DLD & Education

Today there has been a web chat run by @DLDandMe all about the impact having a language disorder has on a child’s education. It is part of their wider work to raise awareness of Developmental Language Disorder  (DLD) and to spread the word to a broader audience, about what DLD is, how to recognise it etc. I joined in a little, although late, but I thought it might be useful to share more detail about this topic, from our own personal experience.

As most readers already know, I am both a speech and language therapist and Mum to our seven year old son – LB – who has DLD. There is a complication to our story, which is that LB experienced early neglect and didn’t come into our lives until he was three and half. It is pretty impossible to pick apart the different impacts of neglect and DLD, with both having made their mark. However, it was clear from fairly early on that the communication difficulties LB experienced were more significant than delay alone and where progress was quite quick in some areas, speech and language has always proved more challenging for him. As much as possible in this post, I’m going to focus on the specific ways DLD has affected LB’s educational progress, notwithstanding the separate effects trauma has had.

LB’s DLD impacted on all areas of his communication development when we first met him – including his ability to understand language (comprehension), his auditory memory, his ability to use words and make sentences (expressive language), his ability to listen and pay attention, his ability to speak clearly and his social communication. When I talk about his presentation back then, in workshops and the like, I can see that it shocks people. And it was shocking, because LB’s language system just couldn’t do what he needed it to – not one part of the complicated whole functioned as it should have. He was very much trapped inside of himself and he wasn’t left with many options other than to express himself through his behaviour.

In the early stages of his pre-school education, this impacted him in a myriad different ways. He was certainly delayed in learning concept words such as his colours, size words, same/different etc. which meant he just couldn’t follow much of the teaching or express answers to what nursery staff would likely consider easy or every day questions. That said, with specific teaching of one concept at a time and plenty of reinforcement in everyday activities and play, LB was able to close the gap pretty quickly. It isn’t that LB can’t learn, because he has developed phenomenally quickly, it’s just that he couldn’t pick these concepts up from the ether, as children with typical language skills would. He required specific teaching, repetition and showing, to get them to stick.

Obviously, struggling with comprehension made it even harder for LB to learn new things. There must have been much of what went on in Nursery that he couldn’t follow. This no doubt exacerbated his difficulties with listening and attention, because it is extremely hard work for anybody to focus on language they don’t comprehend. Imagine having to listen to French or Urdu or Finnish or any other language you aren’t familiar with, for large swathes of each day. It would be exhausting and it wouldn’t take long until you stopped listening. Therefore, in some ways, LB’s DLD exacerbated his DLD. He certainly coped better on a 1:1 and thankfully we were able to provide him with this because I was on adoption leave and he just went to pre-school for a few sessions (and now he has TA support). Keeping distraction levels down and matching our language to the level LB could cope with, was imperative. It meant we could keep language accessible for him most of the time and choose which concepts or structures we wanted to stretch him with. I guess this is where my professional background came in – I suspect creating these ideal learning conditions would be much more difficult for a child whose parents are new to the idea of DLD and whose pre-school setting don’t get it.

Certainly as LB’s comprehension developed, so too did his ability to learn. I know it sounds a bit ridiculous but he did appear to be growing cleverer. I maintain that had he have had a cognitive assessment at the beginning, and one a couple of years later, he would have climbed the percentiles. This is because learning and education is generally acquired through the currency of language. As he acquired more words, he knew what more things were. He was able to express how things work. He was able to enquire and find more information out. The more language you have, the better you become at gaining it. Initially, we just couldn’t have talked about complex ideas such as electricity or natural disasters or endangered animals or health conditions. LB didn’t have the vocabulary to access a discussion or explanation about such things so he essentially wasn’t able to learn about them. It was only when he had gained sufficient depth and breadth of vocabulary and could listen to and follow longer structures, that he was able to develop his knowledge of the world around him. And when this did happen, it was amazing to witness the world opening up to him.

Vocabulary acquisition was a huge ongoing challenge for LB (and me) for a long time. Initially, even though we used lots and lots of modelling strategies, he didn’t seem to be growing a larger vocabulary. Again, like with other aspects of his language system, the more he heard a word used and the more times he managed to store a new one, the better his language processing system got. He has certainly got quicker at acquiring new words, even if this continues to be hard for him. Evidently LB’s language processing system (the bit of our brains that hears words, de-codes them, decides what sounds are in them, and their meaning, and stores them in an organised way, ready to be spoken) was not well-developed. It was laborious for him to use it, meaning that getting his vocabulary as big as he needed it to be must have been an exhausting task for him.

Where LB would once have needed to hear a word used around him for several months, with a high level of repetition, before being able to store and use it, he can now store a new word almost immediately. This has had a huge impact on his ability to be able to keep up with the curriculum. Each new topic brings a cornucopia of new words, which children are expected to immediately absorb in order to follow teaching. If you can’t understand the new words, it’s extremely difficult to follow the new lessons.

Although speedier, LB’s processing system remains inaccurate – he struggles to de-code words so that, without help, he might store ‘Corvette’ as “courgette” or ‘submarine’ as “subramine”. He is aware of this so often requests help – just having someone break a word down into bite-size syllables is a huge help to him and allows him to store a new word correctly. At school he has word webs for new words and is building up a personalised dictionary with his TA.

Despite all the hurdles, LB’s comprehension skills have caught up. He seems able to access the vast majority of teaching in his year 2 classroom without too much difficulty. He does cope better with multi-sensory teaching and visual supports (such as narrative grids, Mind Maps etc.), not least because they help to hold his attention. When LB is tired, his skills in this area do diminish a little and he might need a bit more repetition but overall I think his progress underlines what the right speech and language therapy input can achieve for children with DLD.

LB’s difficulties with auditory memory have impacted in several ways – most notably on his ability to blend sounds together and to learn listed information. Literacy acquisition was always going to be a challenge for LB, as his speech continued to be unintelligible well into year 1, with vowel distortions, and his sound awareness skills (identifying the first sound in words, rhyme, syllables etc) were poor. Even the pre-reading task of describing what’s happening in a picture was ridiculously difficult, because LB didn’t have the sentence structures or vocabulary he needed in his expressive language – something else we taught specifically.

We worked hard on sound awareness in a stepwise manner – identifying the first sound of short words then longer words, then the last sound of short words etc., alongside attending speech and language therapy. Again, I feel that good phonological awareness skills are something LB wouldn’t have been able to acquire organically, but he was very much capable of achieving on a 1:1 basis with a personalised approach.

We stumbled at the point of blending sounds together – a critical final step before literacy could be gained. The difficulty it turned out, after a bit of ‘diagnostic therapy’ (again, thank goodness for my career) was the blasted auditory memory which was struggling to hold three sounds, let alone stick them together. Once more, practise paid off and eventually LB could blend. Which, having already learned his letter shapes – pretty easily, it was a visual task – meant he could read. Progress has been steady since that point, with him progressing through the reading levels as you’d expect. In my opinion, a good phonics approach is essential for a child with DLD. It was a challenge to establish that strong foundation but once it was in place, it served LB well. He is not yet meeting the expectations of the curriculum but his reading is good; he understands text and he can apply his phonic skills to decipher most words. Crucially, he loves books and listening to stories. Keeping things as fun and engaging as possible is another essential tool in encouraging a child with DLD.

However, LB is not yet ready to apply his phonic skills to writing, finding this laborious. The addition of SPAG requirements such as including a noun phrase, or adverbial, pretty much renders writing the very worst aspect of school life for LB and, in my humble opinion, totally takes the fun and imagination out of it for all children.

It is hard to get LB’s teachers to understand just how many demands writing places on the language system of child with DLD. My hunch is that when his reading skills are better still and he’s had more specific phonics teaching, his ability to spell will improve. I suspect that expressing himself on paper, with appropriate grammar, will always have its challenges.

The other area auditory memory difficulties have impacted is LB’s ability to learn listed or sequential information such as the days of the weeks, months and, perhaps most crucially, how to count. Learning the numbers to ten proved extraordinarily challenging for LB so that when he started school, aged 4 and half, he couldn’t count to three in the correct order. The knock on effect of this was that Maths was pretty much impossible. How can you do sums when you haven’t the basic language for it? When “4” or “732” are just as meaningless and unquantifiable? This certainly held LB back and for the first year, perhaps two, of his education, his literacy skills appeared better than his numeracy ones, which lagged significantly behind. However, all the repetition and visual representation eventually paid off and LB learned to count to 10. And then 20. Very soon after that, probably because he could use his logic and ability to see patterns, he could get to 100. Once he had the language, Maths wasn’t so hard at all. In fact, it looks as though LB will meet the expected levels of the National Curriculum for the first time this year, which is no mean feat, given his starting point. Now that he has the language, even the reasoning SATS paper is accessible to him, despite the problems being presented in word form.

Having DLD has made every aspect of LB’s education more challenging for him. However, with the right support, LB has proved over and over again, what children with DLD can achieve and how crucial getting that support in place is. Language underlies all learning and we ignore that at the peril of children with DLD.

 

 

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DLD Awareness Day 2018

It’s been a hefty week for blog-fodder with both National Adoption Week 2018  and International Developmental Language Disorder Awareness Day (Friday 19^th October) landing at the same time – two events I am always keen to talk about.

This year’s theme for DLD day is the ‘ABCs of DLD’. The ‘A’ represents assessing our understanding of DLD. If you want to test how much you know, you can take this handy  Quiz

When I reflect on what I know about it, my professional experience as a speech and language therapist has mainly been usurped by my experiences at home, parenting my son who has DLD. He is currently 6 years old and in Year 2 at school. He has been discharged from speech and language therapy because his scores for both comprehension and expression of language now measure within the expected range for his age. A key thing I have learned is that with the correct intervention, children with DLD can make incredible progress and can catch up (see Speech Therapy Works  for more detail).

Although Little Bear has made unbelievable progress, he does still have DLD. He largely copes well day to day but there are specific times when I notice a difference in how his language system works compared to other people. One time is when he tries to learn a new word or a new name. Little Bear requires much more repetition of unfamiliar vocabulary and often needs me to break new words down into syllables so he can learn them in manageable chunks. He is very good at learning and retaining new words now but the processing part of his speech system isn’t as smooth as it should be and he would struggle to store new words without some specific teaching. If he doesn’t have help to ensure he understands what a word means and what all the bits of it are, he might struggle to say that word correctly e.g. ‘Emily’ recently came out as “Elle-uh-me” and ‘Joseph’ as “Jo-Fitz” or he might mis-store the word e.g. when Little Bear puts on a tall pointy hat, he says he’s being a ‘lizard’ (he means wizard) or he tells me to find things on the ‘window sledge’. Little Bear also uses ‘about’ instead of ‘without’ so will say, “It’s hard to sit on this chair about falling off it.”

Little Bear has good awareness and he knows he’s making the sound errors (he isn’t always aware of the naming errors). He often looks to me at these points to do a bit of speech therapy on the fly to help him. Children with DLD are not un-intelligent. They can learn and retain information like other children, as long as the information is presented to them in an accessible way and/or suitable strategies are employed to help them.

Little Bear’s DLD is also noticeable when he is tired or when he is faced with too much auditory information. He still copes better if large chunks of information are broken down for him and in a conversation it helps him if you are willing to repeat some parts of what you’ve said. He does generally understand the concepts you are talking about and any explanations you give to help him but he can need a little longer to process them, more pauses and sometimes a second chance to listen to the information. If words sound very similar, Little Bear can struggle to differentiate between them e.g. fourteen vs forty, which can impact on his understanding of what he’s heard.

Most of the time, Little Bear can express his thoughts and ideas competently with language, even if they are complex. Occasionally he forgets to reference what he is talking about and we have to ask a few questions to catch up with him. There are some parts of grammar that he makes occasional errors with. We still use modelling strategies at these points.

I think it can be difficult for people who don’t know him well or teachers to see his DLD straight away. Now that his speech sounds are much more accurate, his language difficulties appear more subtle. It isn’t a surprise that DLD is a hidden condition and is widely underdiagnosed or misdiagnosed (see Ensuring Children’s Speech and Language Needs Are Met: A Call to Action for more info).

This brings me to the ‘B’ of the ABCs of DLD – build knowledge.

If you’d like to read more about what Developmental Language Disorder (DLD) is, you can read this previous post: Developmental Language Disorder

DLD is much more prevalent than most people think – 7 times more common than Autism. If you want to estimate how many children are likely to meet the criteria for DLD in your school, you can use this calculator tool: Calculator Tool

A particularly useful source of information to expand your knowledge of DLD is the new RADLD website: www.radld.org

As DLD is often hidden or missed and the consequences of lack of diagnosis/misdiagnosis are so concerning (increased likelihood of unemployment, mental health difficulties and involvement with the criminal justice system) it is imperative that we work together to raise awareness, hence ‘C’ is for create awareness and is my main focus for the day.

Here are some of the things I will be doing to create awareness:

• Emailing my children’s school to share information about DLD and the RADLD website
• Sharing information on my social media channels including tweeting with the hashtag #DLDABC throughout the big day and sharing #my3forDLD
• Sharing this blog
• Wearing my newly printed RADLD campaign t-shirt and hopefully explaining what it’s all about to people who ask me
• Our local newspaper has agreed to print an article I’ve written about DLD on the 18^th. It is going to include a photo of me wearing my campaign t-shirt (their idea, I’m a bit scared and frankly too many people have seen my face this week already!).

 

If you’d like to join in with the fun and make a difference at the same time, you can:

• Use the hashtags #DLDABC and #my3forDLD on Twitter, sharing knowledge, thoughts or ideas
• Share this blog far and wide
• Tell one person what DLD is
• Contact your children’s school to let them know about DLD Awareness Day and the RADLD website (feel free to send them this post)

 

If you have any concerns about your child’s language development or a young person you are working with, contact your local speech and language therapy service. Getting the right support has made an enormous difference to Little Bear. I asked him what difference it had made: “A lot. A big difference because I wasn’t good at talking. It was tricky. My talking is lots better than before. Miles better! I’m good at writing now.” He went on to say that speech therapy was fun and he missed ‘the lady’.

It is never too late to put support in place. Ideally, identification of DLD would be early and support would be tailored and intensive but if the signs have been missed, it isn’t too late. Support in the teenage years continues to be effective.

Teachers, health visitors, social workers, the police, lawyers, people who work in public services (amongst others) all need to know about DLD. They need to know it exists so they can be better at spotting the signs. When we see disruptive behaviour, particularly in classrooms, we need to consider DLD. If we want to improve outcomes for children like Little Bear, we need to spread the word; we need people talking about DLD. Let’s see if we can make that happen…

Speech Therapy Works

As a Speech and Language Therapist it shouldn’t really be a revelation to me that speech and language therapy works. Obviously I have always believed in it otherwise I wouldn’t have stayed with it as a career for over 14 years. It’s just that trusting something works because you understand the theory behind it and actually experiencing something on a practical level, within your own home, with your child, is quite different.

Obviously I have experienced success in my professional life, but that has been within the confines of a large caseload and various time and resource pressures. In the latter part of my NHS career, as a more senior clinician, my main role was assessment and report-writing. I rarely did any therapy as we had a structure where skilled assistants carried out care plans under our supervision. It meant I didn’t get to know children as well as I’d have liked and I didn’t get to share in their small steps of progress week by week. I re-assessed and reviewed progress, seeing improved assessment scores but that isn’t the same as cultivating progression yourself.

Now that I’m an independent therapist I’m really enjoying being able to properly get to know the children I work with. I’m completely invested in their therapy and am just as pleased when they move forwards or overcome something as I am when Little Bear does. I do see (and feel) therapy working now.

However, what we have experienced at home has taken my belief in speech and language therapy to a whole other level.

I was recently running a communication workshop (for adopters, prospective adopters & professionals) when somebody asked me a question that made me realise the examples I talk about in it, from Little Bear’s communication profile, paint a bleak picture. The picture is totally accurate and reflective of his communication skills when we first met him, aged 3 and a half. The picture, detailing significant difficulties with attention and listening, comprehension, expressive language and speech sound disorder was bleak. At the time I was fairly overwhelmed by his level of need and the magnitude of the task ahead of us.

Here is a very brief summary of Little Bear’s presentation then:

Little Bear was not tuned into language at all and did not respond to verbal instruction, including his own name. His comprehension was better than it appeared but significantly delayed for his age. Little Bear had a very small vocabulary that didn’t meet his needs. He did not have words for common, everyday objects such as cow, train, television, food items etc. Little Bear couldn’t answer ‘what’s your name’, his only size word was ‘big’, he couldn’t name colours or count and he couldn’t put more than about 3 or 4 words together. The words that Little Bear did have were unintelligible. Little Bear was extremely frustrated and he was often left with no other option but to express himself with his behaviour.

I quickly realised this wasn’t a straightforward language delay and that Little Bear’s needs met the criteria for Developmental Language Disorder

At the time I had no idea what the prognosis would be but I suspected it wasn’t rosy and that speech and language therapy would be a big part of our lives for years to come. It was hard to know where to start and easy to become overwhelmed by priorities. There were times I really questioned my faith in what I was doing and wondered if we’d ever get to where we were hoping to go.

I did not expect, in my wildest dreams, that 2 and a half years later a speech and language therapist would observe Little Bear in his mainstream classroom and say there was no discernible difference in language skills between himself and his peers and deem him ready for discharge. Yes, his attention and listening skills still mark him out and there are some minor speech errors but his comprehension and expressive language skills are now within the expected range for his age.

This near miraculous improvement is due wholly to one thing: speech and language therapy.

Admittedly our circumstances are unusual: most children with DLD do not have a parent who is a speech and language therapist and able to provide targeted intervention on tap 24/7. Little Bear has essentially undergone an intensive 2 and a half year block of therapy. Strategies have been used by the whole family and are an automatic part of the way we talk with Little Bear, not something we use for just a couple of minutes each day. The key strategies have included: using environmental sounds to capture Little Bear’s interest as a way in to listening to language; reducing our language; modelling of vocabulary, sentence structures and sound patterns; repetition; showing, explaining & checking understanding of complex concepts or new words as well as seizing every possible communication opportunity. We have done some direct work on auditory memory, phonological awareness (initial sounds, syllables, rhyme, blending sounds together) and speech sounds.

I suppose at any one time I have always had a current communication aim in mind, whether it has been a specific language concept or speech sound and I have found ways to weave this into play or our usual day to day lives. I have very rarely, if at all, asked Little Bear to sit at a table and ‘do speech therapy’, it has been a much more holistic and inbuilt approach than that.

Little Bear has also been seen by an NHS speech and language therapist throughout the past 10 months or so. She has taken the lead on sorting out Little Bear’s disordered vowels which have been complex to assess and set goals for. Generally she has started us off with a sound or activity and we have carried it on between sessions.

The NHS therapist has also set language goals for school and has provided them with programmes to carry out, which they have done.

All of these strategies, techniques and approaches have worked. Their effectiveness is inarguable. Yes, the sum total of the input Little Bear has had is massive and yes, me being a speech and language therapist does make things different. However, I truly believe that a similar impact could be gained by providing parents with good quality, strategy based communication training alongside regular sessions with a speech and language therapist, who could do the assessing and target setting bits, as well as providing resources and guidance. Similarly, if speech and language techniques can be embedded into teaching and used holistically as part of the curriculum (not here and there for 10 minutes) that too can be highly effective and impactful.

Little Bear is living and breathing proof of the efficacy of speech and language intervention. Prior to treatment when I’m almost certain that no strategies were in place, he made negligible progress. In fact, on entering pre-school shortly after coming home, Little Bear was assessed as having a delay of more than 2 years in all areas of his development, with speech and language and numeracy being the most delayed areas. Within 2.5 years of therapy, that gap has closed (meaning that Little Bear has essentially made 4.5 years’ worth of progress) and his comprehension and expression now measure within age expectations on standardised assessment.

Speech and Language Therapy works.

Whilst his progress has been phenomenal, I should point out that speech therapy is not a panacea. Little Bear still has DLD and I suspect it will impact him to a greater or lesser degree into adulthood but what therapy has done for him is allowed him to reach his communication potential, despite having DLD. Little Bear still finds it difficult to learn new vocabulary and to figure out the sound patterns in new words but we know what to do and the strategies work. The approaches that we have built into our daily lives will continue as Little Bear is still going to need them and it is imperative we continue to strive for that meeting of full potential. As the demands of the curriculum increase, we might find we need to access formal therapy again and that would be okay too.

I feel extremely proud of Little Bear’s progress and find myself constantly marvelling at the things he can say now. Last week he took part in his second school assembly. He learned more than double the words he managed last time and was able to recite them in front of the school without any prompts at all. The naughty streak in me did notice that other children in his class had to read their lines or forgot them completely (I don’t mean that badly, it’s just he has never been able to keep up with them before, let alone outshine anyone and he’s more than earned his moment of glory). Not only that but he sat really well throughout, no teacher attached to his side like previously, and he spoke loudly and clearly. Several people came to me afterwards to comment on how well he had done, the difference being so stark in comparison to previous public appearances.

I am truly grateful to speech and language therapy for not only giving me a career I love but for unlocking my son.

 

 

I think I had better make some changes to my workshop too. Although people need to see the bleak picture, they also need to see the sunshine over the rainbow picture that can be gained by using the strategies and applying them diligently. Little Bear’s prognosis appeared extremely poor so his progress really is a beacon of hope.