Category: Assessment

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Advance Magazine Online Article Publication

“The importance of thorough pediatric orofacial assessments in speech pathology: It’s not just for speech sounds anymore” will be published in the online edition of Advance for Speech Language Pathologists and Audiologists  on November 16, 2011.

Article Summary: This article explains the importance of documenting orofacial assessment findings for multidisciplinary referral and diagnosis purposes.  It offers several personal clinical case examples of atypical orofacial findings, which let to subsequent medical diagnosis of neurological and genetic disorders. It also explains why in some select circumstances, SLP’s may be the first professionals to observe/record atypical findings.

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Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention.

Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention.

Tatyana Elleseff MA CCC-SLP

 

Note: This article was first published in October 2011 Issue of Adoption Today Magazine (pp. 32-35) http://www.adoptinfo.net/catalog_g111.html?catId=55347

 According to US State Department statistics, over 11,000 children were adopted internationally in the year 2010, with 2,803 of those children being school-aged (between 5-17 years old). Despite a staggering 50% decline in overall inter-country adoptions in the last 10 years, statistics on adoption of older children continue to remain steady (appropriately 3,000 older children were adopted each year, for the past decade). (Retrieved from http://adoption.state.gov/about_us/statistics.php Jul 29, 2011).

 Subsequent to the school aged child’s arrival to US, one of the first considerations that arises, secondary to health concerns and transitional adjustments, is the issue of schooling and appropriate school based services provision. In contrast to children adopted at younger ages, who typically have an opportunity to acquire some English language skills before an academic placement takes place, older international adoptees lack this luxury. Unfortunately, due to their unique linguistic status, many school districts are at a loss regarding best services options for these children.

 Despite the prevalence of available research on this subject, one myth that continues to persist is that older internationally adopted children are “bilingual” and as such should receive remedial services similar to those received by newly entering the country bilingual children (e.g., ESL classes).

 It is very important to understand that most internationally adopted children rapidly lose their birth language, sometimes in as little as several months post arrival (Gindis, 2005), since they are often adopted by parents who do not speak the child’s first language and as such are unable/unwilling to maintain it. Not only are these children not bilingual, they are also not ‘truly’ monolingual, since their first language is lost rather rapidly, while their second language has been gained minimally at the time of loss. Moreover, even during the transition period during which international adoptees are rapidly losing their native language, their birth language is still of no use to them, since it’s not functional in their monolingual, English speaking only, home and school environments. As a result of the above constraints, select researchers have referred to this pattern of language gain, as “second, first language acquisition” (e.g., Roberts, et al., 2005), since the child is acquiring his/her new language literally from scratch.

 This brings me to another myth, that given several years of immersion in a new language rich, home and school environments, most internationally adopted children with (mild) language delays will catch up to their non-adopted monolingual peers academically, without the benefit of any additional services.

 This concept requires clarification, since the majority of parents adopting older children, often have difficulty understanding the extent of their child’s speech and language abilities in their native language at the time of adoption, and the implications for new language transference.

 Research on speech language abilities of older internationally adopted children is still rather limited, despite available studies to date. Some studies (e.g., Glennen & Masters, 2002; Krakow & Roberts, 2003, etc) suggest that age of adoption is strongly correlated with language outcomes. In other words, older internationally adopted children are at risk of having poorer language outcomes than children adopted at younger ages. That is because the longer the child stays in an institutional environment the greater is the risk of a birth language delay. Children in institutional care frequently experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which have long lasting negative impact on their language development. It is also important to understand that language delays in birth language transfer and become language delays in a new language. These delays will typically continue to persist unless appropriate intervention, in the form of speech language services, is provided.

So what are the options available to parents adopting older school age children with respect to determination of their child’s speech and language abilities?

For starters, at the time of adoption, it is very important to gain as much information regarding their child’s birth language abilities (and academic abilities, when applicable) as possible. In many older children (3+ years of age), speech and language delays in birth language (e.g., sound and word mispronunciations, limited vocabulary, grammatical errors, inability to answer simple or abstract questions, short sentence length) can be easily determined based on orphanage staff interviews, observations, and/or review of documentation included in the adoption record. In the Russian Federation, for example, speech language pathologists are assigned to orphanages, so when working with older international adoptees from the Russian Federation, one often finds a short statement in adoption records stating that the child presented with a speech and language delay for which he was receiving services.

If possible, prior to adoption, parents may wish to explore the option of obtaining an independent comprehensive speech language evaluation of the child’s birth language abilities, while the child is still located in the birth country. The above may be significant for a number of reasons. Firstly, it will allow the parents to understand the extent of the child’s language delay in their birth tongue. Secondly, it will increase the parents’ chances of obtaining school based remediation services for their child once they arrive to US.

In the absence of qualified speech pathologists attached to the orphanage or conclusive interviews with medical professionals, paraprofessionals, and teachers (lack of availability, language barrier, time constraints, etc) regarding the child’s speech and language development, it will be very helpful for parents to videotape the child during speaking tasks. Most parents who request pre-adoption consultations are well familiar with videotaping, requested by various pre-adoption professionals (pediatricians, psychologists, etc) in order to review the child’s presenting appearance, fine and gross motor skills, behavior and social skills as well as other areas of functioning. Language video samples should focus on child’s engagement in literacy tasks such as reading a book aloud (if sufficiently literate), and on speaking activities such as telling a story, recalling an episode from daily life or a conversation with familiar person. In the absence of all other data, these samples can later be analyzed and interpreted in order to determine if speech language deficits are present. (Glennen, 2009)

Parents need to understand that internationally adopted children can often be denied special education services in the absence of appropriate documentation. Such denials are often based on misinterpretation of the current IDEA 2004 law. Some denials may be based on the fact that once these children arrive to US, it is very difficult to find a qualified speech language pathologist who can assess the child in their birth language, especially if it’s a less commonly spoken language such as Amharic, Kazakh, or Ukrainian. Additionally, schools may refuse to test internationally adopted children for several years post arrival, on the grounds that these children have yet to attain “adequate language abilities in English” and as such, the testing results will be biased/inadequate, since testing was not standardized on children with similar linguistic abilities. Furthermore, even if the school administers appropriate testing protocols and finds the child’s abilities impaired, testing results may still be dismissed as inaccurate due to the child’s perceived limited English exposure.

Contrastingly, a speech and language report in the child’s birth language will outline the nature and severity of disorder, and state that given the extent of the child’s deficits in his/her birth language, similar pattern will be experienced in English unless intervention is provided. According to one of the leading speech-language researchers, Sharon Glennen, “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)

To continue, some options in locating a speech pathologist in the child’s birth country include consulting with the adoption agency or the local pediatrician, who is providing medical clearance for the child. However, it is very important that the speech language pathologist be licensed and reputable, as unqualified professionals will not be able to make appropriate diagnostic interpretations and suggestions, and may provide erroneous information to the parent.

If the parents are unable to obtain the relevant report in the child’s birth country, the next viable option is to obtain a comprehensive speech language assessment upon arrival to US, from a qualified professional who is well versed in both: the child’s native language as well as speech and language issues unique to assessment of internationally adopted children. Please note that the window of opportunity to assess the school age child in his/her native language is very narrow, as birth language attrition occurs within literally a matter of several months post adoption and is more rapid in children with delayed and disordered speech and language abilities (Gindis, 1999, 2005, 2008).

If the presence of a speech language delay has been confirmed (e.g., documented in adoption paperwork, interpreted through video samples, supported by a psycho-educational assessment, etc) the next step is to request the relevant speech language services for your child through the school system. Typically school administration will ask you to produce such a request in writing. One such letter template is available through the Post Adoption Learning Center (see link below). This template, complete with relevant references, can be modified to each child’s unique circumstances, and submitted along with supporting paperwork (e.g., speech-language, psycho-educational reports) and available video samples. In cases of services denials, an educational attorney specializing in educational policy relevant to international adoptions may need be consulted.

Once the child is qualified for appropriate speech language services in the school system it is also important to understand that language acquisition occurs in a progression, with social language (CLF) preceding cognitive language (CLM) (Gindis, 1999). Communicative Language Fluency (CLF) is language used in social situations for day-to-day social interactions. These skills are used to interact at home, on the playground, in the lunch room, on the school bus, at parties, playing sports and talking on the telephone. Social interactions are usually context embedded. Because they occur in meaningful social contexts they are typically not very demanding cognitively and the language required is not specialized. These language skills usually emerge in internationally adopted children as early as several months post adoption. Once these abilities emerge and solidify it is very important for speech language pathologists not to dismiss the child from services but to continue the treatment and focus it in the realm of cognitive/ academic language.

Cognitive Language Mastery (CLM) refers to language needed for formal academic learning. This includes listening, speaking, reading, and writing about subject area content material including analyzing, synthesizing, judging and evaluating presented information. This level of language learning is essential for a child to succeed in school. Language impaired children adopted at older ages need time and support to become develop cognitive language and become proficient in academic areas, an ability which usually takes a number of years to refine. Before discharging the child from therapy services it is very important that their cognitive/academic language abilities are assessed and are found within average limits.

Understanding the extent of speech language delay in internationally adopted older children AND factors pertaining to appropriate remediation are crucial for delivery of relevant (and meaningful to the child) speech language services as well as ensuring their continued academic success in school setting.

References:

• Gindis, B. (1999) Language-Related Issues for International Adoptees and Adoptive Families. In: T. Tepper, L. Hannon, D. Sandstrom, Eds. “International Adoption: Challenges and Opportunities.” PNPIC, Meadow Lands , PA. , pp. 98-108

• Gindis, B. (2005). Cognitive, language, and educational issues of children adopted from overseas orphanages. Journal of Cognitive Education and Psychology, 4 (3): 290-315.

• Gindis (2008) Abrupt Native Language Loss in International Adoptees Advance for Speech/Language Pathologists and Audiologists Dec 22.

• Glennen, S. & Masters, G. (2002). Typical and atypical language development in infants and toddlers adopted from Eastern Europe. American Journal of Speech-LanguagePathology, 44, 417-433

• Glennen, S., & Bright, B. J. (2005). Five years later: Language in school-age internationally adopted children. Seminars in Speech and Language, 26, 86-101.

• .Glennen, S (2009) Speech and Language Guidelines for Children Adopted from Abroad at Older Ages. Topics in language Disorders 29, 50-64.

• Intercountry Adoption Bureau of Consular Affairs US Department of State Retrieved on Jul 29, 2011 from http://adoption.state.gov/about_us/statistics.php

• Krakow, R. A., & Roberts, J. (2003). Acquisitions of English vocabulary by young Chinese adoptees. Journal of Multilingual Communication Disorders, 1, 169-176.

• Muchnik, M. How to request speech/language services for your child. Retrieved on Aug 2, 2011 from http://www.bgcenterschool.org/FreePresentations/P8-Speech-language-support.shtml

• Roberts, et al, (2005). Language development in preschool-aged children adopted from China. Journal of Speech, Language and Hearing Research, 48, 93-107.

Bio: Tatyana Elleseff MA CCC-SLP is a bilingual speech language pathologist with a full-time affiliation with University of Medicine and Dentistry of New Jersey and a private practice in Somerset, NJ. She received her Master’s Degree from New York University and her Bilingual Extension Certification from Columbia University. Currently she is licensed by the states of New Jersey and New York and holds a Certificate of Clinical Competence from American Speech Language and Hearing Association. She specializes in working with bilingual, multicultural, internationally and domestically adopted at risk children with complex medical, developmental, neurogenic, psychogenic, and acquired communication disorders. For more information about her services call 917-916-7487 or visit her website: www.smartspeechtherapy.com

Cite as: Elleseff, Tatyana (2011, October) Understanding the extent of speech and language delays in older internationally adopted children: Implications for School Based Speech and Language Intervention. Adoption Today.

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What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

What are social pragmatic language deficits and how do they impact international adoptees years post adoption?

Tatyana Elleseff MA CCC-SLP

Scenario:   John is a bright 11 year old boy who was adopted at the age of 3 from Russia by American parents. John’s favorite subject is math, he is good at sports but his most dreaded class is language arts. John has trouble understanding abstract information or summarizing what he has seen, heard or read. John’s grades are steadily slipping and his reading comprehension is below grade level. He has trouble retelling stories and his answers often raise more questions due to being very confusing and difficult to follow. John has trouble maintaining friendships with kids his age, who consider him too immature and feel like he frequently “misses the point” due to his inability to appropriately join play activities and discussions, understand non-verbal body language, maintain conversations on age-level topics, or engage in perspective taking (understand other people’s ideas, feelings, and thoughts). John had not received speech language services immediately post adoption despite exhibiting a severe speech and language delay at the time of adoption. The parents were told that “he’ll catch up quickly”, and he did, or so it seemed, at the time. John is undeniably bright yet with each day he struggles just a little bit more with understanding those around him and getting his point across. John’s scores were within normal limits on typical speech and language tests administered at his school, so he did not qualify for school based speech language therapy. Yet John clearly needs help.

John’s case is by no means unique. Numerous adopted children begin to experience similar difficulties; years post adoption, despite seemingly appropriate early social and academic development. What has many parents bewildered is that often times these difficulties are not glaringly pronounced in the early grades, which leads to delayed referral and lack of appropriate intervention for prolonged period of time.

The name for John’s difficulty is pragmatic language impairment, a diagnosis that has been the subject of numerous research debates since it was originally proposed in 1983 by Rapin and Allen. 

So what is pragmatic language impairment and how exactly does it impact the child’s social and academic language abilities? 

In 1983, Rapin and Allen proposed a classification of children with developmental language disorders. As part of this classification they described a syndrome of language impairment which they termed ‘semantic–pragmatic deficit syndrome’. Children with this disorder were described as being overly verbose, having poor turn–taking skills, poor discourse and narrative skills as well as having difficulty with topic initiation, maintenance and termination. Over the years the diagnostic label for this disorder has changed several times, until it received its current name “pragmatic language impairment” (Bishop, 2000).

Pragmatic language ability involves the ability to appropriately use language (e.g., persuade, request, inform, reject), change language (e.g., talk differently to different audiences, provide background information to unfamiliar listeners, speak differently in different settings, etc) as well as follow conversational rules (e.g., take turns, introduce topics, rephrase sentences, maintain appropriate physical distance during conversational exchanges, use facial expressions and eye contact, etc) all of which culminate into the child’s general ability to appropriately interact with others in a variety of settings.

For most typically developing children, the above comes naturally. However, for children with pragmatic language impairment appropriate social interactions are not easy. Children with pragmatic language impairment often misinterpret social cues, make inappropriate or off-topic comments during conversations, tell stories in a disorganized way, have trouble socially interacting with peers, have difficulty making and keeping friends, have difficulty understanding why they are being rejected by peers, and are at increased risk for bullying.

So why do adopted children experience social pragmatic language deficits many years post adoption? 

Well for one, many internationally adopted children are at high risk for developmental delay because of their exposure to institutional environments. Children in institutional care often experience neglect, lack of language stimulation, lack of appropriate play experiences, lack of enriched community activities, as well as inadequate learning settings all of which has long lasting negative impact on their language development including the development of their pragmatic language skills (especially if they are over 3 years of age). Furthermore, other, often unknown, predisposing factors such as medical, genetic, and family history can also play a negative role in pragmatic language development, since at the time of adoption very little information is known about the child’s birth parents or maternal prenatal care.

Difficulty with detection as well as mistaken diagnoses of pragmatic language impairment 

Whereas detecting difficulties with language content and form is relatively straightforward, pragmatic language deficits are more difficult to detect, because pragmatics are dependent on specific contexts and implicit rules. While many children with pragmatic language impairment will present with poor reading comprehension, low vocabulary, and grammar errors (pronoun reversal, tense confusion) in addition to the already described deficits, not all the children with pragmatic language impairment will manifest the above signs. Moreover, while pragmatic language impairment is diagnosed as one of the primary difficulties in children on autistic spectrum, it can manifest on its own without the diagnosis of autism. Furthermore, due to its complicated constellation of symptoms as well as frequent coexistence with other disorders, pragmatic language impairment as a standalone diagnosis is often difficult to establish without the multidisciplinary team involvement (e.g., to rule out associated psychiatric and neurological impairment).

It is also not uncommon for pragmatic language deficits to manifest in children as challenging behaviors (and in severe cases be misdiagnosed due to the fact that internationally adopted children are at increased risk for psychiatric disorders in childhood, adolescence and adulthood). Parents and teachers often complain that these children tend to “ignore” presented directions, follow their own agenda, and frequently “act out inappropriately”. Unfortunately, since children with pragmatic language impairment rely on literal communication, they tend to understand and carry out concrete instructions and tasks versus understanding indirect requests which contain abstract information. Additionally, since perspective taking abilities are undeveloped in these children, they often fail to understand and as a result ignore or disregard other people’s feelings, ideas, and thoughts, which may further contribute to parents’ and teachers’ beliefs that they are deliberately misbehaving.

Due to difficulties with detection, pragmatic language deficits can persist undetected for several years until they are appropriately diagnosed. What may further complicate detection is that a certain number of children with pragmatic language deficits will perform within the normal range on typical speech and language testing. As a result, unless a specific battery of speech language tests is administered that explicitly targets the identification of pragmatic language deficits, some of these children may be denied speech and language services on the grounds that their total language testing score was too high to qualify them for intervention.

How to initiate an appropriate referral process if you suspect that your school age child has pragmatic language deficits? 

When a child is presenting with a number of above described symptoms, it is recommended that a medical professional such as a neurologist or a psychologist be consulted in order to rule out other more serious diagnoses. Then, the speech language pathologist can perform testing in order to confirm the presence of pragmatic language impairment as well as determine whether any other linguistically based deficits coexist with it. Furthermore, even in cases when the pragmatic language impairment is a secondary diagnosis (e.g. Autism) the speech language pathologist will still need to be involved in order to appropriately address the social linguistic component of this deficit.

To obtain appropriate speech and language testing in a school setting, the first step that parents can take is to consult with the classroom teacher. For the school age child (including preschool and kindergarten) the classroom teacher can be the best parental ally. After all both parents and teachers know the children quite well and can therefore take into account their behavior and functioning in a variety of social and academic contexts. Once the list of difficulties and inappropriate behaviors has been compiled, and both parties agree that the “red flags” merit further attention, the next step is to involve the school speech language pathologist (make a referral) to confirm the presence and/or severity of the impairment via speech language testing.

When attempting to confirm/rule out pragmatic language impairment, the speech language pathologist has the option of using a combination of formal and informal assessments including parental questionnaires, discourse and narrative analyses as well as observation checklists.

Below is the list of select formal and informal speech language assessment instruments which are sensitive to detection of pragmatic language impairment in children as young as 4-5 years of age.

1. Children’s Communication Checklist-2 (CCC–2) (Available: Pearson Publication)
2. Test of Narrative Development (TNL) (Available: Linguisystems Publication)
3. Test of Language Competence Expanded Edition (TLC-E) (Available: Pearson Publication)
4. Test of Pragmatic Language-2 (TOPL-2) (Available: Linguisystems Publication)
5. Social Emotional Evaluation (SEE) (Available: Super Duper Publication)
6. Dynamic Informal Social Thinking Assessment (www.socialthinking.com)
7. Social Language Development Test -Elementary (SLDT-E) (Available: Linguisystems Publication)
8. Social Language Development Test -Adolescent (SLDT-A) (Available: Linguisystems Publication)

It is also very important to note that several formal and informal instruments and analyses need to be administered/performed in order to create a complete diagnostic picture of the child’s deficits.

When to seek private pragmatic language evaluation and therapy services?

Unfortunately, the process of obtaining appropriate social pragmatic assessment in a school setting is often fraught with numerous difficulties. For one, due to financial constraints, not all school districts possess the appropriate, up to date pragmatic language testing instruments.

Another issue is the lack of time. To administer comprehensive assessment which involves 2-3 different assessment instruments, an adequate amount of time (e.g., 2+ hours) is needed in order to create the most comprehensive pragmatic profile for the child. School based speech language pathologists often lack this valuable commodity due to increased case load size (often seeing between 45 to 60 students per week), which leaves them with very limited time for testing.

Further complicating the issue are the special education qualification rules, which are different not just from state to state but in some cases from one school district to the next within the same state. Some school districts strictly stipulate that the child’s performance on testing must be 1.5-2 standard deviations below the normal limits in order to qualify for therapy services.
But what if the therapist is not in possession of any formal assessment instruments and can only do informal assessment?

And what happens to the child who is “not impaired enough” (e.g., 1 SD vs. 1.5 SD)?

Consequently, in recent years more and more parents are opting for private pragmatic language assessments and therapy for their children.

Certainly, there are numerous advantages for going via the private route. For one, parents are directly involved and directly influence the quality of care their children receive.

One advantage to private therapy is that parents can request to be present during the evaluation and therapy sessions. As such, not only do the parents get to understand the extent of the child’s impairment but they also learn valuable techniques and strategies they can utilize in home setting to facilitate carryover and skill generalization (how to ask questions, provide choices, etc).

Another advantage is the provision of individual therapy services in contrast to school based services which are generally attended by groups as large as 4-5 children per session. Here, some might disagree and state that isn’t the point of pragmatic therapy is for the child to practice his/her social skills with other children?

Absolutely! However, before a skill can be generalized it needs to be taught! Most children with pragmatic language impairment initially require individual sessions, in some of which it may be necessary to use drill work to teach a specific skill. Once the necessary skills are taught, only then can children be placed into social groups where they can practice generalizing their skills. Moreover, many of these children greatly benefit from being in group or play settings with typical peers and/or sibling tutors who may facilitate the generalization of the desired skill more naturally, all of which can be arranged within private therapy settings.

Yet another advantage to obtaining private therapy services is that there are some private clinics which are almost exclusively devoted to teaching social pragmatic communication and which offer a variety of therapeutic services including individual therapy, group therapy and even summer camps that target the improvement of pragmatic language and social communication skills.

The flexibility offered by private therapy is also important if a parent is seeking a specific social skills curriculum for their child (e.g., “Socially Speaking”) or if they are interested in social skill training that is based on the methods of specific researchers/authors (e.g., Michelle Garcia Winner MACCC-SLP; Dr. Jed Baker PhD, etc), which may not be offered by their child’s school.

There are many routes open for parents to pursue when it comes to their child’s pragmatic language assessment and intervention. However, the first step in that process is parental education!

To learn more about pragmatic language impairment please visit the ASHA website at www.asha.org and type in your query in the search window located in the upper right corner of the website. To find a professional specializing in assessment and treatment of pragmatic language disorders in your area please visit http://asha.org/proserv/.

References

Adams, C. (2001). “Clinical diagnostic and intervention studies of children with semantic-pragmatic language disorder.” International Journal of Language and Communication Disorders 36(3): 289-305.

Bishop, D. V. (1989). “Autism, Asperger’s syndrome and semantic-pragmatic disorder: Where are the boundaries?” British Journal of Disorders of Communication 24(2): 107-121.

Bishop, D. V. M. and G. Baird (2001). “Parent and teacher report of pragmatic aspects of communication: Use of the Children’s Communication Checklist in a clinical setting.” Developmental Medicine and Child Neurology 43(12): 809-818.

Botting, N., & Conti-Ramsden, G. (1999). Pragmatic language impairment without autism: The children in question. Autism, 3, 371–396.[

Brackenbury, T., & Pye, C. (2005). Semantic deficits in children with language impairments: Issues for clinical assessment. Language, Speech, and Hearing Services in Schools, 36, 5–16.

Burgess, S., & Turkstra, L. S. (2006). Social skills intervention for adolescents with autism spectrum disorders: A review of the experimental evidence. EBP Briefs, 1(4), 1–21.

Camarata, S., M., and T. Gibson (1999). “Pragmatic Language Deficits in Attention-Deficit Hyperactivity Disorder (ADHD).” Mental Retardation and Developmental Disabilities 5: 207-214.

Ketelaars, M. P., Cuperus, J. M., Jansonius, K., & Verhoeven, L. (2009). Pragmatic language impairment and associated behavioural problems. International Journal of Language and Communication Disorders, 45, 204–214.

Ketelaars, M. P., Cuperus, J. M., Van Daal, J., Jansonius, K., & Verhoeven, L. (2009). Screening for pragmatic language impairment: The potential of the Children’s Communication Checklist. Research in Developmental Disabilities, 30, 952–960.

Miniscalco, C., Hagberg, B., Kadesjö, B., Westerlund, M., & Gillberg, C. (2007). Narrative skills, cognitive profiles and neuropsychiatric disorders in 7-8-year-old children with late developing language. International Journal of Language and Communication Disorders, 42, 665–681.
Rapin I, Allen D (1983). Developmental language disorders: Nosologic considerations. In U. Kirk (Ed.), Neuropsychology of language, reading, and spelling (pp. 155–184). : Academic Press.