Specific Language Impairment (TEL): Diagnosis, Assessment, and Legal Framework

Legal Framework and Educational Changes

Law 20201: Amendments to Education Grants

• This Act amends DFL No. 2 of 1998, Education, on grants to schools and other statutory bodies.
• Changes the concept of Basic General Education, Special Education, and Special Differential Education.

• Special Needs Education (SEN) Expansion:

  • Widens the concept of Special Needs Education to include Humanistic-Scientific Secondary Education (Temporary SEN).
  • Explains the concept of SEN as non-permanent needs requiring students at some point in their school life as a result of a disorder or disability diagnosed by a competent professional. These students need extra help and support to enter or progress in the curriculum for a certain period of schooling.
  • This Regulation will consider attentional deficits and specific language and learning disorders.
  • Explains the term competent professional.
• It must be explicit that an unauthorized professional is ineligible for diagnosis of revenues and expenses.
• Clarifies the penalties that the professional authority will suffer for carrying out fraudulent diagnoses, and the holder that uses them for school subsidies.
• Modifies and increases school subsidies for special schools.
• Finds that for pre-school, primary, or secondary pupils requiring hospitalization in specialized centers or at the place determined by the attending physician, or who are receiving ambulatory medical treatment, the Ministry of Education will provide the appropriate attention in school rather than by prescription.

Specific Language Impairment (TEL)

Definition of TEL

A language disorder is the abnormal acquisition, comprehension, or expression of spoken or written language. The problem may involve all, one, or any component (phonological, morphological, semantic, syntactic, or pragmatic) of the language system. Individuals with language disorders often have difficulty processing language or abstracting significant information, as well as issues with storage and retrieval of short-term memory.

Decree 1300-1302 (Based on DSM-IV)

Children with SLI are defined as those with a late onset or slow development of speech that is not explained by a sensory, auditory, or motor deficit, mental deficiency, mental diseases, pervasive developmental disorders, social withdrawal, emotional injury, or evident brain dysfunction. TEL falls into expressive and mixed (receptive-expressive) types.

Expressive TEL

(A) Low scores on standardized tests of expressive language relative to receptive language. Receptive language is normal or slightly altered. Clinical manifestations include extremely limited vocabulary, errors in verb tenses, difficulties in memorizing words, or producing sentences in length and complexity appropriate to their age.

(B) The expressive language difficulties interfere with academic or occupational achievement or social communication.

(C) Does not meet criteria for Mixed Receptive-Expressive Language Disorder or Pervasive Developmental Disorder (PDD).

(D) If mental retardation, motor or sensory speech deficit, or environmental deprivation is present, poor language must exceed those usually associated with such problems.

Mixed Receptive-Expressive TEL

(A) Scores of developmental assessments of receptive and expressive language are below those obtained from assessments of nonverbal intellectual capacity. Symptoms include those of expressive language disorder, as well as difficulty understanding words, sentences, or specific types of words, such as spatial terms.

(B) The deficiencies of receptive and expressive language significantly interfere with academic or occupational achievement or social communication.

(C) Does not meet criteria for PDD.

(D) If mental retardation, motor or sensory deficit, or environmental deprivation of speech is present, the language deficits must be in excess of those usually associated with these problems.

Etiology of TEL

• Cause unknown and controversial.
• Possible genetic and hereditary links.
• Possible changes related to brain structures involved in alterations in information processing in the brain.
• Possible change in the perception of auditory information.

Language Assessment Procedures

General Evaluation Steps

• Clinical Observation
• Application History and Interview with parents and/or teachers.
• Analysis of compiled data for a later diagnosis.
• Set physical changes and make a general observation of the structures of the Orofacial Apparatus (OFA).
• Analyze possible changes in a sample of spontaneous speech, not just through tests.
• By observing, establish the existence of patterns that appear to be erroneous, but may be normal in special situations (speed of speech, sociocultural context, etc.).
• Always consider the child's age and its evolution.
• Establish the child's behavior during the assessment and socio-communicative interaction.

Evaluation: Children Under 3 Years

• Psychomotor Development Test (TEPSI). Consists of 3 subtests: coordination, language, and motor skills.

Evaluation: Children 3 to 6 Years 11 Months

Application of Standardized Tests

TEPROSIF-R (Test to Assess Phonological Simplification Processes):

Test of Chilean origin, created by the speech therapist and linguist Maggiolo Mariangela and Maria Mercedes Pavez, in collaboration with a group of students in the career of audiology at the University of Chile, between 1989 and 1990. It is based on the theory of Natural Phonology from the work of Stampe (1969) and Ingram (1983). It was updated in 2008, giving rise to TEPROSIF-R. Responses are phonologically transcribed. This version uses a sample of 620 children from III, IV, V, VII, and MR regions, with input from speech therapists of these regions.

General Structure of the TEPROSIF-R Test

• Set of Pictures: 37 black and white drawings.
• Blades: Consist of a sheet with two drawings, one above and one below. The first is created to give an example for the child, and the second elicits words.
• Answer Sheet: Contains data for the child, and the items of verbal stimuli, next to each transcribed phonetically expressed by the minor. Then there are 5 columns: 3 for the identification of the PFS, 1 for the total, and 1 for other answers.
• Analysis Sheet: Created to simplify the analysis of the test.

Understanding Phonological Simplification Processes (PFS): These are strategies in the normal development of phonology, which children use to simplify their speech, and which are gradually phased out along the stages of development until the child achieves a production similar to the adult.

Application of the TEPROSIF-R Test

• Joint problems should be discarded.
• The test is applied individually, under conditions suitable for an evaluation.
• The examiner should be familiar with the test.
• The examiner applies the test to the child sitting next to the set of sheets in front of them.
• Instructions: "Look, I'll show you some pictures and say something about them. In the picture above, I say a complete sentence, and when you show the bottom, you complete the sentence."
• Such sheets are used to familiarize the child with the test. It is necessary that the child understood the instruction to continue the test.
• It is important that the examiner should be clear that they must elicit the words, NOT direct imitation.
• Always seek the full implementation of the test.
• Do not apply the test when the child has unintelligible speech, as analysis is difficult.
• In the case of making a sweep, analyze the initial 15 items and note if the child has problems or not by comparing the total PFS proposed rule for them. In the event of problems, the entire test must be performed.

Analysis of Results (TEPROSIF-R)

• To facilitate the analysis, the child's responses can be recorded.
• You must carefully analyze each expression of the minor, classified into 3 types of processes.
• Generally, every process within an emission is equivalent to one point.
• If the answer does not fit with the types of PFS, it is considered another response (NR: no response, NT: not transcribed, OP: another word, PNI: processes unidentifiable, PNC: processes not classifiable in the categories proposed). These responses are not scored.

Standards and Interpretation of Results (TEPROSIF-R)

3 performance levels are considered: normal, at risk, and deficient. We must remember that the fewer the PFS, the better the performance of the child. Performance standards are classified by age group.

• Test exploratory Spanish grammar A. Toronto (Comprehension - Spanish Grammar Expression)
• Test for auditory language comprehension E. (Comprehension - Morphology - Syntax - Semantics)

Evaluation: Children Older than 6 Years 11 Months

• LVET-R: Picture Vocabulary Test
• Illinois Test of Psycholinguistic Abilities (ITPA) (evaluates children 3 to 10 years)

Casual Test Application (Children over 6 years 11 months)

Assessment Guideline for School Speech Therapy (PEFE) / For children ages 7 to 12, evaluates the semantic level and Morphosyntactic Level.

Sample Language

• Evaluate the expression of the minor.
• You can perform a detailed analysis of the child's language.

Evaluation: Children Under 3 Years

Scale for the Emergence of Receptive Language - Expressive (REEL)

• Evaluates from 0 months to 36 months.

Evaluation: Children Over 11 Years

Procedures for Evaluating Speech (PLOT)

• Evaluates mainly adolescents.
• Evaluates Semantic skills related to speech.
• Evaluates Description / Narrative.
• Guideline Evaluates Comparison of pragmatic skills, based on Tattershall.
• Test of Articulation of Repetition (TAR).

Diagnosis and Legal Decrees

Diagnosis

• Analyze data collected on history, standardized tests, articulation tests, informal guidelines, and clinical observation.
• Always consider the age range of children and their developmental stage.
• Establish differential diagnosis (Normal - Abnormal).
• Make appropriate referrals in cases that merit it.
• Set associated alterations.
• Communicate the diagnosis to parents, the multidisciplinary team, and the child's teachers.
• Inform and explain to the family the meaning of the diagnosis.
• Provide guidance to the family in relation to the possibilities of schooling.

Decree 1300-1302

• Enacted on December 30, 2002.
• Approves plans and programs of study for students with specific language impairment.
• Born from the Organic Constitutional Law on Education and the Law of Integration for People with Disabilities.
• Replaces Decree No. 192/97 related to the care of children with primary, secondary, acquired, and speech development communication disorders.
• Regulates the attention of students in special language schools and TEL PIE (Integration Program).
• Sets the speech-language pathology task.
• Sets the pedagogical work.
• Normalizes ingress and egress of children with SLI.
• Sets Specific Curriculum for students with SLI.
• Attention should be performed in speech therapy sessions of 30 minutes, individually or in groups of up to 3 children.
• Indicates conditions for differential diagnosis:
  • Mental deficiency
  • Hearing loss
  • Deafness
  • Cerebral Palsy (CP)
  • Serious disturbances in the relationship and communication capacity that alter social adjustment, behavior, and individual development
  • Voice alteration
• States that any assessment must be conducted with the permission of parents or guardians.

Change in Decree 170

Functions of the Audiologist (Speech-Language Pathologist)

Speech Therapy Assessment

Assessing Children Over 6 Years

Instructions on care of children with specific language disorders:

• The tests used must conform to the structure stated in Instruction No. 0610 and in ACT 1300-1302.
• In the case of students whose ages exceed those set forth in the Education Act No. 1300-1302, it is suggested that the evaluation procedure includes the following elements:

1. Detailed and complete history.
2. Clinical Observation, including aspects such as physical characteristics of the child, anatomic characteristics of fonoarticulatorios organs, description of the child's behavior, and type of communicative interaction.
3. Records of language that consist of a written transcript of spontaneous speech and narrative of the child. To that end, a record of at least 1 page must be included.
4. A Protocol consigning pragmatic elements relating to the handling of language.
5. To supplement and confirm the diagnosis, it will be necessary to apply formal tests such as the Illinois Test of Psycholinguistic Abilities (ITPA) or other appropriate test(s) for the age range of the children evaluated.
6. Likewise, information on performance at the phonetic-phonological level is needed, which requires performing and recording an articulation sweep.

Instruction No. 610

• Issued in April 2005.
• Clarifies and reiterates aspects of Decree 1300-1302 for proper application.
• Explains criteria for admission, admission diagnosis, professional accreditation of the audiologist, health teaching, graduation of students, roles of professionals involved, the specific plan development, integration of children under 3 years, and children with cleft palate and TEL.
• Describes the role and workload of professionals specializing in speech-language pathology and language teachers.
• Clarifies that the diagnosis of income must apply at least 2 instruments to assess comprehension and expression.
• Explains that a report must be delivered to the family explaining the TEL condition, including suggestions and activities for home.
• Sets the accreditation of the professional speech pathologist; they must be registered at the regional level in the corresponding SECREDUC.
• Audiologists with foreign qualifications must be validated in the University of Chile.

Mathematical Formula for Speech-Language Pathologist Hours

ACT 170

• Enacted in August 2009.
• Uses the CIF (International Classification of Functioning, Disability and Health) criteria to establish diagnoses.
• This regulation lays down the rules, instruments, diagnostic tests, and the profile of competent professionals to be applied to identify pupils with SEN.
• Clarification of the term SEN.
• Emphasis is placed on the diagnosis made by a competent professional.
• Integrates new impairments and disabilities such as Specific Learning Disorders, Attention Deficit Hyperactivity Disorder (with and without), Deaf-Blind Services included in Multideficit, and Multideficit.
• Clarifies conceptualizations related to these alterations.
• Amends Decree 1300-1302.
• Emphasizes the use of evidence of a national standard, current, and valid version. It adds that the evaluation must consider the application of educational tests that are related to the curricular learning of the child evaluated.
• Sets that the diagnostic evaluation will be recorded in a single form supplied by the Ministry of Education.
• In case more background information on the child is needed, they should be referred to appropriate specialists and this information recorded in the Single Form.
• It provides that the competent professional is one who is enrolled in the National Registration System for Professional Special Education Evaluation and Diagnosis and meets the professional skills established by order of the Ministry of Education.

Regarding TEL (ACT 170)

It uses a new definition according to CIF, and provides definitions of the DSM IV-R classification.

Annexed Data and Classification

Classification of Language Disorders

There are a variety of classifications of speech disorders, which are due to different types of theories and inclinations of their authors. Some rankings are based on the severity of the conditions, others on the age of onset, and some on their symptoms. In Chile, the law defines TEL classification criteria based on DSM IV and ICD-10.

Ingram (1970) Classification

The classification is based on the severity of the conditions from grade I to IV. This classification was used by the language schools under Decree 192.

• Grade I (Mild): Delay in the acquisition of sounds in words. Language understanding is normal. Expressive language performance is below chronological age.
• Grade II (Moderate): More severe delay in acquiring the sounds of words and language development. Understanding is normal. Semantic deficit. Syntax is altered. Abundant pragmatic imperatives and "verbal gestures" (wake-up call), poor initiative, and difficulty starting conversations.
• Grade III (Severe): Even more severe delay in the acquisition of sounds and language development. Difficulties in understanding. Important delay at the semantic and syntactic level. Pragmatic conversation focused on self; pragmatic adjustments to the situation or the speaker are poor. The thematic coherence is unstable.
• Grade IV (Very Severe): Great developmental disorder of spoken language. Difficulty in understanding language and the meaning of other sounds. Deafness is often apparent.

Rapin and Allen (1983-87) Classification

Uses a clinical approach and is widely used by therapists because of its practicality.

• Phonological Programming Deficit: Comprehension is relatively normal, but there is a flow of production, but with little clarity, making it almost unintelligible. Notable improvement in articulatory quality in repetition tasks of isolated elements (syllables, short words), but not when it comes to long words or phrases.
• Phonological-Syntactic Deficit: Corresponds to "dysphasia." These subjects have better understanding than expression, but have difficulty understanding when the statement is long, includes complex structures, is ambiguous, is presented out of context, or is issued quickly. In speech, difficulties in articulation, fluency, and above all, learning and use of links and morphological markers are highlighted. In some cases, the sequential training of statements itself is laborious.
• Syntactic Lexicon Deficit: The delay will exceed its alterations in pronunciation, but there is great difficulty of evocation and stability of the lexicon. The understanding of single words may be normal or nearly normal, but not sentences. There is an abundance of "catch phrases," disruption, paraphasias, and great difficulty in maintaining the sequential order and using morphological statements when they have to express complexity beyond simple dialogues.
• Auditory Verbal Agnosia: The subject does not understand the language but can communicate with natural gestures. Their expression is zero or near zero, even in repetition. This is comparable to mixed congenital aphasia or word deafness.
• Verbal Dyspraxia (Speech Disorder): The subject has normal understanding or nearly normal, but with great difficulties in organizing the articulation of phonemes and words. It affects prosody. Statements are limited to one or two words, difficult to understand. Does not improve in repetition tasks. In its extreme limit, the subject is completely mute, comparable to expressive congenital aphasia.
• Semantic-Pragmatic Deficit: The subject may have early language development within a relatively normal range and free of significant speech problems. Their statements may also appear well developed. However, they suffer great difficulties in understanding, sometimes resulting in the level of expression being greater than understanding. Above all, the need to adapt their language to the interactive environment is stressed; the pragmatic adjustments to the situation or the speaker are poor, thematic coherence can be unstable, and echolalia or perseverations are common.

Summary of Rapin and Allen Classification

Le Heuzay, Gerard, and Dugas (1990)

This is an adaptation of Rapin and Allen from the Crosson brain function model.

• Phonological Syntactic Disruption Syndrome: Better understanding of speech. Speech appears to be very small, laborious, often unintelligible, and unstable. Resistant agrammatism. Good information value of utterances. Small lexicon but smooth evocation.
• Phonological Production Syndrome: Expressive difficulties predominate, but in this case, the expression is quite smooth although uncontrolled and often unintelligible, even in repetition. Disorders of syntax and chronological organization problems. Difficulties in recall.
• Receptive Dysphasia: Severely impaired understanding, despite surface expression developing in a natural situation in context, but with serious problems of naming, phonemic paraphasias, and syntactic disorders in addressed situations.

Neurolinguistic Model (Crosson, 1992)

Crosson proposed a Neurolinguistic Model involving structures like:

• Thalamus
• Basal nuclei
• The anterior portion of Broca's area

The VLOS pulvinar nucleus and ventral anterior thalamus are connected to Wernicke's area. All these structures would be involved in semantic analysis. The thalamic anterior structures (NVA), inhibition of the globus pallidus, and caudate nucleus stria up circuits involved in verbal flow and the sequential organization of sentences.

DSM-IV Criteria for Specific Language Impairment

Definition of Specific Language Impairment (SLI)

• According to Benton (1964): Developmental disorder characterized by severe problems of expression and language comprehension in the absence of hearing loss, mental retardation, or emotional disturbance.
• ASHA (1980): Abnormal acquisition or expression, comprehension of spoken or written language. The problem may involve all, one, or some of the components (phonological, morphological, semantic, pragmatic) of the linguistic system. Frequent problems with language processing or abstraction of meaningful information storage and retrieval of memory.
• General Consensus: Consists of a hard-lasting disorder of varying severity for the processing of language, which cannot be attributed to mental retardation or sensory or motor deficits. (Rapin and Allen 1983, Bishop 1987, Leonard, 1998; Aguado, 1999; Chevrie-Muller, 2001).

SLI Diagnostic Criteria (Exclusion)

Currently, an exclusion criterion is used for the diagnosis of SLI, as it is considered that this language disorder cannot be explained by associated alterations (Rinkert, 2006).

• 25 dB hearing level in conversational frequencies.
• Normal emotional and behavioral indicators.
• Superior performance IQ 85.
• No signs of neurological disorder.
• Normal speech motor skills.
• Linguistic ability: Score on language tests - 2 standard deviations or lower.

Linguistic Features of TEL

Phonology

• Children with TEL have altered the normal development of phonology, resulting in the presence of PFS (Phonological Simplification Processes) exceeding those expected for their chronological age (failure to produce initial unstressed syllables, errors of substitution and assimilation).
• Difficulties in understanding speech.
• A child at the age of 6 years should have a full development of phonology and should not have difficulty in articulating phonemes.

Phonological Simplification Processes (PFS)

Based on the theory of Natural Phonology (Stampe, 1969; Ingram, 1983):

• Are part of the language development of children.
• Function as systematic strategies for reducing the phonological complexity of words.
• This theory states 3 types of PFS: a) Related to the structure of the syllable, b) Replacement, c) Assimilation.

The child simplifies emissions by reducing the basic syllabic structure of the word (CV or CV + CV structure: Deleting syllable final consonants, consonant clusters or diphthongs reducing, altering the geometry of the word).

Examples:

• TRAIN = / ten /
• BRIDGE = / pente /
• BANANA = / plántantano /
• PANTS = / patalón /
• BUTTERFLY = / mops /
• UMBRELLA = / Umbrellas /

PFS Types of Syllabic Structure

• Reduction of consonant cluster.
• Reduction of diphthongs.
• Omission of consonant-Trabant.
• Coalescence Failure unstressed elements.
• Omission of syllable.
• Addition of phonemes or syllables.
• Investment of phonemes or syllables.

PFS Replacement

Consists of changing phonemes belonging to one class by another class of phonemes (e.g., fricatives by occlusive: / Poka / by / foka /).

Other examples:

• Home / Kapha /
• Suitcase / naléta /
• Pasto / Paht /
• Canto / Kahta /
• Guitar / Gitara /
• Phone / telésono /

Replacement PFS Rates

• Processes affecting the syllable phonemes lock (aspiration) e.g., / avocado / / Paht /.
• Processes by area of articulation: labial and dental posteriorización of e.g., / Scarf / / kufánda /; frontalization of palatal and velar; rounding consonants.
• Processes by mode of articulation: Oclusivización of fricative or affricate phonemes, Fricativización of occlusive or Africa phoneme; fricatives together e.g., / mat /, / alsómbra /.
• Process according to phonation, articulation, or quality: Sonarización of consonants, Afonización, or loss of sonority of consonants.
• Processes as fundamental trait: liquid / illiquid phonemes: Semiconsonantización of liquid phonemes, Substitution of liquid phonemes together.
• Process according to additional resonance: Nazalición phoneme.
• Processes affecting the vowel phonemes: Replacement of vowels or dissimilation.

PFS Assimilation

Involves replacing phonemes to make them similar or identical to others present in the word.

Examples:

• Truck / kanionéta /
• Phone / tenéfono /
• Clock / lelólx /
• Bed / breast /
• Shoe / Cover up /

PFS Assimilation Rates

• Assimilation-identical: e.g., / Scarf / / bubánda /
• Assimilation by similarities: e.g., Lip, dental, palatal, watch, liquid phonemes assimilation, nasal assimilation, vowel assimilation, syllabic assimilation.

Semantic Features of TEL

• Evidence of a slow acquisition of words and meanings, showing a reduced vocabulary in relation to their chronological age.
• Delay in acquisition of first words.
• Delay the lexical explosion at 18-24 months.
• Difficulty using words they already understand.
• Use of wildcard or general words instead of more specific words.
• Discontinuous speech flow with pauses, interjections, and repetitions.
• Difficulties in lexical access.

Morphosyntax

Morphology

• Omission of plural morphemes, verb inflection, and omissions of articles, auxiliary, and copulative verbs.
• Confusion between the singular and plural forms of words.

Syntax

• Very short productions.
• Few changes.
• Low number of complex sentences.
• Low range of sentences.

Pragmatics

• Few comments about people or events.
• Difficulties describing facts.
• Lack of interaction with adults, limited to shifts.
• Limited use of gestures.
• Passivity in the conversation and inappropriate use of speech turn.
• Difficulties keeping the topic of conversation.
• Difficulties in the use of discursive and narrative strategies.
• Great difficulty interacting with peers.

TEL Assessment in Speech Therapy

The assessment process includes:

• Clinical Observation
• Anamnesis (History Taking)
• Establishing Rapport
• OFA (Orofacial Apparatus) Evaluation
• Articulatory Sweep
• Hearing Screening

Child Anamnesis

You should consider:

• Reason for consultation.
• Personal history of the child (e.g., birth history, psychomotor development, major diseases).
• Language Development.
• Family history (e.g., relationships with family, friends, siblings with similar symptoms).
• School history.
• Other relevant observations (e.g., feeding/power).

Rapport

It is essential to achieve an appropriate approach with the minor to be evaluated, especially since children may manifest shyness toward strangers. Rapport should be carried out in a natural environment, trying to draw the child's attention. You can use themes of interest to them, such as cartoons, toys, or striking objects.

OFA Evaluation

• The evaluation should try to be non-traumatic or invasive to the child.
• Explain to the child and their parents what will be performed and which tools will be used.
• Evaluate all fonoarticulatorios organs.
• Use a sample protocol.

Articulatory Sweep

Objective:

• Evaluate the articulatory repertoire of a child.
• Evidence of phoneme inconsistencies.
• Evidence or rule dyslalias.

In Chile, the TAR and TAS are used—simple tests requiring the child to repeat words, with no age limit, quick and easy application. They evaluate direct syllable phonemes (initial, middle, end, and Trabant), as well as vowel diphones, consonants, and sentences of varying geometry. (See TAR-TAS protocol).

TAR Application

Directions: "I'll say a few words and then I want you to repeat them." If the child is shy or worried about the answers, add: "Do not worry, it doesn't matter how well you can say them."

Hearing Screening

It is done to rule out hearing impairment. Performed in a natural context, using 3 tests:

• Whispered voice (whispering or murmuring)
• Normal voice
• High-intensity voice

Concomitant Alterations

• Dyslalias: In many cases, children with SLI have dyslalias or articulatory inconsistencies.
• Learning Disorders: Without proper language development, the acquisition of literacy and mathematics can be altered. Reading and learning can be affected in children with SLI (between 40 and 70%).
• Difficulties in Attention-Concentration: In some cases, children with SLI demonstrate difficulties sustaining attention and concentration during activities.

Differential Diagnosis

Phonological Disorder vs. Simple Language Delay

The child with a phonological programming disorder, although having a delay in sequencing and articulation of phonemes with respect to their age, also produces phonological forms that are not present in younger children.

Language Disorder

• Monfort and Juárez note that the fluidity of these children is higher than those with expressive TEL.
• Narbona says the changes are not systematic phonics; phonemes can be altered in words repeated correctly in isolated syllables. Difficulties increase with the length of the word, and a word can be altered differently each time.

Classification of Phonological Disorders (Dodd and McCormack, 1995)

• Consistent Deviant Disorder: All processes can be described in terms of one or more rules. These rules can coexist with delayed rules or rules not appropriate to age. The child uses one or more deviant facilitating rules, but they do not vary with linguistic change. Dodd and McCormack think that in this case there is a deficit of phonological awareness.
• Inconsistent Disorder: In this case, phonological facilitation rules cannot be identified, although these errors may result from complex inconsistent phonological rules. The child varies in the pronunciation of a word.

Phonological Disorder according to DSM IV

• (A) Failure to use developmentally expected speech sounds and language for the age of the subject (e.g., errors in the production, use, representation, or organization of sounds).
• (B) Deficiencies in the production of speech sounds interfere with academic or occupational achievement or social communication.
• (C) If mental retardation, motor or sensory speech deficit, or environmental deprivation is present, poor speech must exceed those usually associated with these problems.

Simple Language Delay

According to Juarez and Monfort (1992), this is a delayed onset of language levels that primarily affects expression and is not explained by intellectual, sensory, or behavioral deficits. Theoretically, the mechanisms and evolutionary stages of normal development are respected, but with a lag.

Features of Simple Language Delay

• Appearance of the first words after 2 years (instead of 12 to 18 months).
• First combinations of 2 or 3 words at 3 years (instead of 2 years).
• Persistence of numerous phonetic difficulties, failure of syllables after 3 years.
• Limited vocabulary, fewer than 200 words spoken at 3 years.
• There is an improvement with age and total resolution around 6-7 years.

It differs from TEL, since in TEL, the disorders are more persistent, lasting at school age and into adolescence, often accompanied by other neuropsychological disorders that compromise attention, memory, and graphomotor function.

Differential Diagnosis: Speech Fluency

• Slurred speech
• Dyslalias
• Stuttering or Spasmofemia

Dyslalia

Alterations in the articulation of phonemes, which can be:

Evolutionary or Physiological Dyslalias

• There is a phase in the development of language where the child does not articulate or distorts some phonemes well.
• Usually disappear with time; professional intervention is not always necessary.
• It usually causes anxiety to parents who think it is a more serious delay.

Audiogenic Dyslalia

• A disorder in the articulation of phonemes produced by a hearing deficit.
• Often associated with hearing loss, often concomitant with changes in voice and rhythm.

Organic Dyslalia (Diglossia)

• A joint disorder of phonemes caused by alterations in peripheral organs of speech and central neurological origin.
• Etiology: Malformations of the bucofonador musculoskeletal apparatus (e.g., cleft lip, cleft palate, macroglossia, malpositioned teeth and jaws).

Functional Dyslalia

• Changes in the articulation of certain phonemes as a result of poor coordination of the OFA necessary to articulate them.
• There is no physical or organic disorder, but a functional disability.
• The most frequent functional dyslalias in terms of phonemes affected are sigmatism (defect of the phoneme "s"); lambdacism (defect in the phoneme "l"); rhotacism (defect in the phoneme "r" and "rr"); gammacism (defect in the phoneme "g", "k" and "j"); deltacism (defect in the phonemes "d" and "t").
• When alterations include large numbers of consonant and vowel phonemes, verbal output is sometimes unintelligible (multiple dyslalias).

Stammering (Stuttering)

ICD-10 criteria for the diagnosis of stuttering:

• A. Impaired flow and normal temporal organization of speech (suitable for the subject's age), characterized by frequent occurrence of more of the following phenomena:

1. Repetitions of sounds and syllables
2. Prolongations of sounds
3. Interjections
4. Fragmented words (e.g., pauses within a word)
5. Audible or silent blocks (pauses in speech)
6. Circumlocutions (word substitutions to avoid problematic words)
7. Words produced with an excess of physical tension
8. Monosyllabic word repetitions (e.g., "I-I-I see")

B. Altering the flow interferes with academic or occupational achievement or social communication. C. If a motor or sensory deficit of speech is present, speech impairments are higher than those usually associated with these problems.

Differential Diagnosis: Psychological Disorders

• Selective mutism
• Attention Deficit Syndrome, with or without Hyperactivity

Selective Mutism

ICD-10 criteria for the diagnosis of selective mutism:

http://www.psicomed.net/cie_10/cie10_F94.html>

• A. Persistent inability to speak in specific social situations (where speaking is expected, e.g., at school) despite speaking in other situations.
• B. The disturbance interferes with work or school performance or social communication.
• C. The duration of the disturbance is at least 1 month (not limited to the first month of school).
• D. The inability to speak is not due to a lack of knowledge or fluency in the spoken language required in the social situation.
• E. The disturbance is not better accounted for by the presence of a communication disorder (e.g., stuttering) and does not occur exclusively during the course of a pervasive developmental disorder, schizophrenia, or other psychotic disorder.

Attention Deficit

Attention Deficit Disorder (AD) is a condition that causes changes in attention span and concentration and occurs in children with normal intelligence. It may or may not be associated with hyperactivity and impulsivity. What characterizes the child with ADHD is the increased frequency and intensity of these behaviors when compared with peers of the same age. The attention deficit can have consequences on children's school performance (failing grades), development of personality (low self-esteem, feelings of futility and frustration), and social integration (difficulty interacting with others, isolation, discipline problems, social rejection, and discrimination).

Differential Diagnosis: Severe Communication Disorders

• Pervasive Developmental Disorder (TGD)
• Dysphasia

Pervasive Developmental Disorder (TGD)

According to the DSM-IV and ICD-10, the term Pervasive has a general character as it is a serious and widespread disruption of several areas of development:

• Social interaction
• Communication
• Stereotyped activities and interests

Dysphasia

Severe language disorder whose causes are not due to obvious reasons such as deafness, mental retardation, a motor impairment, emotional disorders, or personality disorders (Seron and Aguilar, 1992).

According to DSM-IV (1995), criteria for diagnosis of dysphasia are:

• Persistent deficits in language at all levels of comprehension and expression.
• Delay timing and deviation from normal patterns of acquisition and development.
• Serious communication problems.
• Difficulties in school learning.
• The alteration was not due to sensory, intellectual, or severe motor deficits.

Differential Diagnosis: Sensory Disorders

Hearing Loss

Hearing loss is called the inability to hear normally, whatever the degree of this.

• Conductive hearing loss: One in which sounds have trouble following the normal way (damage to the outer or middle ear) and therefore there is a hearing loss greater than 20 dB. In these patients, bone vibrator stimulation is normal because the inner ear is normal.
• Sensorineural hearing loss: If the damage is at the inner ear, the sound will be conducted the same as the air, and bone conduction will exist the same loss.
• Mixed hearing loss: One in which there is an injury to the CAE and/or middle ear and also an injury to the inner ear. Airway is abnormal and bone conduction is still abnormal; there is a clear separation between the two (10 or more dB).

Language Assessment Levels

Phonological Level

Objectives:

• Determine if the child has problems or not in their phonological development.
• Make a detection or screening of the phonological system.
• Determine the status of the child's phonological system.
• Predict the course of evolution.
• Determine the need for intervention.
• Establish guidelines for possible intervention.

Always Consider...

• Analyze changes in a sample of spontaneous speech and not just through the Test.
• Recognize the existence of patterns that, although apparently erroneous, may be normal in special situations (speed of speech, social and cultural context).
• Investigate the influence of context.
• Identifying phonological simplification processes, always considering the child's age and its evolution.
• During the administration of an articulatory test, consider the total production of the word and not only the phoneme investigated, determining whether there are differences in tests of spontaneous recall and repetition.

Testing for Phonological Level

• Observation of OFA.
• Articulatory Sweep (ART).
• Formal tests: TEPROSIF-R.
• Informal tests: PCC (Percentage of Consonants Correct).

PCC = Percentage of Consonants Correct: Is obtained from a sample of 100, by dividing the total number of correct consonants by the total number of consonants in the sample and multiplying by 100.

PCC Formula

PCC = (TOTAL NUMBER OF CORRECT Consonants / TOTAL NUMBER OF Consonants) X 100

Semantic Level

In Understanding (Receptive) evaluate:

• Decoding and attribution of meaning to verbal stimuli.
• Lexical meaning.
• Semantic-grammatical meaning.

In Expression evaluate:

• Selecting the right words for the referent.
• Proper organization of words in the sentence.

Significance Assessment Lexicon

Evaluated through: Identification of drawings or concrete referents, definitions, associations.

• Overextension.
• Infraextensión: limiting the use of a general word for something specific (e.g., "tatoh" may mean only my blue shoes).
• Erroneous reference.
• Deficit words.
• Overextension: expanding the use of a word (e.g., "Daddy" can be used to refer to any man).

Figurative Meaning

Figurative meaning is understood as that extracted from the relationships of words whose referents are not usual (e.g., Idioms, Metaphors, Jokes, Riddles, Inferences). Is evaluated through the use of plates or using jokes and riddles.

Testing for Semantic Level

• Formal Tests: LVET-R subtests, TECAL, ITPA subtests (verbal analogies).
• Non-standardized Tests: IDL (Lexical Diversity Index).

TECAL (Test of Auditory Comprehension of Language)

Test created by American author Elizabeth Carrow in 1965 (TACL). Its aim was to obtain information about the understanding of linguistic structures based on the performance of the subject, assign a level of development of understanding, and determine whether or not the child has a deficit in language comprehension. It is a highly structured instrument that assesses understanding of the vocabulary, morphology, and syntax. It applies to children in an age range that goes from 3.0 years to 6.11 years. The test discriminates between the different age ranges in normal children with language disorders. In Chile, the test translation and adaptation of TECAL was made in 1983. The test was applied to a sample of 120 Chilean children with normal language development to validate the reliability of the instrument. The adaptation was done by professional linguists and speech pathologists at the University of Chile in conjunction with students from the race. In 1985, the test was applied to a sample of 30 children with impaired language comprehension. In 2002, the TECAL test was included in Decree 1300-1302 for the diagnosis of specific language impairment.

Features of the TECAL Instrument

• The test has 101 items: 48 are categorized Vocabulary, 41 Morphology, and 12 Syntax.
• Contemplates 4 initial example items to familiarize the child with the test.
• It has a protocol consisting of a child's identification section, an answer section, and a separate analysis by the categories of vocabulary, morphology, and syntax.
• The artwork consists of 101 sheets, with 3 pictures at the bottom in each of them.
• One of the drawings represents the reference that corresponds to the linguistic structure evaluated.
• Another drawing is a contrast of the referent.
• The third picture is usually a distraction.
• At the top of the sheet, the linguistic structure is evaluated.

TECAL Application Instructions

• The test is administered individually by a single examiner and in an environment free of distractions.
• The type of motor response is nonverbal: marking the sheet corresponding to the word or language structure that the examiner has indicated orally.
• The set of blades is positioned so that the child faces the drawings and the graphics of linguistic structures are in front of the evaluator.
• The verbal instruction is: "Now let's see some pictures, pay attention. I will say a word and want you to show me the picture that corresponds to the word I said."
• At the beginning, show the child the incentive sheets to make sure they understand what to do.

Scoring, Registration, and Evaluation of Responses (TECAL)

The answers given by the child are recorded on a log sheet. Each correct answer is assigned 1 point. Wrong answers do not score, but should be recorded for qualitative analysis.

Lexical Diversity Index (LDI)

• Lexical diversity analysis in 50 or more items.
• Application: 3 to 8 years.
• Is calculated by dividing the number of different words by the total number of words produced.

IDL = Number of different words / Total number of words produced

IDL Norms:

• 3 YEARS IDL = 0.46 to 0.50
• 4 YEARS IDL = 0.50 to 0.65
• 5 YEARS IDL = 0.65
• 6 YEARS IDL = 0.66
• 7 YEARS IDL = 0.68
• 8 YEARS IDL = 0.68 to 0.69

Morphosyntactic Level

Objectives:

• Determine the performance and morphosyntactic development in decoding (reading) and encoding (expression) grammar.
• Determine the presence of impaired morphosyntactic dimension.
• Set the level or degree of morphosyntactic change.

Testing for Morphosyntactic Level

• Standardized: TECAL, STSG, ITPA.
• Non-standardized: LME (Mean Length of Utterance), speech samples.

Average Length of Sentence (LME)

• Requires 50-100 statements.
• Application: 1.5 and 5 years or 5 to 18 years old, according to the author.
• Is calculated by dividing the total number of different words by the number of statements.

LME = Number of different words / Number of statements

Pragmatic Level

The evaluation focuses on at least two respects:

Communicative Functions

Communicative functions are abstract units that reflect the speaker's communicative intent. They refer to the speaker's motivation, the goals, and purposes to be achieved by communicating with the listener.

Conversational Skills

The conversation can be understood as an interactive sequence of speech acts or as the result of the communicative exchange between two or more partners who are enrolled in a social context and runs application specific skills.

• Formal talks Organization
• Development of the ability to maintain the meaning
• Ability to adapt to the participants

Testing for Pragmatic Level

Informal Guidelines: Checklist Tattershall pragmatic language, patterns matching.