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S is a grade 2 (7 year old) male student with normal nonverbal intelligence, and presents with a possible language impairment. S was nominated by his teacher to be assessed for his receptive and expressive abilities. His teacher reports that he has difficulty answering questions, with utterance that consists of omissions, reduced grammatical markers and when he is called upon, appears frustrated during independent reading time. Specifically, he has a hard time decoding unknown words and also has difficulty answering comprehension-based questions, with decreased logical and sequential discourse skills. The teacher is concerned about his current reading comprehension is limited by problems decoding text, understanding the text while reading, or recalling text information after reading.
Developmental language disorders (DLD) is a condition where a child has difficulties understanding and/or producing language and these difficulties impact on their everyday life (Centre of Clinical Research, 2017). In the absence of intellectual disabilities, such as autism and Down syndrome, children with LI characteristically struggle with the processing and production of spoken language. Some of the specific areas in which many of these children have difficulty are word finding, narrative retell and understanding, receptive and expressive vocabulary, grammatical understanding and expression, phonological processing, and working memory (e.g., Boudreau & Constanza-Smith, 2011; Edwards, Beckman, & Munson, 2004; Gathercole & Baddeley, 1990). Dorothy Bishop has been a dynamic individual advocating for Developmental Language Disorder (DLD).Speech pathology Australia (2018) also mentions that children has some difficulty with the production of complex language, across the domains of syntax, morphology, phonology, semantics, and pragmatics.
Developmental language disorder remains one of the most misdiagnosed, but frequent disorders in society (Boyle, Gillham, Smith., 1996)( Tomblin , Smith, and Zhang , 1997). This could be due to the fact that there is still a barrier in establishing a universal/consistent terminology, which may cause confusion among parents and possible stakeholders, as well as the effect a DLD may have on an individual (Bishop, 2010). With an indication of 5-8% of children having a DLD, and an estimated 7% in Australia according to statistics from 2009 (Australian Bureau of Statistics, 2009). This issue remains of utmost importance as these statistics may be even higher in other societies. This disorder poses a risk of possible burden on the society. This disorder has a strict following criteria that it has to adhere to be seen as a burden (Law, 2017). This will include the financial strain it may have on the society, pertaining to Medicare claims made by Speech Pathologists (Commonwealth of Australia, 2014).
Public health
Similarly in Victoria, Australia, a practice review showed that many language promotion programs and strategies are currently being used to enhance language outcomes in 0-3-year-olds (Law & Pagnamenta, 2017).
Evidence of upstream preventative services
Upstream preventive services, will aim at the purpose of prevention rather than treatment. The issue remains, that if prevention was ineffective, that intervention based approaches should receive attention. This interventions goal is to promote the language skills of young socially disadvantaged children (Warr-Leeper, 2001). It is important to note that, many of these intervention approaches show promising outcomes when provided in bigger groups. This will be necessary for those individuals who does not always have access to services. The risk is that, as has been the case in other health areas, universal interventions may have a more
positive effect on more advantaged children (White., Adams, Heywood, 2009)( Marulis., Neuman B. 2010). The golden standard will be to provide therapy according to each individuals needs (Marmot. 2010).
There is a useful distinction to be drawn between truly universal services that are equally available to everyone, services which are targeted to a specific subpopulation (targeted-selective), and those which are delivered according to Individual need (targeted-indicated)(Asmussen,., Feinstein., Martin., & Chowdry, 2016). By providing a combination of these services will be beneficial.
Implications and recommendations.
Researchers among various income countries has proposed for DLD to be seen as a public health issue. (Law et al, 2013) DLD meets the criteria for a domain that fits within a public health framework as it places a large burden on society, is distributed unfairly, and there is evidence that upstream preventive strategies could reduce the burden of DLD if population health approaches are taken.
LANGUAGE INTERVENTION
What is the intervention options for children with language disorders?
Some language intervention programs target specific language skills (e.g., phonology, semantics, syntax, morphology), while others are more holistic in nature, targeting a broader range of language and communication skills (e.g., expressive language interventions and receptive language interventions).
Models and approaches to child language intervention (Paul, 2001)
Clinician-directed intervention
This intervention approach uses behaviour modification (learning theory/ behaviourism). The clinician takes the lead in directing therapy and modify techniques to achieve the selected target. This entails a highly structured and controlled by the clinician. The specific materials used are important as well as the sequence how these materials are used during activities. During this approach the form of responses are required, the types and frequency of reinforcement needed to achieve the wanted language goal. Target language becomes highly salient during intervention. The clinician provides clear reinforcement to increase the frequency of the selected language behaviours, and controls the clinical context to ensure optimal change. The clinician also provides opportunity for repeated practice of the selected target for e.g.
Naturalistic approach (Peterson, 2004)
Various speech therapy programs have been developed to assist in language, literacy and learning. Regarding language, Peterson (2004) has pointed out the most important naturalistic, but functional approaches used in intervention approaches. A number of related language intervention procedures have been developed for use in the childs natural settings, including the childs home, classroom, or child care. These procedures include incidental teaching (e.g., Hart & Risley, 1975), mand-modeling (e.g., Rogers-Warren & Warren, 1980; Warren, McQuarter, & Rogers- Warren, 1984), and delayed prompt or time-delay (e.g., Halle, Marshall, & Spradlin, 1979). Taken together, these procedures might be termed naturalistic language teaching. From experience I have also seen more generalization of language in the therapeutic environment, but also reported by parents.
Functional approach (Owens, 2004)
I have learned that the role of the therapist cannot be underestimated. The therapist will play a nurturing and supportive role during the intervention process. The therapist will facilitate and serve as a consultant in the intervention process. Intervention strategies are normally used in a naturalistic environment where any response is better than none at al. From experience I have learned, that limiting corrections made to utterance, the child will feel more comfortable and motivated to participate in therapy. Indirect expansion methods are preferred rather than direct corrections. The child will therefor lead the therapy and therapy will be structured around the developmental goals. Language and communication will then influenced by the context. Which has provided the necessary and favourable outcomes. Whole language (Paul, 2001), is self-explanatory, which is also used as the basic assumption is that oral language is best learned in meaningful contexts i.e. where the purpose of communication is to send a message or convey meaning and for the listener to understand the meaning. This is also known as a functional approach to language learning. This approach encompasses all language modalities (speaking, listening, reading and writing) are integrated to make meaning and cannot be broken up into discreet parts. The whole language approach also allow the child to gradually construct new knowledge from their experiences, without correction or reinforcement reward is in the successful communication of intended meaning)What remains a problem is that some children have difficulties with only specific components of language and require more focus on particular aspects of language.
Narrative Interventions
Parents can play an integral part in narrative interventions, which can be executed during functional activities, such as fetching children from school and guiding the narrative intervention. Narrative interventions focus on improving a child’s story-telling ability, including the ability to provide context for the listener. Through this the child is able to use narrative structures (story grammars) to organize events; and utilize microstructure (e.g., syntactic complexity, temporal and causal conjunctions, coordinating conjunctions, elaborated phrases, and adverbs) to enhance the clarity of the narrative. Narratives can provide a naturalistic means of targeting specific language difficulties. By implementing this approach, it provides an opportunity for the parents to provide the needed morphology, syntax and metacognitive stimulation through language stimulation (Paul, 2001).
Parent-Mediated/Implemented/Involvement
Parent-mediated or implemented interventions consist of parents’ using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills. This approach also includes the parents and involves them in therapy. This approach can be useful in the South Africa, as well as lower income countries to promote language stimulation and prevent language disorders or delays.
PHONOLOGICAL INTERVENTION
Phonological Awareness (PA) remains one of the main building blocks for reading and writing.
Phonological awareness is the skill of being able to identify and manipulate individual phonemes in a word (Begin to Read. 1996). A phoneme is the smallest unit of sound which adds meaning to a word. Phonological awareness is also the ability to form a relationship between these phonemes and the letters of the alphabet.
There are 3 linguistic levels of phonological awareness: Syllable awareness, onset-rime awareness and phoneme awareness. The easiest of these three levels is syllable awareness. This level involves the childs ability to know that words can be broken down into different syllables and that each syllable must have a vowel. Although this may be subconscious, the child will have an awareness of where one syllable ends and another starts. Syllable awareness is usually used to teach spelling to older children and is used verbally with
younger children (Gillon. 2004). Onset-rime is the second level. Once a word has been broken up into its various syllables, each syllable can be broken into its onset and its rime. The onset consists of the consonants before the vowel in the syllable. The rime consists of the rest of the syllable (the vowel and the consonants which come after). Ones ability in the onset-rime awareness level is assessed via rhyming tasks. The final level of phonological awareness is the phoneme awareness. As discussed earlier, a phoneme is the smallest unit of sound which adds meaning to a word. This is the last and most important level for a child to master. Once onset-rime has been completed, a child will learn how each word is made up of a number of various sounds for example, table is phonetically made up of the following sounds: /t/, /eI/, /b/, /l/ (these sounds have been phonetically transcribed).
Phonological awareness is acquired by children before they begin to read and write. The acquisition of phonological awareness usually begins around the age of 4 years. This is when the child becomes aware of letters (depending on their exposure)(Bowen, 2011) At this age children love nursery rhymes. They are able to recognise rhyme and syllables as well as blend syllables together. Blending is when syllables or sounds are joined in order to make a word. From the age of 5 children are building their vocabulary. They are able to alliterate, match the beginning sounds of words, produce rhyme and do onset-rime segmentation. Segmentation is when words are broken down into their syllables or phonemes. At the age of 5 years, 6 months, a child is able to manipulate syllables. Manipulation is removing a syllable or phoneme in order to make a new word. Children are also able to blend and segment phonemes. These abilities allow children to develop decoding skills which are important when learning to read and write. A child who is around 6 years of age is able to add, delete and substitute phonemes (Snowling & Stackhouse, 2006). It is important to note that children do not follow this exact developmental process. According to other authors such as Tolman and Moats (2009), sound deletion, addition and manipulation of consonant clusters can occur as late as 7 or 8 years of age.
Although there is a large amount of research which has been done on the development of phonological awareness in English, there have been few studies done on the other official South African languages. A paper done on Sesotho speaking children in South Africa implies that although little research has been done on the development of phonological awareness is Sesotho speaking children; there is some evidence to show that it is acquired in the same manner as English (Demuth. 2007). A literature review done speaks about phonological awareness in the development of bilingual children in South Africa. According to this literature review, there are 3 different opinions as to how phonological awareness skills from ones first language (L1) can be used to achieve the same level of language in ones second language (L2). The first opinion is that the process of phonological awareness occurs cross-linguistically. The second opinion states that phonological process skills are transferred from L1 to L2 or L3 while they are being developed in the childs L1. The final opinion states that it cannot be proven that phonological awareness skills can be transferred from a childs L1 to their L2 with the current research that is available. Bilingualism negatively impacts a childs phonological awareness skills (Milwidsky. 2009). In this study, working memory and phonological awareness skills between 2 groups were assessed. The children who had a L2 used unrelated skills in order to conduct the phonological awareness task. This supports the theory that phonological awareness skills are not transferred across languages. There needs to be more research done in this area in order for an individual theory to be prominent.
Phonological awareness is very important for literacy. Literacy consists of reading (interpreting graphic symbols into sounds) and writing (constructing graphic symbols from sounds). Poor phonological awareness is proven to be related to poor reading abilities which impact a childs vocabulary and general knowledge (Cockcroft, Broom & Grrenop. 1999). A study done by Lundberg, Olofsson and Wall in 2008 showed that over 70% of children with phonological awareness skills before any type of literacy was learnt, achieved better in their reading and spelling tests in the first year of school than those who had below average phonological awareness skills. The most important level of phonological awareness for a child to master is the phoneme level. This is because a child needs to be able to hear the phonemes in a word in order to sound out novel words when reading. This is important for writing as well. Although the phoneme level is the most important level for a child to reach, onset-rime is just as useful as onset-rime helps children to recognise common groups of sounds within words which can help them to decode words when reading as well as to spell them when writing.
Phonological awareness is fundamental for reading and writing. The three linguistic levels carefully guide children to learn decoding skills which a child will use when learning to read and spell. The insufficient amount of literature on the phonological awareness development in South African languages other than English, cannot allow for conclusive evidence on this topic. Franz Kafka once said, A book must be the axe for the frozen sea within us. Every child should thus have the right to feel this way when reading a book and we should, therefore, focus on phonological awareness and help those who struggle to become readers.
Phonological Processes (Oller, 1975)
This is a strategy used by younger typical developmental individuals, and usually form 1.5 years to 4 years of age. The reason for using this process is to simplify adult speech sounds. For example, children omit weakly stressed sounds in a word, such as elephant as ephant. With this phonological processed being evident it is noted that speech might be perceived as unintelligible at times (Roth & Worthington, 2011)
The cycles approach, by Hodson and Paden (1983) is a known phonological process intervention used for highly intelligible individuals. There phonological patterns are identified and each pattern will be addressed with a 5-16 week period. The session sequence includes 1) auditory bombardment, 2) production training, 3) stimulabiity probes and 4) at home activities to ensure generalization occurs. After intervention has taken place, the child is given time to internalize the new learnt pattern, until the clinician introduces new patterns. The goal is to ensure that the child is able to generalize the pattern in spontaneous speech (Roth & Worthington, 2011).
SPEECH DISORDERS
The traditional Approach by Van Riper (1975) has provided favourable outcomes in therapy. This is a phonetic based approach, and is also known as the sensory-based approach, motor based approach. This intervention focuses primarily on sensory training first, which allows the client to be able to differentiate correct vs. incorrect productions as times. The training involves 1) speech sound discrimination level, 2) achieving phonetic placement, 3) producing sounds in isolation, 4) producing the sound in nonsense syllable, 5) producing the sound in initial, medial and final positions, 6) producing the sound in phrases and sentences and 7) producing the sound in conversational speech. This approach has provided the best possible outcomes in therapy when working with children and adults.
CONCLUSION
From a personal perspective, I have never used one exclusive intervention approach. I have always used eclectic approach when providing intervention to each individual. It is important to keep in mind that not every child will reflect the same progress of have the same goals for language intervention. Language is a natural instinct humans and should also be treated in that manner. Indirect and direct methods has worked in therapy, but some children require a more structured approach than others. From clinical experience and years in therapy, one will acquire the ability to be sensitive to individuals personalities and communicative needs. By doing that, the needs of the clinician and the therapist remains in balance.
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