Understanding DLD

Tiffany Hogan: Hi, I'm Tiffany Hogan. I'm a clinical speech language pathologist. Early in my career, I worked with preschool children who had difficulty learning language. It was really exciting because I could see that they were making these changes, and then they would go on to first, second, third grade, and I would get a call back from their parents saying they were now struggling with reading. And that created a big pivot in my career. So the past several decades, I've been studying the connection between speech language and literacy development. And that's what I'm going to be sharing with you today is that work — language comprehension — and in particular, children who struggle with language comprehension who have developmental language disorder.

Developmental language disorder is when a child or adult has difficulty understanding or using language. They have difficulty learning vocabulary words and how to connect words to make grammatical sentences. DLD occurs in one in 10 children. So in every classroom, we expect to see about two children who have DLD. Children with DLD are often misrepresented by personality traits, so these children can be said to be shy or hesitant. Sometimes they drop sentences, so they may start saying a sentence like, "This weekend I..." And then they just stop. They tell unclear stories. So when you ask them about what went on this weekend, they may start to tell you, but they're leaving key ingredients out. So they're leaving out the setting of the story, who maybe the main character is. When you listen to a story by a child with DLD, you may walk away just not really understanding it.

They also, because of this language difficulty, may look to their peers because they're not understanding the language in the classroom. They may look to their left and the right to see what their peers are doing, and that helps them to know how to respond. They also have difficulty with multi-step directions. All of these characteristics of DLD leads educators and parents to misrepresent children with DLD as being mischievous, uncooperative. They can also be emotional because they're not able to convey their wants and needs through language. And most unfortunately, they can be referred to as being unintelligent. And that is not correct because language and intelligence are two separate things. So children with DLD are not unintelligent. They have difficulty processing and using language. You may ask yourself, "Why haven't I heard of DLD if it occurs in one in 10 children and I have potentially two children in my classroom? Why have I not heard of DLD?" Well, it's because these children have been referred to by many different labels.

In the psychological world, these children are referred to as having a language disorder or a specific learning disability in language. In the medical field, these children are referred to as having an expressive language disorder or an expressive and receptive language disorder. In the school system, these children are referred to as having a developmental delay, a speech and language impairment, a communication disorder, or a specific learning disability in comprehension. But all of these labels are referring to the same group of children, children who have developmental language disorder or DLD.

Reading is complex. The simple view of reading boils down the complexity of reading comprehension into two primary components — word recognition and language comprehension. What have we learned from the simple view? We know from the simple view of reading that we have to consider both word recognition and language comprehension when we're thinking about how a child comprehends text. If we think of only one component, we're missing out on a big part of what we need for children to be able to comprehend text. Let's break this down and look at the differences between word reading and listening comprehension. Word reading is the ability to accurately translate printed letter patterns into spoken words. When I say spoken words here, I don't just mean reading aloud, because if you're reading silently, you're creating an inner voice, which is those spoken words. Listening comprehension is the ability to understand the spoken language that's created by those words and also the spoken language that is heard in the ambient environment.

When I'm talking about language comprehension, I'm talking about knowledge because language is the conduit to knowledge acquisition. It's part and parcel. Now I'm going to share with you how oral language development sets the foundation for reading comprehension. I call this language meets the simple view. Language is also complex and is made up of three components. The sounds of language are what are primarily underpinning a child's ability to learn to read because when children are learning to read words, they're connecting their sounds with letters. Language also involves the social use of language or what we call pragmatics. That's the intonation or sarcasm we might see in language. It's what gives us meaning beyond the words and sentences. The third component of language is content. That's the meaning behind language conveyed through vocabulary words and grammatical structures. It's the social use of language and the content of language that lays the foundation for the child's ability to understand language as they hear it in their environment and as they read it from text.

Using the simple view of reading has been very powerful to help us understand individual differences in why some children struggle to learn to read. Reading struggles come from either difficulty in word recognition or difficulty in language comprehension. We use this knowledge to subgroup struggling readers. This subgrouping has been referred to as the quadrant model. It has two primary components — word reading and listening comprehension. What we do in our studies is we look for children who have difficulty comprehending text. That means that when they're asked to read a passage, they have difficulty answering questions about that passage. And what we find is that some of these children have poor word reading, but have good language comprehension. That means that they have difficulty reading the words on the page so they read them more slowly or less accurately. But if you read the passage to them, then they are able to understand it.

And this has been referred to as a ... children with dyslexia. The opposite side of the quadrant is children who have good word reading, but poor listening comprehension. These children can read the words on a page accurately and fluently. But when you ask them to recall the story that they read, or if you take away the print and you read a story to them, they have difficulty answering questions about that story. These children have been referred to as children who are hyperlexic. They've also been referred to as children who are poor comprehenders, and they've been referred to as children who have a specific comprehension deficit. I'm going to refer to them as children who have developmental language disorder. They have difficulty comprehending language even if they can read the words on the page. 50 to 80% of children with dyslexia have co-occurring DLD, and 50 to 80% of children with developmental language disorder have co-occurring dyslexia.
Let's talk about some facts about dyslexia, and we're going to compare those to children who have developmental language disorder. A person is born with dyslexia and it persists across their lifespan. It's because it's a brain difference that makes it difficult for them to connect letters and sounds. This occurs in approximately one in 10 children. A person is born with DLD and it persists across the lifespan. It's a brain difference that makes it difficult for these children to understand the language that they hear in their ambient environment. It occurs in approximately one in 10 children. Children with DLD have difficulty learning words and remembering them. So we see difficulties in vocabulary development. We also see difficulties in their ability to learn grammar and to use it. This is real data in which each circle represents an individual child in the quadrant model. What you can see is that children do not fall neatly into each of the quadrants.
Instead, you see a spread of individual differences. So if you have a child, for instance, who fits the profile of having dyslexia, they may not fit it extremely because there's a range of severity in dyslexia. Likewise, for children who have difficulties in language comprehension but have good word reading, it's all relative. So some children are going to have more difficulty in word reading and slightly less difficulty in language comprehension. And there's going to be some children that are going to be on the border and they may still need some support because the cut points of whether you're poor or good in word reading or language comprehension are arbitrary. So we need to support children where they are along the continuum. If you work with children who have dyslexia or have children in your classroom who struggle with word reading, we need to attend to their language comprehension because of the high overlap between dyslexia and DLD.
So the implications for this work involving the simple view and language foundations is that we have to assess both word reading and language abilities. If we think of reading as only reading words or if we think of reading as only understanding text, we're missing out on the complexity of what it takes to really have good reading comprehension.

What does language development look like in children with DLD? We've studied these children for a century, and what we find is that children with DLD consistently develop language late. This has been characterized by Mabel Rice as a train leaving the station late. We know they follow the same track or trajectory of language learning as they're typically developing peers, but they're often delayed over time. Now delay here does not mean that they will catch up. Delay means that they're following the same trajectory, but they will need support over time because they do not catch up in their language development.

Margarita Orrego: We started seeing a little bit of difficulties when she was trying to express her needs or answer questions or descriptions. So when I check with the pediatrician, she said, "Oh no, don't worry." And this is usually what happens with bilingual children. So she started preschool. That's when we realized that it was not a problem of bilingual exposure.

Paula Orrego: I was behind in my expressive language by two years and a few months and my receptive language by one year. So I was a four-year-old understanding at around a three-year-old level speaking at a two and a few months year level. The thing with developmental language disorder, DLD, is that you get help for it, you get better. You can sound like any other typically developed person in terms of language, but this is something that follows you throughout your life.

Tiffany Hogan: Ideally, we would like to support children early. Research has shown that we have special windows of opportunity. When we're thinking about preventing long-term difficulty, it's ideal if we first screen for both DLD and dyslexia in pre-K through first grade so that we can provide high quality instruction and support over time. If we do so, we see fewer negative consequences long-term, and we see early reading success. So what I'm going to tell you in this part of the presentation is some of the work that we've done with our school partners across the nation to think about better ways to identify and support children with developmental language disorder.

Currently, schools are using multi-tiered systems of support to identify children who are struggling in word reading and may have dyslexia. The approach is used to support all children where they are to differentiate instruction so that children can learn how to read. Multi-tiered systems of support, shorthand referred to as MTSS, include six key components. These six components are broken into instruction and assessment. For instruction, the first component is ensuring evidence-based classroom reading instruction at tier one for all children. Analogous to that is making sure that all children are screened at the beginning of the school year to determine who might be at risk for word reading difficulties. Children who are identified as at risk would then be further assessed through progress monitoring. Progress monitoring is assessing these skills over time and looking for growth. Children who are initially determined to be at risk for word reading difficulty may be put into a small group for targeted instruction around word reading.

Small groups provide more opportunity for children to learn with more individualized instruction with their teacher. If a child does not make progress with this boost that they should receive in a small group, they will be eligible for individualized assessment to determine if they need an individualized education plan through special education. What we're doing is working with schools to create a similar MTSS process focused on language comprehension. This is so that we ensure that we're attending to both sides of the simple view, not just word reading, but we have systematic processes in place to improve language comprehension for all children. Now I'm going to provide you information about what you can do at each tier for both instruction and assessment to identify and support children with DLD. We know that children with dyslexia make the greatest gains in word reading when they are exposed to systematic explicit phonics instruction.
We want the same systematic explicit instruction and language comprehension so children with DLD can thrive.

First, we will discuss screening for DLD. Currently, research shows that only 20% of children with developmental language disorder are ever identified in the school system for support. This means that this year alone, half a million US kindergartners were struggling without support, and they were misrepresented as characteristics that I mentioned before, such as being hesitant, shy, unintelligent, and these are problematic because instead of those difficulties, these children have a neurodiversity that makes it difficult for their brain to comprehend language. What we want to do is try to identify more children with DLD to provide them support. But first you may wonder who are these 20% of children who are identified? Maybe they're the most severe children. However, we find that is not the case. The children who are identified for DLD have two common characteristics. One, they have an overt difficulty in a co-occurring condition, meaning that they have difficulty reading words, so they may not be identified as having dyslexia.

They may have difficulty in attentional processes, and they're identified as having ADHD. If they're identified initially with dyslexia, ADHD, or some other difficulty, they may receive a comprehensive evaluation that reveals developmental language disorder. The second characteristic and the most prominent characteristic associated with these children is they have a parent who has high socioeconomic status. Socioeconomic status means they have high income or high education, so they're able to fight for services for their child. This is a clear social justice issue. If children who receive support services are only those who happen to have another disability or happen to have financial resources that someone can lobby for them to receive support. How do we change this? We change this by having schools implement universal screening for developmental language disorder. We're starting to see universal screening become more commonplace for dyslexia. Now we can add on a screening involving language comprehension so we can identify children with developmental language disorder.

It's very difficult to determine who has DLD by just observing language in the classroom. That's because DLD can be hidden. It's a lot like vision screening. Vision screening is now commonplace in schools, but before it was common, teachers and parents were told that you would be able to recognize if your child has difficulty seeing. They may squint, they may sit closer to their TV or computer, but vision screening has shown us that many children do not show those overt signs until you test their vision and determine that they need glasses. I bet many of you can think of friends and relatives who first learned that they needed glasses when they were first tested in the kindergarten or first grade years. It's difficult for teachers to determine who has DLD in their classroom because children often play it safe with language. They're looking around, they're seeing what their peers are saying, and they may mimic that, or they rely on familiar phrasing.
The only time you can really determine who has DLD is if you tax the system, make it difficult enough that you can start to reveal the individual differences, and then you would know who has language difficulties and who doesn't.

Once you put in place screening for DLD and you identify some children who are struggling, you'll want to monitor their progress in language and provide them small group instruction. Here are some of the ways that you can support children's language development in the classroom, either in the bigger classroom of tier one or into a small group support. Number one, you will want to break down complex language. The language of the classroom is very complex. Children are hearing many multiple step directions, so you will want to break down those multi-step directions, for instance, into individual components. You will want to use visuals and print. So when you're giving instructions, you will want to have a visual of what you mean by that instruction, and you'll want to have it written out. You will want to facilitate peer interactions. Children with DLD may be hesitant to engage with peers in social situations and also in group work and small group instruction.

You'll want to facilitate this by acting as a scaffold. So if a child with DLD wants to say hi to a peer and you notice that they're hanging back, maybe they're looking hesitant, you can help them by giving them the verbiage to actually interact with their peers. Provide them the words that they need for peer interactions. Four, you want to make sure that they feel the strengths that they have. You will want to point those strengths out to them. Every day they're encountering language, language of the classroom, language of the environment. That's how we communicate. But they may have another strength, like maybe they're very good in art. Maybe they're very good in sports. Maybe they're very good in visualizing a math problem. This will be something that you want to explicitly point out to them because they're often encountering their weakness consistently. Five, share information about DLD with your peers, with parents that you interact with, with your administration.

Talk about DLD. Make sure that people in the child's environment understand that this is a neurobiological difficulty that this child is encountering and that educator, parent, or adult support can help the child along the way. Number six, you want to collaborate with speech language pathologists when possible. The more people who can support children with DLD, the better. The speech language pathologists in your environments are language experts, so they can help you to have different ways to specifically work with children in your classroom. Children with DLD benefit from having a language-rich environment and support from all of the educators that they encounter in the classroom and in special education. And lastly, you will want to ensure that language is being assessed. If you have concerns about a child who is struggling in your classroom, make sure that you have assessed language as a possible reason for their struggle.

Our goal in working with our school partners is to create routine screening for word reading difficulties to identify children who are at risk for dyslexia. At the same time, we want to have screening for language difficulties to identify developmental language disorder.

You may wonder why schools aren't screening for DLD. Well, there's several reasons that we find that schools are not currently screening for DLD. One of them is the myth that language screening is unreliable. We have many reliable screeners for language that can be implemented in the classroom. The second reason is that there is a myth that speech language pathologists are the only professionals that can administer language screeners. Educators of all backgrounds can administer language screening assessments because the training protocols for language screening are in place and available to you. But the third reason for not screening is the most difficult to understand, and I'm going to break it down for you now. Oftentimes, schools already believe that they're testing for language, but they're actually not. And this is because when we look across development, the simple view of reading is not so simple. What we find is in the early grades, when you give a reading comprehension assessment, you are actually measuring word reading.

And this is because early texts have to be basic enough in language so that children can read the words on the page. So the language created by text is not difficult enough to tax the system of a child with DLD. This means that in the early grades, when you give reading comprehension measures, you are not going to uncover who has DLD because children with DLD have the basic language skills to answer comprehension questions because the text is so basic. As an example, this is a passage for grade one children. What you can see is they are asked to read a short sentence and fill in the blank. This is a measure of reading comprehension in the early grades. You will see that the words are very basic so that the children can read them. This means that the language is very basic as well. So children with developmental language disorder can actually get this question correct and look like they have good comprehension if they're able to read the words on the page.

In the later grades, the text becomes more complex, but word reading starts to hit a plateau. So as long as children can read the words on the page, it's the language skills that then determine if they're able to answer the questions. Here's an example. You can see that in this fourth grade passage, there's more words, there's more complicated vocabulary, there's more complicated grammar. Children who can read the words on the page have to then rely on their language skills to comprehend the passage. This shift of the influence of word reading in the early grades and language comprehension in the later grades results in a phenomenon called late emerging poor readers. This is when you have children who seem to be doing okay in the early grades. And then around third or fourth grade, we start to see them hit what we call a slump. So you might've heard of the fourth grade reading slump.

But what longitudinal data shows us is that late emerging poor readers are actually late identified. That's because early tests of reading comprehension are actually word reading assessments. When we look back in longitudinal data, we find that if you actually measure language comprehension in those early grades, kindergarten, first, second grade, you identify children who are going to struggle later on and you can provide them those early supports that they need to be successful. The difficulty with early identification is that young children can't read words. So how do I identify those who are going to be poor readers before they start to read? Longitudinal research has shown us that the connections between speech, language, and literacy allow us a window into the future reading ability for young children. For preschool, if children have difficulties in early code-related abilities such as phonological awareness, rapid automatic naming, and letter identification, this is a crystal ball into their future word reading difficulties.

So we need to provide them support early on. The same can be said for language comprehension. If a preschooler has difficulty learning words and connecting words together to make grammatically correct sentences, this is a window into their future difficulty with language comprehension.

Jodi Winn: I'm a parent of a young woman who has DLD. We noticed communication difficulty when she was a toddler. Other people weren't able to understand her and I was doing a lot of translating for them. She had great gestures, great facial expressions, great inflection in her speech, but she struggled with articulation. And so once articulation was addressed and rectified, we moved on and we tested language. And that is when she was officially diagnosed with DLD. She struggled with verbs in particular, pronouns, complex sentences. She had an IEP initiated when she was in preschool and she was discharged when she was in fifth grade. She struggled in school. We spent a lot of time doing homework, excessive hours at the kitchen table. There were tears on both parts, both she and I at times. She required a lot of support, especially after being discharged from the IEP.

When she no longer received services, then I really had to step up my game. I had to hire tutors. I enlisted neighbors and family members to help me help her because I couldn't do it all.

Tiffany Hogan: A common story that I hear is a parent coming to me and saying that their child has three different disabilities and they're asking me, how do I support all of these different difficulties in their child? First, they'll tell me that their child was a late talker and that their child received early intervention services from birth to three. And at that time, their speech language pathologist who served them told them, "Your child has a developmental delay." Then the child may make enough progress that they are not seen by that early interventionist, and then they move on to preschool. And in the preschool years, maybe they're in preschool one to two years, and then they hear from their teacher that they're concerned that the child has a speech and language impairment. So they may go on to receive services potentially by another speech language pathologist or an educator as having speech and language impairment.
Then they may make improvement. They go on to elementary school where they're not receiving services. A few years in, there'll be another concern by their teacher that says they're not comprehending what they're hearing. They're not answering the questions to the stories. So then they get referred and then they have a label of specific learning disability. Well, where does DLD fit in this story? Developmental language disorder is the underlying condition that results in these labels that are used to qualify a child for receiving support services. So what we see is that these multiple labels are resulting in missed support services for the child across the years. It's also very confusing to parents and educators because they believe that the child has a different difficulty across the age span. If we diagnose the child with developmental language disorder, then we would know what difficulty they have, and we would be able to change the support services as the child needs them across time.

We do this already with autism, for example. If a child has a diagnosis of autism, that label doesn't leave them. They have that label and they carry that label with them. It tells the people around them what to anticipate about how they might react with the academic environment and language so we can provide the supports we need. We want to see something similar for children with developmental language disorder. We also want to see a consistent label for developmental language disorder so that we can get more research around these children. When children are called by many different labels, we see one study that might involve children who have a speech and language impairment. We'd see another study that might involve children who have a specific learning disability in comprehension. It's difficult to take all of that research and apply it to practice if we don't have a consistent label for the children that we're studying.

Jodi Winn: She still struggles with completing homework in a timely manner just because it takes her so long to comprehend the assignment and then actually complete the assignment. Some of the ways that she's managed to deal with these barriers is learning strategies, compensatory strategies to pace herself, to take breaks, to talk to the teacher and say, "I'm struggling with this. Can I have extra time? Or maybe can we change this a little bit so that it's easier for me to do?" DLD is something that will stay with her for the rest of her life, and it's something that she's going to have to learn how to advocate for herself and learn how to incorporate compensatory strategies to accomplish certain goals that she may have for herself. The sky's the limit for these kids to not place any low expectations on them because they have DLD. If they put their mind to it, they can accomplish it.
My daughter is now a sophomore at a university and she's doing well, and I'm excited to see where she goes from here.

Tiffany Hogan: In 2017, a meeting was convened, and the consensus was that we would call these children children with developmental language disorder. And now we're working through that advocacy to make changes across multiple platforms. So recently, developmental language disorder was added to the psychological manual for diagnostic support. So in psychology, they'll now be referred to as children with developmental language disorder. Medically, in the ICD-11 codes that are used for medical diagnosis, developmental language disorder was added. We received guidance from the U.S. Department of Education that DLD can be used as a qualifying category for children to receive special education and support services. In the world of reading, developmental language disorder is featured in the defining guide for the science of reading created by the Reading League. In terms of educational policy, states are starting to screen for dyslexia, and in doing so, some states have started to add screening for DLD, the first being Virginia, with many more coming on board.
I've had the opportunity to co-found with colleagues an informational website about developmental language disorder called dldandme.org. On this website, we distill research findings for educators, parents, and persons with DLD. Some of the topics include the social impact of DLD, academic impact of DLD, how DLD is the same and different than autism. And now every year in mid-October, we have a Developmental Language Disorder Awareness Day where we light up monuments all over the world in the color of purple and yellow to bring awareness for DLD. We want to consider how to ensure that a label of DLD is helpful and not harmful. We want the label to be a vehicle so that the child can receive the support they need so they can grow. We need to collaborate with children and adults who have DLD so we can learn from their lived experiences to know how to best support them.

I love this quote, "A ship is safe in the harbor," but that's not what ships are for. You are that ship that's getting out of the harbor and you're the one that will make a difference in the lives of a child with DLD.

Paula Orrego: The disorder will always be with you and it could make things more difficult, but that doesn't make things impossible.

Margarita Orrego: If you think your child has a language problem, seek help immediately. For a parent, it is hard, but the only way you're going to support your child is if you accept and if you don't panic. I think those are the two first things that you have to do.

Paula Orrego: Just because you have a language disorder does not define who you are and what you are capable of doing.

Tiffany Hogan: Thank you so much for taking the time to listen to this presentation and getting the ship out of the safety of the harbor and out into the world where it's meant to be. I hope you will use this information to go out into the world and change it one child at a time.

VO: Reading Universe is made possible by generous support from Jim and Donna Barksdale; the Hastings/Quillin Fund, an advised fund of the Silicon Valley Community Foundation; the Emily Hall Tremaine Foundation; the AFT; and several anonymous donors. 

[On Screen Credits
Producer: Noel Gunther
Associate Producer: Mary-Kate Wilson
Video Editor & Motion Graphics: Alan Brain
Post-Production Supervisors: James Allgood, Christian Lindstrom
Graphic Design: Connor McDonald, Camilla Brinton, Sagetopia
Camera: Allie Humenuk
Audio: Lyle Bibler
Special Thanks: Boys Town Hospital, DLDandMe.org, Dr. Karla McGregor, Jodi Oliver, Margarita Orrego, Paula Orrego]

If you enjoyed this video, please subscribe to our YouTube channel @RUTeaching. Reading Universe is a service of WETA, Washington D.C., and was developed in collaboration with the Barksdale Reading Institute and First Book.

Tiffany Hogan: This is Reading Universe.