DS just been diagnosed with specific language disorder

[Soutty]

Hi

My DS has just been diagnosed with severe specific language disorder. I had been expecting a diagnosis of autism but the SALT that he saw was fairly adamant that he didn't meet the criteria. He apparently scored quite highly on the social responsiveness scale and the area where his language disorder is most severe is in her experience not an area where autistic children typically struggle with the most.

Feeling very confused. We've been doing ABA/VBA for a few months now with some success but now I'm not quite sure what direction we should be travelling in. SALT thinks he should be in a school with a language unit but he has just got into the same school as his older sister (which I think very highly of) and I really would rather that he went there and got a statement specfying several hours of speech therapy and (ideally) VBA as well.

Mentioned his sensory issues to the SALT - she seemed to think they go hand in hand with language disorders very often and are not necessarily an indication of autism. She thinks he might need occupational therapy for that if SPD is diagnosed as well.

I am taking DS to see a well respected NHS paed who does private work called Daphne Keen at the end of July (mega waiting list) and will be really confused if he gets a diagnosis of autism now.

Sorry for the rambling post, just feeling a bit confused and not sure what the best thing is that I can do for DS at this point - other than applying for a statement which I will now definitely be doing.

Hi. I'm a Speech and Language Therapist in the NHS working with young people with ASD and SLI.

You will struggle to get him VBA in his statement with a diagnosis of SLI, I feel.. an SLI diagnosis by its nature precludes a diagnosis of ASD but I do have children on my caseload with ASD who have language scores similar to some of my children with SLI. Though the clinical features are different and it's difficult to explain online, and not very helpful if not relevant to your ds.

Sensory issues are not uncommon in SLI at all.. but vary in degree.

I work in a language unit. They vary from area to area but where I work, the level of intensive SLT input works out at about 25-30 hours a week and our students do make good progress. It would be my first choice if my own children ever needed provision for language disorder, though I do know that the quality of a unit is very much dependent on the training and experience of the staff running them and how well they work together and I would need to investigate.

I also have ABA/VB training (it's how I got into this whole thing) and there are benefits to some of the ABA/VB approaches that will have enabled your ds to make progress.. but there are ALSO significant differences between SLI and ASD and many of the typical drills that work best for clients with ASD are not always best for students with SLI.

That's not to say that students with SLI don't benefit from behavioural approaches to language teaching - I use Precision teaching of vocabulary for my students, but I combine it with more traditional word webbing/elaborated practice for example. Things like errorless learning, scripting, modelling, successive reduction of prompts are extremely useful and systematic planned teaching would be core to all SLI therapy really, but the type of grammatical error in a classic profile of SLI really does (in my probably biased opinion!) need to be targeted by a speech and language therapist with specialist knowledge of the disorder. Children with SLI tend to do strange things with language regardless of how they are taught and "mastered" targets tend to resurface when language demands increase so it pays to have someone who knows straight away what is going on - the linguistic knowledge that I have really helps me to interpret and work out what needs to happen next. When we target these things we do so in a behavioural way (though I appreciate that not all units will do this in the way you will be used to with ABA/VB).

I think you could argue for some VB/ABA but given how hard that is for people with children with autism to win at tribunal when there is a much stronger evidence base, it will be tricky for you...

It is hard. I don't think that therapy for language for ASD in the NHS is very good. At all. VB/ABA is a million times better for the language disorders that most typically arise with ASD at this point in time in this system. However, I'm not as sold on ABA/VB as a primary form of intervention for SLI at all in the absence of a very experienced, knowledgeable SLT who understands the disorder and behavioural methodologies also.

I hope this makes sense?

SLT based input - direct input would be 3 hours a week not 25-30!

Thanks, yes it does make sense. Is it really the case though that the absolute maximum SLT input a child can get is 3 hours a week? What, even if their disorder is severe and there are no places at a school with a speech and language unit?

My issue is that there isn't one for miles and it has been ofsted rated inadequate. They have had 10 heads in less than 2 years. I don't want him to go there.

I don't blame you. My experience is that turnover of heads/senior leadership turmoil like that suggests that the school itself will be in disarray. You might have great teachers within the school but without leadership and vision it's not the best, especially for children with additional needs and ones as rare and poorly understood as SLI (even ASD, which a lot of people think they know about).

On the other hand, the best unit I ever worked in was in an Ofsted school rated "satisfactory" (though the unit was deemed outstanding, this wasn't on the public inspection report) so I would investigate it further as although it's not ideal, units can still be valuable if the team within the unit is well managed and well run. If not, well.. that's a different story.

3 hours is a lot, don't underestimate it. It would be 2-3 hours from the SLT, 3 hours carryover from a specially trained assistant and then 19 hours of in class carryover. Think of the SLT as being like your consultant - setting and reviewing progress on programmes. Very few ABA programmes would have that amount of weekly input from their consultant.

In my units, the 3 hours I spend with a child would basically be me working with them on the programmes that have been set trying to increase their success - Like in ABA teams, every team member would feed back on what's being going well etc and what needs support. The assistant who carries over would be in this session too and we would work together. I would model, she would try it out, I would tweak it, we would agree on the goals for that week's work which would be reviewed next session. I tend to do one which is a social group in my settings too so 2 individual plus 1 group. All of these programmes are repeated while I am away at other settings and I am in daily email contact if staff need support. The support staff in class have all had training and also have responsibility for carryover so act as keyworkers for particular children.

Not all units work like this. I don't think mine is gold standard, there is a lot I would like to improve. I woud like ideally to have all of this AND have the opportunity to go more into class and ensure that the provision is at a quality I would like from my support staff as this is where they spend most of the day.. I would particularly like to kick some teachers up the bum who just leave everything to support staff. I have one setting where there is good commitment to whole school support of the unit's approaches and where a cohort of teachers have committed to weekly ongoing speech and language training and act as champions within subject areas for the whole school, but in that school, I haven't really got as good a set up for individual and group work as the resources were allocated more for training than for individual students?

The ultimate unit (if one exists?) would ideally have a tightly run unit with support from the senior leadership team to truly integrate students at all levels, with intensive SLT support AND carryover for all students. Unfortunately, very few settings have full time SLT support these days. When I started, I had half a week - now it's a day and a half - and the students' needs have become more extreme. I used to have the luxury of going around the support staff modelling in-class support as well as doing more individual and more group. I don't now.

Evidence-wise, there just isn't enough in terms of dosage for you to really fight for more than this. If you can get an SLT to write a very tight report that suggests a high degree of individual is needed and is very careful in terms of wording specifying level of training/duration of input etc etc, you may have some luck but unfortunately those sorts of statements are really difficult to procure these days even where there is a much stronger evidence base.

I hope this doesn't sound too down-hearted, just trying to be realistic.

you may find this blog helpful. The writer used to post on here - and might still, I can't remember the name she posted under.

Thank you for taking the time to respond so comprehensively. It's much appreciated. Agnes thanks for the link, it made for encouraging reading.

Hi my DD1 has very severe SLI and she has quite a few autistic traits but iv been told that is quite normal for a child with SLI, If you can get ur DS into a school with a SLI unit or a language unit do, for it will work wonders for him, I just wish that this option was available for my DD. A SEN statement will also help, My DD has 1 and gets 20hrs 1-1 a week, not that it is helping her. sorry i wont go on cause im having lots of problems atm with schools (or should i say the lack of)

working9while5 can i please ask you something from a professional point of view please.

IF a MS high school with the SLI unit turns down a child because there scores are to low and they feel that they cant meet there needs as set out in there statement, and the SN school feels that the child is to bright for them yet they couldnt meet the childs SLI needs either, what would you recommend to do

Should a SALT be saying that a DC has or hasn't got ASD? I know they probably are the first professional to see DC with ASD so have experience, but they are not qualified to DX ASD. Or was the DX from a team that included a SALT and other medically qualified professionals? I would be waiting until you have seen Daphne Keen before getting too definite.

Ellen, I know what you're saying.. but SLI has a very specific sort of profile and we're the only ones who can dx SLI.. so it's a thorny one. I would never consider that I can diagnose ASD without an MDT but I would share my thinking with a parent if I felt it was SLI and explain my rationale for that diagnosis, which might also involve discussing the differences between ASD and SLI. We have a pretty major role in differential diagnosis of these two disorders as part of the MDT so though we are certainly not in the position to do a stand alone diagnosis, no one else can really comment on the language in the same way we do and we can talk about how our observations on language and communication point in one way or the other. There are no absolutes as both are diagnoses based on behavioural observation but I wouldn't avoid saying SLI if I felt the profile was clear because the child was also undergoing ASD assessment, and I would let the parent know that my contribution to the assessment would be to say that in my professional opinion SLI was the most appropriate diagnosis. Though I would probably also say this in the context of the whole MDT process and explain my role in that?

Alison, your situation is just awful. I really don't know. What's your gut feeling? It would very much depend on the settings involved and your dd's specific needs/profile. In your case your options seem to be:

• push for a statement which would give maximum support within M/S which would involve them paying for appropriate SLT input and training of staff/support
• the similar for the SN school or a split placement between MS and SN
• an out of area placement in a specialist unit e.g. ICAN. You have a good case for this but it is not an easy sort of thing to decide.

I'm sorry it's not been straightforward for you.

Ellen, what working9while5 has said is exactly what the SALT said. In her opinion, based on his performance in the tests she carried out, how he presented and reading the reports already done she felt he had SLI and is putting in her report that she doesn't think his language disorder is ASD related. She does think he has sensory issues (as do I) but she says that they often go hand in hand with SLI and aren't necessarily indicative of ASD.

I knew he didn't have severe ASD so I had been prepared for an ASD with an associated language disorder - I think I would have preferred that to severe SLI in all honesty.

I haven't cancelled the appointment with Daphne Keen. I want a range of opinion and she is top of the tree but I also do respect this SALT's opinion as she came very highly recommended by my VBA consultant, qualified in 1984, specialises in paediatric SALT and in particular ASD and a wide variety of language disorders. She has worked in language units and I trust her judgement. She might turn out to be wrong but I don't think she came to her conclusion frivolously.

You may very well still get the diagnosis you would like. ASD assessment is multidisciplinary for a reason and I have certainly had the experience that I have thought SLI and other information has come to light in the MDT that skews that.. What it comes down to is that both are based purely on behavioural observation and certain profiles on assessment but both conditions are heterogenous and overlapping so there is room for manouevre in the assessment and no absolute "truth". I have just done research with groups of participants with SLI and ASD and in some cases (not by any means all) there is very little difference in key features of presentation.

I've also had the occasional experience where the team have agreed SLI but have given an ASD diagnosis because the specific needs of the child have been more suited to ASD intervention (which you never know, may happen in your case if the VB is something that seems to really have worked).

In any case, whatever the final diagnosis on paper, if a SALT thinks that your child fits an SLI profile you are going to need significant and substantial input from a SALT with expertise in that area. The major danger I see with an ASD diagnosis is that this support is often entirely absent and seriousl language issues are ignored and not intervened with outside of interventions like ABA. I would want a SALT with SLI experience to be very involved with designing your ABA programme if you end up with an ASD diagnosis and pursue the VB route.

Didn't mean to put down the SALT. My DS's ASD was spotted by his lovely SALT, but she just pointed me in the direction of the right paed, she never mentioned ASD herself. She was part of the MDT that DXed him, though. I just thought it was unusual for a SALT to give an opinion like that before a paed has seen him.

working9while5, again you have pretty much said what the SALT said - she is worried that if he gets a diagnosis of ASD he won't get the language support that he needs. VBA has increased DS's expressive language to the point where he uses short sentences which are sometimes clear and precise, sometimes painfully muddled. However it's his receptive speech that is worse and I am not sure if VBA has helped that as he wasn't tested before we started doing it.

People have always said that DS is watchful and observant and I just wonder if a lot of the time he gets what is going on not by understanding language as a whole but by reading body language and seizing on certain words.

A good example of how he tries to fit in and pretend he understands more than he does was at the park the other week. A boy was at the top of the climbing frame. DS went up and said "boy what you doing up there?" The boy was very articulate and chatty. DS watched him carefully and followed what he did. When the boy started to give complex instructions about a game he wanted to play DS said "no". The little boy might have thought he didn't want to play that particular game. I know that DS said no to cover up the fact that he didn't know what he was expected to do.

Whatever the problem is, it's best to know and get the right treatment. At the moment I'm covering my bases by continuing with VBA but getting speech therapy for him that works on his understanding. My consultant said from day 1 that his biggest deficit is speech, hence why she put my on to this SALT for assessment. Whatever the final diagnosis, his statement is definitely going to focus on help for that.

Ellenjane, you are right, SALTS should not diagnose ASD or rule it out - but they are qualified to diagnose language disorders. I think her report will say that in her opinion his language disorder is not ASD related and give her reasons. It's then up to other professionals who are involved in assessing him to decide how much weight to give to her report, depending on how he presents when they see him and how he performs in the tests that they give him. So got to sweat it out until the end of July when I see Daphne Keen. All I want really is certainty so I can get cracking on getting him the help he needs.

Oh and also Ellenjane, the only paed that has seen DS so far has ruled out ASD and she has seen that report. I just didn't really have too much faith in that paed which is why I want a second opinion from Daphne Keen.

Funnily enough, the only person who has said frankly that they think he has autism was the first private speech therapist that I got for him when he'd just turned 3. It nearly knocked me sideways particularly as she gave me a very grim long term prognosis (needing care as an adult, special schools etc) and then said he didn't have enough speech for her to work with. I remember thinking who the hell are you to tell me all this so I know where you're coming from. Having said that, she was the person who got me to start the assessment procedure in the first place.

Hi Soutty,
I posted earlier about my son who has also been diagnosed with a SLI. My child is attending Early intervention services and was assessed first by a SALT using the preschool CELF his receptive scores were really very low in the first percentile and then he had a full cognitive assessment with a clinical psychologist. In Ireland a child cannot be given a diagnosis of SLI unless the non verbal iq is within normal range 90 or above. I have a joint report from both professionals for his application into a language unit. A SALT on their own cannot diagnose a specific language disorder. Just to add he also was diagnosed at 2.5 years with severe sensory difficulties. He is sensory seeking. He had been receiving Occupational therapy since and has made great progress. I am concerned about his motor planning and fine motor skills as well. Sensory difficulties can create a barrier to learning and for my child he needs to be regulated so that his language skills can improve. I hope this is of some help.

Thank you - it is of great help.

"A SALT on their own cannot diagnose a specific language disorder"

Gorta, that's not as true here in the UK where many psychologists do not do cognitive assessments. A greater weight is given here to the educational impact of language disorder than whether or not it meets strict criteria as in the ICD-10 or DSM-IV (although there is some variation in this from area to area) and reports tend to emphasise clinical features of the disorder as much as the formal standardised score e.g classic SLI features. Reports here are also very different to those that are provided in Ireland where they are much more technical and based on standardised assessment. In part, this is because of the large number of multilingual and multicultural clients we see which means standardised assessments are of questionable validity. It is also because there are a great many EPs who feel a bit dubious about diagnosing these conditions based on standardised procedures alone and who are very much in favour of more ecologically valid assessments (e.g. observing day to day functioning vs relying on stand-alone assessments).

There are pros and cons to this difference.Unfortunately, it is frequently the case here that I have to explain to Educational Psychologists what SLI is and what profile of scores indicates it. This is by no means true of everyone in the profession and I have met some great EPs, but it is very different to what seems to happen in Ireland (I have done assessments in Ireland for the purpose of gaining additional resourced hours etc) where the EP seems to take the lead in a lot of diagnosis and resource decisions and SLI can be very poorly understood. I have sadly met a lot of Paediatricians and GPs who have never even heard of SLI...

I frequently have had the situation where I have had to really make a strong case to an EP to do a cognitive assessment but I can't insist they do, but obviously need to be able to diagnose SLI. So a situation has arisen in many areas where, for example, if a child has a clear discrepancy between their standard score on the CELF, say, and any other measure of nonverbal intelligence (even including such informal measures as the Aston Index Draw a Man test), this is considered sufficient basis to make the diagnosis. There is also less reliance on the textbook definition of a -2 SD discrepancy between performance and verbal IQ so that there are children with -1.5SD differences where the cognitive measure is less stringent e.g. the Raven's Matrices which we can administer and it is what is needed in terms of intervention that determines access to a language unit. In fact, in practice if there is a large discrepancy between performance across different areas of the National Curriculum e.g. Speaking and Listening and Maths/Science, this also counts. So it is not unknown for children with additional diagnoses that would preclude a standard diagnosis of SLI to get a place e.g. moderate sensorineural hearing loss, acquired aphasia, social communication disorder, microcephaly etc. However, this means that there isn't as "pure" an understanding of SLI which can muddy the waters and mean that some authorities have very poor understanding of the extent to which a person with "classic SLI" can be disabled by their condition in the absence of other difficulties. Ironic, really!

In some ways though, all of this is a bit academic because children with classic presentation of severe language disorder (whether classically "specific" or not) need a lot of intensive help and in some ways the boundaries between conditions are arbitrary and unhelpful as nearly all of these conditions present differently across individuals.

Just to clarify as I read this again I realise a sentence in the second paragraph truncated. I didn't mean to suggest SLI was poorly understood by EPs in Ireland.. I was trying to say it was misunderstood here by some professionals.

Reading tthis thread has been really interesting.

My DD has SLI although I am not sure we have it written down in that form, instead we have severe language difficulties (she is also 1st centile for receptive and expressive) or disordered language. No one here seems to fully understand it as a diagnosis on its own. She also has microcephaly, sensory processing issues and glue ear, serious memory issues with language (I guess this will be the SLI) and sometimes she has been described as having learning difficulties.

She definately does have learning difficulties but as her statement says this is because her difficulties with language affect every area of her development. We had an ICAN assessment and a well written statement and the school have just applied for full support-30 hours. She is in mainstream and has a lot of intervention there but I would have chosen a unit had there been one where we live.

Our school is very supportive however which makes a massive difference judging by what I have read of what others go through. She now has behaviour issues which I think are due to the sensory processing, she gets overwhelmed and will lash out. Also she is relying on guess work a lot of the time it must be exhausting. I have had times thinking she has autism and tbh it wouldnt surprise me if we eventually were givent he diagnosis as she has a lot of behaviours that are usually associated with autism but the psychologist has also said they could be in line with her level of development in some cases.

Sorry to waffle on I am still unclear as to whether dd is officially described as having SLI, GDD or whether in time it will be autism! So in a similar position really but it shows we are not the only parents of children with similar collection of symptoms. AFAISIC have been good at putting me in touch with other parents and talking through school issues with me.

I agree AFAISIC are really helpful and supportive. My son has a non specific language disorder, it isn't severe but we went through all the rounds of SALT and SEN, he never had a statement and got practically no help on the NHS. We paid for private speech therapy which really helped him to understand his own issues and therefore address his self esteem which was very low for a lot of his primary school years. The single thing that made the most difference to him was Listening Therapy. After going through a course of this he made incredible progress and has sailed through secondary education, he is happy now. He is just about to take GCSEs and will always struggle slightly, but it is a world away from what we imagined in his primary years. I would certainly take a look at the Listening Therapy programme if I were you. Good luck.

Hi, Finding this thread very interesting - currently studying the role of the slt in differential diagnosis of asd and sli and the management of the two and am finding lots of research that supports working9while5's points. It does appear tricky to seperate the two in some cases and I wish you all the best!

In that case sltstudent, would you like to meet/work with my ds as a case study? London.

That would be brilliant but unfortunately I am due to start a 7 week block of placement and not sure how much time I'd have to balance my workload!

I think the poster whose blog you gave the link to now posts under a different name and I think her DS got a recent ASD diagnosis