Does an SLI Label Really Restrict Services? It all depends who you ask. Or perhaps more importantly, where they live. Features
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Features  |   December 01, 2018
Does an SLI Label Really Restrict Services?
Author Notes
  • Nancy Volkers is a freelance medical writer based in Vermont. nvolkers@nasw.org
    Nancy Volkers is a freelance medical writer based in Vermont. nvolkers@nasw.org×
Article Information
Language Disorders / Specific Language Impairment / Features
Features   |   December 01, 2018
Does an SLI Label Really Restrict Services?
The ASHA Leader, December 2018, Vol. 23, 54-61. doi:10.1044/leader.FTR2.23122018.54
The ASHA Leader, December 2018, Vol. 23, 54-61. doi:10.1044/leader.FTR2.23122018.54
Names matter, and they can change. Edema was once called dropsy. Constantinople became Istanbul. And Google started out as BackRub.
Could specific language impairment (SLI) be the next to change—to developmental learning disorder (DLD)? That question has been the source of spirited debate in the communication sciences and disorders community. Fueling the debate is a 2016 recommendation from some researchers that SLI is not a useful diagnostic category.
As part of the CATALISE (Criteria and Terminology Applied to Language Impairments: Synthesizing the Evidence) project, 44 out of 57 researchers from six countries backed using the broader category of DLD, which does not factor IQ into the diagnosis. (An SLI diagnosis requires that a child have nonverbal IQ scores above 85, in addition to language problems; see sources.)
In the years following that recommendation, some researchers and clinicians have strongly endorsed substituting DLD for SLI, while others have just as vehemently criticized such a move. A major objection, mostly in the research community, has been that removing the IQ criterion would introduce so much noise into research that it would render results useless and forestall development of interventions.
However, proponents of the switch believe that SLI’s IQ requirement is too restrictive, as is the fact that the diagnosis cannot be used if the child has another condition (including a mental health diagnosis or a behavioral issue; see sources).
Because of these factors, some clinicians and researchers believe that SLI may limit services to children with lower IQs or other co-occurring conditions. “I have heard this argument that if we don’t use a broader term then we’re not serving all the kids, and I just don’t know if that’s true,” says Pamela Hadley, associate professor in the Department of Speech and Hearing Science at the University of Illinois.
So is it true? The answer may largely depend on how, in a given country, you are defining language disorders, and how determinations are made about providing services based on those definitions.

The ICD-10 defines SLI slightly differently from the research literature, and the DSM-5 does not mention the term, instead using the more general “language disorder.”

SLI diagnostics
The criteria for SLI vary somewhat. In the research literature, a child with SLI generally has language test scores at least 1.25 standard deviations below the mean, coupled with a nonverbal IQ score of 85 or higher, though this definition isn’t universal. The International Classification of Diseases (ICD-10) defines SLI slightly differently, and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), does not mention the term, instead using the more general “language disorder.”
In its Practice Portal, ASHA uses the term “spoken language disorders” and recognizes SLI as part of this category. ASHA defines an SLI as “a primary disability not accompanied by an intellectual disability, global developmental delay, hearing or other sensory impairment, motor dysfunction, or other mental disorder or medical condition.”
Although children with SLI do not have a known cause for their language issues, research has found that the condition runs in families. The language problems found in these children (see box below) aren’t unique to English speakers, says Laurence B. Leonard, Rachel E. Stark Distinguished Professor in the Department of Speech, Language, and Hearing Sciences at Purdue University.
“The field has not studied every language, but we’ve studied a lot of European languages and some Asian languages and we find it,” Leonard says. “It seems that whatever the weakest links are in any given language—the details that are acquired later by typical kids—those are the details that are really hard for kids with SLI.” (Leonard’s book “Children with Specific Language Impairment” is considered the classic reference for SLI.)
Children with SLI also are at risk for social and behavioral problems, as well as educational difficulties, including reading problems and other learning disabilities. For every 100 kindergartners, about seven of them have SLI (see the study led by J. Bruce Tomlin in sources), making it more common than autism spectrum disorder.

Although children with SLI do not have a known cause for their language issues, research has found that the condition runs in families.

Terminology and school services
When it comes to schools’ and health care systems’ detection of different kinds of language disorders, there is variability across countries, notes Sean Redmond, professor in the Department of Communication Sciences and Disorders at the University of Utah, who served as one of the six U.S. panel members on CATALISE. Sometimes children with co-occurring issues (like low nonverbal IQ or attention-deficit hyperactivity disorder) are identified more readily than those with SLI who don’t have these additional problems. In contrast, other settings may require a discrepancy between verbal and nonverbal abilities for children to receive some kinds of services.
Terminology also differs across countries. For example, in the United Kingdom, a child with “learning difficulties” is a child with a low IQ, whereas in the United States, the term refers to a child with a specific learning disability. “This causes endless mutual incomprehension,” says Dorothy Bishop, professor of developmental neuropsychology at Oxford University and convener of the CATALISE panel.
In the United States, children are qualified for services in schools under categories specified by the Individuals With Disabilities Education Act (IDEA). This legislation does not use the term SLI or DLD; the act defines a broad category of “speech or language impairment,” often (and confusingly) abbreviated as S-L-I. Speech or language impairment can refer to any communication disorder, including stuttering, a speech sound disorder, a written or spoken language impairment, or a voice impairment. Because this category includes such wide-ranging disorders, it’s difficult, if not impossible, to discern how many U.S. children with SLI or DLD are being served (or not served).
Also, given that each U.S. state or local district is then tasked with defining what constitutes a speech or language impairment, a new term for a language impairment will have little to no effect, Hadley says: “DLD is not going to converge with the way kids are given services in U.S. schools.”

IDEA legislation does not use the term SLI or DLD; the act defines a broad category of “speech or language impairment,” often (and confusingly) abbreviated as S-L-I.

Exclusion by IQ?
In other countries, strict implementation of SLI criteria could mean more limited school services: A 2014 article led by Sheila Reilly (see sources) notes that in parts of Australia and Ireland, SLI exclusionary criteria developed for research have been used to determine eligibility for services and the allocation of classroom resources. They reported that one set of criteria defines SLI as follows:
  • Language ability more than two standard deviations below the mean.

  • A nonverbal IQ score of 90 or above.

  • The language impairment cannot be accounted for by any medical condition, mental health issue, family dysfunction, cultural factor, exposure to adverse environmental conditions, or linguistic factor (such as learning a second language).

  • The child must have a history of an ongoing problem and no expectation that the problem would subside without intervention.

The authors note that applying such strict criteria could easily cause many children to be deemed ineligible for services. “Given the lack of empirical evidence to support the existence of the SLI category, whether defined using relatively loose or stringent criteria, we argue that the continued use of the term SLI may in fact be disadvantaging children with non-specific language impairment and those from socially disadvantaged backgrounds,” they write.
Other researchers argue that it is indefensible to suggest that there is a lack of empirical support for the SLI diagnostic category, especially considering that more than 1,150 articles written in English with “specific language impairment” in the title have been published since 2000, including 35 authored by Bishop (see box below for sources of these numbers). Despite this robust evidence base, some children with SLI may not receive the services they need in a school setting for several reasons—including that they may be viewed as just not paying attention, not trying hard enough, or not being smart, rather than having a diagnosable and treatable condition (although a language disorder is diagnosable by an SLP).
Another complexity is confusion over whether a child with SLI can have any other condition or impairment. Because SLI is sometimes viewed and defined as a “pure” impairment that cannot exist in the presence of other medical or mental health conditions, some clinicians don’t use it. In reality, most children on caseloads have multiple issues, such as attention issues or behavior problems, says Redmond.
“So from a clinician’s perspective, of course they think there’s no such thing as SLI, because they never see it,” Redmond says. Children with SLI are sometimes identified only when they start to exhibit reading problems or behavior problems, which may be caused or exacerbated by the language impairment.
“Some proponents of abandoning SLI as a diagnostic category for clinical reasons have argued that, because there’s no evidence indicating that treatments designed for SLI are any less beneficial for children who exhibit language impairment and nonverbal IQs lower than 85, we should just assume that both groups of children will benefit similarly and lump them altogether under the DLD label,” observes Margaret Rogers, ASHA chief staff officer for science and research.
“Response to intervention is a really important consideration in this debate,” Rogers says, “but unfortunately, there hasn’t been much published research investigating whether children whose nonverbal IQs are less than versus greater than 85 derive similar benefits from treatments designed for children with SLI.
“Most of the extant research wasn’t specifically designed to address this question, and therefore these studies have a number of weaknesses,” Rogers says. “These include that sample sizes were too small to yield sufficient statistical power to detect a difference; some studies haven’t controlled for the initial starting levels of performance across the two groups (just age) nor factored in the differences between the untreated trajectories of change expected for these two groups; and others fail to investigate important service-delivery variables, such as whether both groups need the same intensity and duration of treatment to make equivalent improvements.”
Redmond points to these research gaps in a 2016 article in the Journal of Speech, Language, and Hearing Research. “Additional investigations are needed to more clearly delineate the impact of low nonverbal abilities on children’s responses to interventions,” he writes.
Rogers notes: “It seems unfortunate that this sort of research wasn’t conducted before efforts were marshaled to eliminate the SLI category. There is tremendous pressure to ensure that the public’s investment in research will drive improvements in clinical service delivery, for both reimbursement/funding and ethical reasons. And there is a strong scientific evidence base pertaining to SLI, so abandoning this diagnostic category just seems tantamount to shooting ourselves in the foot.”

Some observers see the broader DLD category as a way to improve advocacy for children’s services in countries with one national health care system.

Health care system effects
The workings of a country’s health care system are another potential driver for backing one language disorder term over another. Some observers see the broader DLD category as a way to improve advocacy for children’s services in countries with one national health care system. In those countries, services are rationed, and children’s services are in funding competition with services for other groups, such as those who are elderly or impoverished. Of the 57 experts on the second phase of the CATALISE project, 51 were from five countries with national health care systems (United Kingdom, New Zealand, Canada, Ireland, Australia); the other six were from the United States.
Though there is a movement to use the term DLD in the United Kingdom, Australia and the other non-U.S. countries represented in the CATALISE project, it’s not clear how much momentum exists in the United States. “The advocates pushing for the change are saying that DLD is now the new term, and we all have to use this,” says Mabel Rice, the Fred & Virginia Merrill Distinguished Professor of Advanced Studies at the University of Kansas. “I’m fascinated by how it’s going down.”
Some U.S. researchers and practitioners just don’t see the benefits of forcing a terminology change and would rather see more flexibility. “I reject being forced to choose one over the other; the terms have different uses in different contexts,” says Redmond. “Sometimes I want to study mammals (DLD), and other times I’m interested in felines (SLI). Telling me that I now have to refer to felines as mammals only seems strange to me. If it makes a clinician’s life easier to use DLD, that’s fine, but I should be able to select the subgroup I need for my research and then label them as precisely as possible.”
Others actually see negative effects of a complete switch from SLI to DLD.“A change to DLD would be a bad move,” says Geraldine Wallach, professor emerita in the Department of Speech-Language Pathology at California State Long Beach, “Any time you use the word ‘developmental,’ that suggests that the kids are behind, slower. It suggests a kind of catch-up. These kids are not behind; they’re different.”
In the United States, DLD is typically not used because of challenges with reimbursement of services. Some insurance companies have the misperception that services for DLD do not meet the criteria for “medical necessity,” says Diane Paul, ASHA’s director of clinical issues in speech-language pathology. What matters the most is that clients receive the language intervention services they need, regardless of the terminology used, Paul says.
Bishop has heard differently. “The main thing that people in the U.S. tell me is that it is important to have a term that will ensure insurance coverage,” she says. “SLI is not a DSM category and therefore is not recognized by insurers, whereas DLD is a subset of Language Disorder, which is the term used in DSM-5. DLD is also the preferred term in ICD-11.”
But would a move from SLI to DLD bring this category the sort of publicity, heightened awareness and advocacy that Bishop and the CATALISE panel seek? Could there be an associated uptick in diagnosis and services? When it comes to services, Wallach, for one, isn’t sure a label change will ultimately make much difference.
“All labels can be problematic,” she says. “It’s not the label that will lead us to the intervention. You have to look at each kid and see how the issues manifest in their life. You have to get beneath the label.”
Language Impairment or Learning Disability?

A child is diagnosed with specific language impairment (SLI) at age 4. Five years later, the child is in third grade and struggling with reading, writing, understanding instructions and expressing himself orally. School personnel suggest the child may have a learning disability. Is this separate from SLI, or is it another part of the same condition?

Almost 25 years ago, an article (the lead author was Anthony Bashir; see sources) asked this question: “Are we speaking about a group of children, who by virtue of learning context, are called by different names, but who in reality evidence a continuum of deficits in language learning?”

More recently, communication sciences and disorders researchers Lei Sun and Geraldine Wallach reintroduced the idea. In a 2014 article in Topics in Language Disorders, they write: “By definition, a disorder of spoken or written language is a learning disability. The converse also is true—that is, a learning disability is a language disorder. The one exception is the child who might be identified as having a learning disability based only on impairment of the ability to ‘do mathematical calculations,’ but even in this case, language may be implicated.”

“Kids who have SLI and kids who have a learning disability are really the same population,” says Wallach, now professor emerita of speech-language pathology at California State Long Beach. “The SLI label very often changes because the language impairment shows up as an academic problem. It may not look overtly like a language problem, but it’s still language-related.”

Many young children with SLI meet criteria for learning disability as older children and adolescents; even after high school, many teens with a preschool diagnosis of SLI lagged behind in reading comprehension, word identification, spelling and other areas.

In 1982, ASHA used the term “language learning disability” (LLD) in an article describing the role of the speech-language pathologist in learning disabilities (see sources). Although not part of any official diagnosis, LLD applies to children and adolescents who could be diagnosed with either SLI or learning disability. Sun and Wallach suggest that the term LLD might be helpful “in avoiding false dichotomies that obscure the language base common to both.”

—Nancy Volkers

Database Sources for SLI Literature Search

There have been 1,154 articles published since 2000 with specific language impairment (SLI) in the title, according to a search using the below criteria:

  • The following 12 databases were searched: PubMed; ERIC; ScienceDirect; CINAHL Plus with Full Text; Communication & Mass Media Complete; Education Research Complete; Health Source: Nursing/Academic Edition; Library, Information Science & Technology Abstracts; MEDLINE; Psychology and Behavioral Sciences Collection; PsycINFO; and Teacher Reference Center.

  • The articles were de-duplicated. Non-English articles were rejected; however, articles with foreign-language titles and English abstracts were retained (<10 articles). Article errata/corrigenda were also rejected.

  • Any article with “SLI” or “specific language” in the title was kept, to capture articles using variations in language, such as “specifically language impaired” and “specific-language impairment.”

Sources
American Speech-Language-Hearing Association (ASHA) Committee on Language Learning Disabilities., (1982). The role of the speech-language pathologist in learning disabilities. ASHA, 24, 937–944. [PubMed]
American Speech-Language-Hearing Association (ASHA) Committee on Language Learning Disabilities., (1982). The role of the speech-language pathologist in learning disabilities. ASHA, 24, 937–944. [PubMed]×
Bashir, A. S., Kuban, K. C., Kleinman, S., & Scavuzzo, A. (1984). Issues in language disorders: Considerations of cause, maintenance and change. ASHA Reports, 12, 92(), 92–106.
Bashir, A. S., Kuban, K. C., Kleinman, S., & Scavuzzo, A. (1984). Issues in language disorders: Considerations of cause, maintenance and change. ASHA Reports, 12, 92(), 92–106.×
Bishop, D. V. M. (2017). Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD). International Journal of Language & Communication Disorders, 52(6), 671–680. [Article] [PubMed]
Bishop, D. V. M. (2017). Why is it so hard to reach agreement on terminology? The case of developmental language disorder (DLD). International Journal of Language & Communication Disorders, 52(6), 671–680. [Article] [PubMed]×
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Leonard, L. B. (1987). Is specific language impairment a useful construct? In Rosenberg S. (Ed.),. Cambridge monographs and texts in applied psycholinguistics. Advances in applied psycholinguistics, Vol. 1. Disorders of first-language development; Vol. 2. Reading, writing, and language learning, (1–39). New York: Cambridge University Press.
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Reilly, R., Tomblin, J. B., Law, J. McKean, Mensah, F. K., Morgan, A. … Wake, M. (2014). Specific language impairment: A convenient label for whom? International Journal of Language & Communication Disorders, 49(4), 416–451. [Article] [PubMed]
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Rice, M. L. (2014). Advocating for SLI. Commentary on Bishop, D. V. M., 2014. Ten questions about terminology for children with unexplained language problems. International Journal of Language and Communication Disorders, 49, 381–415. [Article] [PubMed]
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Rice, M. L., Redmond, S. M., & Hoffman, L. (2006). Mean length of utterance in children with specific language impairment and in younger control children shows concurrent validity and stable and parallel growth trajectories. Journal of Speech, Language, and Hearing Research, 49(4), 793–808. [Article]
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December 2018
Volume 23, Issue 12