended. However, when the student is giving a formal presentation in class, the vocabulary may be new, and more complex and sustained syntax is expected. The student may be worried about what his peers are thinking as he speaks. Thus, the way in which the presentation is given must be planned out. Increased demands require more working memory resources to maintain and integrate the language used and comprehended. When working memory is stressed, the student's language may break down, and behaviors, such as word–finding problems (i.e., mazes) may result.

Given that linguistic context affects the working memory resources available to the student, it is important to consider the context in which communication is breaking down and whether working memory load is a factor. When I conduct an evaluation, I am always considering what the working memory demands may be in varying linguistic contexts.


Given the differing working memory and linguistic demands of varying contexts, there are multiple levels of discourse that I believe should be sampled when assessing adolescents or young adults. These multiple levels of discourse can be found in both written and spoken language measures, and they vary along a continuum of unplanned to planned communication. Conversational, narrative, and expository discourse samples are all examples of discourse that vary along the planned continuum. Conversational discourse is defined as unstructured or unplanned spoken interactions between two or more individuals. This is considered unplanned because speakers rarely plan discourse beyond the next utterance or conversational turn (Hadley, 1998). Narrative and expository discourse require increased cohesiveness and higher–order planning (Hadley, 1998), and in some instances, a more advanced level of semantics and syntax. Narrative discourse requires planning as the student tells a complete story about happenings or events. Expository discourse includes relating factual or technical information, such as descriptions, procedural guidelines, or cause–effect relationships (Hadley, 1998). Both narrative and expository discourse require that the student plan and organize his or her thoughts in a cohesive way, determine the important components to include in the discourse, consider the listener's background knowledge, and use appropriate vocabulary. Thus, the linguistic demands are much higher for expository and narrative discourse, and it follows then that sampling different types of discourse will help to determine whether communication is breaking down at the higher linguistic levels.

When collecting discourse samples, I suggest starting out with conversational discourse to establish rapport with the student and determine the individual's interests and hobbies. The clinician should facilitate a brief conversation with the student regarding topics such as family status, personal interests, challenges at school, and/or extracurricular interests and hobbies. The clinician should ask open–ended questions whenever possible (e.g., "Tell me what it's like to be the only boy in the family"). Following this conversation, the clinician can elicit expository discourse on topics related to the student's interests. For example, if the student likes a specific activity (e.g., football), the clinician may have the student describe that activity as if the clinician is naïve to it (e.g., "I'm not certain of the rules of football, so please explain them to me"). If the student feels strongly about a particular social issue (e.g., a school dress code), the clinician can have the student give a persuasive argument for or against the issue (e.g., "Explain why students should be able to wear anything they want to school"). Finally, narrative discourse should be elicited on a topic that is not scripted or familiar to the student. Appropriate procedures will be discussed in detail in the narrative assessment section of this chapter.


In addition to eliciting different types of discourse, it is important to sample language in varying settings, such as in academic or social contexts with peers, teachers, and/or parents (Nelson, 1994). As mentioned earlier, an adolescent may speak differently with peers (e.g., using simple vocabulary and slang) than when speaking with teachers (e.g., using formal language and avoiding slang). Furthermore, just as there are subtle rules for how a student should interact socially with peers and others, the classroom has its own culture, which may involve spoken and unspoken rules about how to communicate (Nelson, 1994). The language of the classroom can be very metalinguistic in that the language of language (e.g., circle the adverb in the sentence) and figurative language (e.g., idioms, such as cut down to size) are often used. Thus, I believe that a complete language assessment should include observations and assessments of the student's language comprehension and use in all the major contexts in which he or she is functioning.

Word Finding

Often the student with a spoken language deficit may experience word retrieval difficulties— or maze behaviors—in demanding linguistic contexts and settings, such as expository discourse in the classroom, which are indicative of underlying linguistic concerns. These maze behaviors include talking around the subject (i.e., circumlocutions), using nonspecific words (e.g., thing, stuff), abandoning a topic before completing the initiated thought (i.e., orphans), and so forth. Any of these maze patterns may negatively affect the individual's ability to communicate, resulting in increased frustration levels. These maze behaviors, although disruptive, may be symptomatic of deeper linguistic issues, such as taxed working memory; limited semantics, syntax, or pragmatics; and/or restricted executive functioning. Although I make note of the specific mazes used, I find that it is even more important to determine the context in which the mazes occur. For instance, do the mazes occur in speaking contexts where formal syntax and semantics are required or do they occur in conversation with peers where the student must focus more on the social use of language? Thus, semantics and syntax should be assessed in individuals who produce mazes to determine the underlying cause of these word–finding difficulties. In this way, I focus on the means to directly target the problem (e.g., poor syntactic knowledge) in treatment versus targeting the symptoms.

Literate Language

The increased semantic and syntactic complexity found in contexts such as narrative and expository discourse is often referred to as literate language. According to Westby (2005), literate language is characterized by the use of complex semantic variables such as conjunctions (e.g., moreover, conversely, therefore), mental linguistic verbs (e.g., decided, thought, recalled), adverbs (e.g., accidentally, suddenly), and advanced syntactic structures such as elaborated noun phrases (e.g., John, the lifeguard). Literate language is found in the more formal spoken language contexts, including narrative, expository, and written language discourse. Furthermore, it is through exposure to literate language in books and writing that students develop and are subsequently expected to use literate language. Literate language is essential for the adolescent or adult to achieve academic success, and thus it is an important component of the adolescent and adult assessment. Specific semantic and syntactic structures typically seen in the literate language of adolescents and young adults are discussed in the following sections in this chapter.

Semantics and the Literate Lexicon

Semantics play an important part in the development of adolescents' and young adults' use of literate language. Specifically, the semantic aspect of literate language is composed of the literate lexicon and figurative language. The literate lexicon consists of words that occur with low frequency in spoken language yet occur in academic texts in high school and college (Nippold, 1998). Words included in a literate lexicon may be concrete entities with domain–specific definitions (e.g., metamorphosis, insecticide, ecosystem), abstract nouns with abstract definitions (e.g.,kindness, freedom, diversion), metacognitive verbs that refer to how individuals speak (e.g.,predict, argue, demand) and think (e.g., hypothesize, infer, reflect), and words and phrases that link ideas across sentences (e.g., adverbial conjuncts such as meanwhile, therefore, in contrast to) (Nippold, 1993; 1998; Nippold, Ward– Lonergan, & Fanning, 2005; Westby, 1998).

Vocabulary development, specifically the development of the literate lexicon, continues through adulthood and is greatly facilitated by the literate activities of reading and writing. Moreover, the learning of vocabulary is a gradual process in which the full understanding of abstract concepts and multiple meanings of words culminates in late adolescence and adulthood through exposure and experiences with new vocabulary. Researchers have found that the ability to provide definitions for concrete and abstract nouns improves markedly during adolescence because adolescents are more likely than younger school–age children to include important characteristics and specific category terms in a formal style (e.g., McGhee–Bidlack, 1991). Thus, abstract verb understanding and usage is continually improving and developing well into adulthood.

Given this research, when I complete an assessment it is important to consider whether a student has the ability to comprehend and produce concrete and abstract nouns, metacognitive verbs, and adverbial conjuncts and phrases. Some standardized tests are available with subtests that assess semantic concepts such as understanding multiple meanings and the relations between words. These include The Clinical Evaluation of Language Fundamentals, Fourth Edition (CELF–4; Semel, Wiig, & Secord, 2004), the Test of Language Development, Third Edition: Intermediate (TOLD–3; Hammill & Newcomer, 1997), and the Test of Adolescent Language, Third Edition (TOAL–3; Hammill, Brown, Larsen, & Wiederholt, 1997). These tests, however, are limited and may not adequately reveal whether the student uses higher–level vocabulary required in literate language. Thus, I believe it is appropriate to examine students' language at the higher–level discourse levels (e.g., narrative, expository) and establish instances in which an appropriate literate lexicon should have been or was indeed used. Of course, written language samples (which will be discussed in Chapter 5) provide a formal and appropriate context for using a literate lexicon and should therefore also be analyzed for higher–level semantics.

Semantics and Figurative Language

The production and comprehension of figurative language, or nonliteral language, continues to develop and should be assessed through adolescence and adulthood 60 Wolter (Nippold, 1998). Figurative language includes metaphors, similes, idioms, and proverbs. Understanding figurative language is important for an older student's academic and social success. In the classroom, researchers have documented that more than one third of teachers' spoken utterances contain examples of figurative language (Lazar, Warr–Leeper, Nicholson, & Johnson, 1989). Furthermore, figurative language is common in the textbooks and written materials often used in classrooms (Nippold, 1991). Socially, figurative language provides an important way to relate to peers as well as to establish and maintain a sense of identity (Reed, McLeod, & McAllister, 1999). The following sections delineate the differing types of figurative language.

Metaphors and Similes

Metaphors are figurative expressions in which one element is compared to another based on one or more shared features (e.g., She's a skinny rail). Similes are variations of a metaphor in which comparisons between two or more elements are made explicit through the use of the words like or a (e.g., She's as quiet as a mouse). Although a thorough understanding of metaphors and similes develops with age, children are able to comprehend them as early as preschool (Gardner, 1974; Nippold, 1998). The ability to express the meaning of metaphors and similes, however, is a bit more complex, and according to Siltanen (1981, as cited by Nippold, 1998) students 15&#ndash;18 years of age have been found to experience some difficulties interpreting more abstract or difficult metaphors (e.g., Genius is perseverance in action). Thus, I would expect adolescents to interpret more transparent or concrete similes or metaphors easily (e.g., hard as a rock) and be less adept at understanding those that contain abstract concepts (e.g., calm as a hurricane).

Idioms and Slang

Idioms are expressions with a fixed meaning that cannot be figured out through the literal interpretation of words (e.g., kicked the bucket, raining cats and dogs). The comprehension of idioms is linked to the contextual support available (Nippold, 1998; Nippold & Martin, 1989). Idiom usage is pervasive in the academic setting. Nippold (1991) reported that approximately 9% of all utterances produced in eighth–grade classrooms contain idioms, and Kreuz and Roberts (1993) found that approximately 18%–20% of all language in contemporary American literature contains idioms. Therefore, it is important that students have a grasp of idioms and how to understand new instances of them to be successful in the classroom.

Slang terms (e.g., cool, right on) are words or phrases that have fixed meaning based on conventional use of a term over time in specific subcultures (Nippold, 1998). Slang is sometimes used by specific subcultures to identify the group as different or unique. This is especially true in adolescent subculture because slang is used by adolescents not only to fit in and relate socially to peers but also to set themselves apart from their parents. Thus, some slang terms change over time, and what was used by one adolescent subculture or generation (e.g., groovy, bogus) becomes outdated by the next generation. Therefore, it is important that the clinician be aware of what terms are being used by the assessed student's peers and not expect outdated slang to be understood or appreciated.


Proverbs are statements or phrases used to warn, promise, or advise others (e.g., a stitch in time saves nine). Again, context plays an important role in the understanding of proverbs. Conflicting research exists as to whether early adolescents find the production and comprehension of proverbs difficult. It is known, however, that it is important to present proverbs in context for students to fully comprehend their meanings. Moreover, Nippold (1998) asserted that proverbs can vary along a continuum of concreteness (e.g., a leopard cannot change its spots) to abstractness (e.g., success is first a dream). If a proverb is more easily visualized, it is typically more easily understood. Proverb complexity can also be affected by the degree of familiarity of a specific proverb. Adolescents first understand concrete and familiar proverbs, while comprehension of more abstract proverbs may appear in adulthood.

Assessment of Figurative Language

There are some standardized tests that may be used to determine whether the student understands and/or produces figurative language. One such test is the Test of Language Competence–Expanded (TLC–E; Wiig & Secord, 1993).When administering a test such as this, it is important to remember that figurative language may change from generation to generation and some students may not have had exposure to specific figurative expressions. Given the dynamic nature of figurative language, I believe it is important to consider the functionality of how and when it is understood by a student. This can be done by observing the student in contexts such as communicating with peers in the school hallway, interacting with teachers in the classroom, or discussing tasks with co–workers at a job. The clinician should try to determine whether communication breakdowns occur when specific figurative language is being produced or interpreted by the student. In addition to observations, the clinician also may review the student's spoken and written language in conversational, narrative, and expository discourse contexts to determine whether figurative language is being used appropriately.