Dorothy BishoppersName, Margaret J. SnowlingpersName, Paul A. ThompsonpersName, Trisha GreenhalghpersName (2017date). “Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with language development: Terminology.” Journal of Child Psychology and Psychiatrytitle·venue.
Object of study — THE VOCABULARY OF CHILDREN'S LANGUAGEterm PROBLEMS, DECIDED BY DELPHI - 57 panellists across six English-speaking countries and eight professions rating 21 statements over two rounds, with every agreement percentage published and the two failing items named
Research question — what to call languageterm problems in children, when the most frequent term in the research literature is the one the panel most disagrees about, and when the label decides whether a child gets a service
Contribution — twelve consensus statements: 'language disorderterm' defined by functional impact and prognosisterm·var rather than by test cut-offs, 'developmental language disorderterm' for cases with no known biomedical cause, and exclusionary criteria replaced by a threefold distinction
phenomenon · claim-type · cross-domain-transfer · mechanism · claim-relation · replication-status · limitation — grounded in the full text| phenomenon | a field in which the same child receives four different diagnoses depending on which professional sees them, and in which a term's exclusion criteria had become grounds for refusing services — “The terminology used for neurodevelopmental disorders can create the impression that there is a set of distinct conditions, but the reality is that many children have a mixture of problems. Indeed, the same problems may be labelled differently depending on the professional the child sees. For example, the same child may be regarded as having DLD by a SLT/P, dyslexia by a teacher, auditory processing disorder by an audiologist, or ADHD by a paediatrician.” | |
| claim-type | method — “There is no agreed criterion for when a Delphi consensus is deemed adequate for an item – in the literature, values from 51% to 80% agreement have been used (Hasson et al., 2000 ). We aimed for 75% agreement as a reasonable goal.” | |
| method — evidence | — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” | |
| object of study — evidence | — “We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ ( DLD ) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD , (b) DLD can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLD does not require a mismatch between verbal and nonverbal ability.” | |
| research question — evidence | — “The term Specific Language Impairment (SLI) has been widely used to refer to children whose language development is not following the usual course despite typical development in other areas. However, professionals and lay people alike appear to be far less familiar with SLI compared with dyslexia or autism (Kamhi, 2004 ). Of more concern, Ebbels ( 2014 ) described how use of the term SLI had become controversial, because it seemed not to reflect clinical realities and excluded many children from services.” | |
| contribution — evidence | — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | |
| mechanism | A TERM ABOLISHED RATHER THAN REDEFINED, WITH THE COST OF DOING SO PRINTED: 'The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement ... Ultimately, the decision was made to reject the term. A major drawback ... is that IT CREATES A DISCONTINUITY WITH PRIOR LITERATURE, WHICH COULD AFFECT FUTURE META-ANALYSES AND SYSTEMATIC REVIEWS ... rather than redefining the term, it would be better to abolish it.' Four bodies in this corpus heard the continuity argument and kept a term they called suboptimal. This one heard it and went the other way [CORRECTED 2026-08-23. THE COUNT IS THREE, NOT FOUR, and the same correction was applied to the note of a concept edges row earlier today and MISSED THIS FIELD - the record has been stating three and four about itself ever since, which an audit caught. The three, named so the claim can be re-run: 'cruz-jentoft2010' ('THE TERM DYNAPENIA IS BETTER SUITED ... however SARCOPENIA IS ALREADY A WIDELY RECOGNISED TERM, SO REPLACING IT MIGHT LEAD TO FURTHER CONFUSION'), 'buck2011' ('a PRAGMATIC COMPROMISE between IUPAC/CAS nomenclature, internal consistency and existing LEGACY USAGE') and 'bronte2016' ('THE TERM MDSC MAY NOT BE OPTIMAL ... SHOULD BE RETAINED TO ASSURE CONSISTENCY'). The fourth I counted was 'staab2017' keeping PPV, SMD, VV and CSD as ICD-11 INDEX TERMS - preserving RETIRED names as cross-references, which is not keeping a suboptimal term IN USE. A cross-record count in a prose field is a claim about the corpus that nothing in the corpus checks, which is why it is now written with its members. The superseded sentence is kept verbatim above rather than deleted.] — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | mechanisms[0] |
| mechanism | AND THE CONSENSUS THRESHOLD ITSELF HAS NO AGREED VALUE, SAID BEFORE ONE IS CHOSEN: `There is no agreed criterion for when A Delphi consensus is deemed adequate for an item - in the literature, VALUES FROM 51% TO 80% agreement have been used. WE AIMED FOR 75% AGREEMENT AS A REASONABLE GOAL.` staab2017 published a decision rule and then missed it. This one publishes that the method has no rule, declares 75% in advance, and reports at 78% — “There is no agreed criterion for when a Delphi consensus is deemed adequate for an item – in the literature, values from 51% to 80% agreement have been used (Hasson et al., 2000 ). We aimed for 75% agreement as a reasonable goal.” | mechanisms[1] |
| mechanism | AND THE PANEL TESTED WHETHER ITS OWN AGREEMENT WAS AN ARTEFACT OF WHO WAS ON IT: `Kruskal-Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status ... None of these comparisons was statistically significant after correction ... Given the small sample size, we cannot rule out an effect.` A control on a definitional PROCESS rather than on a measurement - and the negative result is reported with its power caveat attached — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” | mechanisms[2] |
| mechanism | AND A FAILURE OF CONSENSUS READ AS EVIDENCE ABOUT THE WORLD, NOT ABOUT THE PANEL: `we failed to reach consensus about possible terminology for linguistic subtypes of DLD. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLD do not neatly divide into subtypes along linguistic lines.` The two items that failed scored 68% and 46%, and both were about subtypes — “Finally, although it was generally agreed that there is considerable heterogeneity in children with DLD, we failed to reach consensus about possible terminology for linguistic subtypes of DLD. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLD do not neatly divide into subtypes along linguistic lines.” | mechanisms[3] |
| mechanism | AND ONE CHILD, FOUR DIAGNOSES, CHOSEN BY WHICH PROFESSIONAL IS IN THE ROOM: `The terminology used for neurodevelopmental disorders can create the impression that there is a set of distinct conditions, but the reality is that many children have a mixture of problems ... the same child may be regarded as having DLD by a SLT/P, dyslexia by a teacher, auditory processing disorder by an audiologist, or ADHD by a paediatrician.` The label is a property of the observer — “The terminology used for neurodevelopmental disorders can create the impression that there is a set of distinct conditions, but the reality is that many children have a mixture of problems. Indeed, the same problems may be labelled differently depending on the professional the child sees. For example, the same child may be regarded as having DLD by a SLT/P, dyslexia by a teacher, auditory processing disorder by an audiologist, or ADHD by a paediatrician.” | mechanisms[4] |
| mechanism | AND A DEFINITIONAL ELEMENT REMOVED FOR WHAT IT WAS BEING USED TO DO, NOT FOR BEING WRONG: `Panel members were concerned that, instead of being used for diagnostic differentiation, exclusionary criteria were sometimes interpreted as criteria for denying services to children.` haas2018 deleted a word because it confused clinicians; this panel deleted a whole criterion TYPE because of what administrators did with it — “Use (and misuse) of exclusionary factors in definitions of language disorder was a major issue leading to dissatisfaction with terminology in this field. Panel members were concerned that, instead of being used for diagnostic differentiation, exclusionary criteria were sometimes interpreted as criteria for denying services to children.” | mechanisms[5] |
| mechanism | AND THE REPLACEMENT IS A THREE-WAY SPLIT WHERE THERE HAD BEEN A GATE: `Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co-occurring conditions.` Only the first is diagnostically exclusive; the other two are recorded and do not preclude the diagnosis — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | mechanisms[6] |
| mechanism | AND THE TWO OBJECTIONS TO THE CHOSEN MODIFIER POINT IN OPPOSITE DIRECTIONS: `Some panel members noted specific meanings of `DEVELOPMENTAL` that were not intended: for example, that this was something that the child might `GROW OUT OF`, or - quite the converse - that a developmental problem meant that the child would be unable to develop language.` A modifier misread in two contradictory ways, and kept anyway - because the alternatives (`primary`, `specific`) drew the same objection — “Some panel members noted specific meanings of ‘developmental’ that were not intended: for example, that this was something that the child might ‘grow out of’, or – quite the converse – that a developmental problem meant that the child would be unable to develop language.” | mechanisms[7] |
| mechanism | AND `DISORDER` WAS PREFERRED TO `IMPAIRMENT` ON FOUR NAMED GROUNDS, WITH THE COUNTER-ARGUMENT PRINTED: for `the greater seriousness and importance associated with the term`, consistency with ASD/DCD/ADHD, and compatibility with DSM-5 and ICD-11 - against `concerns that the term `DISORDER` had medical connotations and placed the problem `INSIDE THE CHILD`, when it might be contextually dependent` — “Arguments for preferring the term ‘disorder’ to ‘impairment’ included the greater seriousness and importance associated with the term; consistency with other neurodevelopmental disorders (autism spectrum disorder, developmental coordination disorder, attention deficit hyperactivity disorder); and compatibility with the two main diagnostic systems, DSM‐5 (American Psychiatric Association, 2013 ) and ICD‐11 (Baird, personal communication). Some panel members expressed concerns that the term ‘disorder’ had medical connotations and placed the problem ‘inside the child’, when it might be contextually dependent.” | mechanisms[8] |
| mechanism | AND A CATEGORY CREATED FOR ONE AUDIENCE AND EXPLICITLY DISCLAIMED FOR THE OTHERS: SLCN is recommended because `the number of children with specific needs ... has resource implications`, and then: `It is not anticipated that this terminology will be useful for those doing research on the nature or causes of language disorders, nor will it be helpful in explaining a child's difficulties to parents or in determining a treatment pathway.` A term with its audience written into it, and the non-audiences named — “It is not anticipated that this terminology will be useful for those doing research on the nature or causes of language disorders, nor will it be helpful in explaining a child's difficulties to parents or in determining a treatment pathway. It could, however, serve a purpose for those who need to plan services, who may need to estimate how many children are likely to require additional support and to bridge across professional divides” | mechanisms[9] |
| mechanism | AND THE DELPHI'S OWN EFFECT IS MEASURED: round 1 agreement ran `from 30% to 98% for the 16 items, with a median value of 74%`; round 2 ran `from 46% to 98% across items, with a median value of 90%`. The median moved 16 points between rounds, with a one-day meeting and anonymised feedback in between — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” | mechanisms[10] |
| mechanism | AND THE OLD NOSOLOGY IS DIAGNOSED BEFORE IT IS REPLACED: `it has in the past been based on information from a mixture of different levels of description` - presenting severity, co-occurring nonlanguage problems, and putative biological or environmental causes - which `implies that the constellation of verbal and nonverbal skills will map onto natural subtypes with distinct causes ... However, this approach has not worked.` A classification built on three incommensurable axes at once — “A complicating factor in the nosology of language disorders is that it has in the past been based on information from a mixture of different levels of description: information about the severity and type of presenting problems with language; co‐occurring problems in nonlanguage domains, such as nonverbal ability, social interaction or attention; and putative biological and environmental causes, such as brain damage, a genetic syndrome or social disadvantage. This approach implies that the constellation of verbal and nonverbal skills will map onto natural subtypes with distinct causes, such that we can use the linguistic, cognitive and behavioural profile to distinguish the child whose language problems have environmental or genetic origins. However, this approach has not worked.” | mechanisms[11] |
| extends | CATALISE phase 1 (Bishop et al. 2016), which used the same panel to agree CRITERIA for identifying language problems; this second phase takes the TERMINOLOGY — “We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ ( DLD ) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD , (b) DLD can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLD does not require a mismatch between verbal and nonverbal ability.” | claim_relations[0] |
| critiques | the term 'specific language impairment' - abolished rather than redefined, because 'specific' 'had connotations that were misleading and confusing' — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | claim_relations[1] |
| critiques | DSM-5's social (pragmatic) communication disorder, considered for adoption and declined on two stated grounds — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | claim_relations[2] |
| critiques | nosologies built on a mixture of levels of description - presenting severity, co-occurring nonlanguage problems and putative causes at once - which 'has not worked' — “A complicating factor in the nosology of language disorders is that it has in the past been based on information from a mixture of different levels of description: information about the severity and type of presenting problems with language; co‐occurring problems in nonlanguage domains, such as nonverbal ability, social interaction or attention; and putative biological and environmental causes, such as brain damage, a genetic syndrome or social disadvantage. This approach implies that the constellation of verbal and nonverbal skills will map onto natural subtypes with distinct causes, such that we can use the linguistic, cognitive and behavioural profile to distinguish the child whose language problems have environmental or genetic origins. However, this approach has not worked.” | claim_relations[3] |
| sense | `language disorder` (this paper) - problems `LIKELY TO ENDURE INTO MIDDLE CHILDHOOD AND BEYOND, WITH A SIGNIFICANT IMPACT on everyday social interactions or educational progress`; defined by PROGNOSIS and FUNCTION, explicitly not by a test cut-off and not by a verbal/nonverbal discrepancy — “In particular, it cautions against defining language disorder solely in terms of statistical cut‐offs on language tests. Note also that we reject any attempt to use discrepancy scores to draw a distinction between ‘disorder’ and ‘delay’: the term ‘language delay’ was widely rejected by our panel members as confusing and illogical.” | senses[0] |
| sense | `developmental` (this paper's sense) - `the condition emerges in the course of development, rather than being acquired or associated with a known biomedical cause`; NOT `the child might grow out of it` and NOT `unable to develop language`, both of which panel members read into it — “Some panel members noted specific meanings of ‘developmental’ that were not intended: for example, that this was something that the child might ‘grow out of’, or – quite the converse – that a developmental problem meant that the child would be unable to develop language.” | senses[1] |
| sense | `SLCN` - a superordinate category recommended FOR POLICYMAKERS AND SERVICE PLANNERS ONLY, and disclaimed for researchers, for parents and for treatment planning in the same paragraph — “It is not anticipated that this terminology will be useful for those doing research on the nature or causes of language disorders, nor will it be helpful in explaining a child's difficulties to parents or in determining a treatment pathway. It could, however, serve a purpose for those who need to plan services, who may need to estimate how many children are likely to require additional support and to bridge across professional divides” | senses[2] |
| sense | `specific` (in Specific Language Impairment) - a modifier the panel abolished rather than redefined, because it `had connotations that were misleading and confusing` and because the discrepancy reading it invited was `DISCREDITED` — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | senses[3] |
| control | Kruskal-Wallis tests on every item for an effect of geographical location (six countries) or professional status (SLT/P vs. others), Bonferroni-corrected at .001 — partial — “Of the original panel, two declined to take part in CATALISE‐2 for personal reasons, leaving a panel of 57 individuals, whose characteristics are shown in Table 1 . Nine panel members had a close relative with impaired language development.” — rules out the possibility that the consensus is an artefact of who was recruited to the panel rather than of the subject matter — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” | controls[0] |
| control | two rating rounds with anonymised distributions and comments fed back between them, plus a one-day meeting attended by 22 panellists and 23 additional stakeholders — held — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” — rules out a consensus that is just the first-round wording — “The percentage agreement (combining strongly agree with agree) ranged from 30% to 98% for the 16 items, with a median value of 74%.” | controls[1] |
| control | reporting the two items that failed to reach the threshold, with their agreement percentages, instead of dropping them — failed — “Finally, although it was generally agreed that there is considerable heterogeneity in children with DLD, we failed to reach consensus about possible terminology for linguistic subtypes of DLD. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLD do not neatly divide into subtypes along linguistic lines.” — rules out a consensus document that reads as if everything was agreed — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” | controls[2] |
| weight | CATALISE phase 1 (Bishop et al. 2016), which used the same panel to agree CRITERIA for identifying language problems; this second phase takes the TERMINOLOGY — 0.95 — “We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ ( DLD ) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD , (b) DLD can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLD does not require a mismatch between verbal and nonverbal ability.” | claim_relations[0] |
| weight | the term 'specific language impairment' - abolished rather than redefined, because 'specific' 'had connotations that were misleading and confusing' — 0.95 — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | claim_relations[1] |
| weight | DSM-5's social (pragmatic) communication disorder, considered for adoption and declined on two stated grounds — 0.9 — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | claim_relations[2] |
| weight | nosologies built on a mixture of levels of description - presenting severity, co-occurring nonlanguage problems and putative causes at once - which 'has not worked' — 0.9 — “A complicating factor in the nosology of language disorders is that it has in the past been based on information from a mixture of different levels of description: information about the severity and type of presenting problems with language; co‐occurring problems in nonlanguage domains, such as nonverbal ability, social interaction or attention; and putative biological and environmental causes, such as brain damage, a genetic syndrome or social disadvantage. This approach implies that the constellation of verbal and nonverbal skills will map onto natural subtypes with distinct causes, such that we can use the linguistic, cognitive and behavioural profile to distinguish the child whose language problems have environmental or genetic origins. However, this approach has not worked.” | claim_relations[3] |
| note | DLD —part-of→ SLCN — 'Figure 2 Venn…' The two terms exist for different readers - SLCN is recommended for policymakers and DISCLAIMED for researchers and parents in the same paragraph, so the containment is also a statement about AUDIENCE, which no field of ours records — “Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLD is nested within the broader SLCN category” | concept_edges[0] |
| relation | DLD —part-of→ SLCN — DLD is a proper subset of the service-planning category SLCN, which also contains dysarthria, fluency and voice problems, and children whose only need is unfamiliarity with the language of instruction — “Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLD is nested within the broader SLCN category” | concept_edges[0] |
| weight | DLD —part-of→ SLCN — 0.95 — “Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLD is nested within the broader SLCN category” | concept_edges[0] |
| audit | Specific Language Impairment —renamed-across-fields→ DLD — Audit 2026-09-28: DOUBTFUL - read against its span and kept, but the panel REJECTED 'SLI' in favour of DLD within one field; renamed-across-fields overstates. — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | concept_edges[1] |
| note | Specific Language Impairment —renamed-across-fields→ DLD — 'The term Specific Language Impairment…' The corpus has four bodies that kept a suboptimal term for continuity and this is the first that refused to. [CORRECTED 2026-08-23 by the project, after the project could not verify it and said so: THE COUNT IS THREE, NOT FOUR. The three, named so the claim can be re-run: 'cruz-jentoft2010' ('THE TERM DYNAPENIA IS BETTER SUITED ... however SARCOPENIA IS ALREADY A WIDELY RECOGNISED TERM, SO REPLACING IT MIGHT LEAD TO FURTHER CONFUSION'), 'buck2011' ('a PRAGMATIC COMPROMISE between IUPAC/CAS nomenclature, internal consistency and existing LEGACY USAGE') and 'bronte2016' ('THE TERM MDSC MAY NOT BE OPTIMAL ... SHOULD BE RETAINED TO ASSURE CONSISTENCY'). The fourth I counted was 'staab2017' keeping PPV, SMD, VV and CSD as ICD-11 INDEX TERMS - preserving RETIRED names as cross-references, which is not keeping a suboptimal term IN USE. A different act, and counting it was the error. The superseded sentence is kept verbatim above rather than deleted, per an internal tool: a correction that erases what it corrects asks to be taken on trust.] Called honestly: this is an abolition plus a recommendation, not a one-for-one rename, and the two terms do not have the same extension - DLD drops the nonverbal-discrepancy requirement SLI was read as carrying — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | concept_edges[1] |
| relation | Specific Language Impairment —renamed-across-fields→ DLD — SLI is ABOLISHED rather than redefined and DLD recommended in its place, at a stated cost: a discontinuity with the prior literature that could affect future meta-analyses — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | concept_edges[1] |
| weight | Specific Language Impairment —renamed-across-fields→ DLD — 0.95 — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | concept_edges[1] |
| note | differentiating conditions —distinct-from→ risk factors — 'RATHER THAN USING…' The distinction exists because the old single category was being used administratively: 'exclusionary criteria WERE…' — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concept_edges[2] |
| relation | differentiating conditions —distinct-from→ risk factors — only differentiating conditions are diagnostically exclusive; risk factors are recorded and DO NOT preclude a diagnosis of DLD — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concept_edges[2] |
| weight | differentiating conditions —distinct-from→ risk factors — 0.95 — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concept_edges[2] |
| note | pragmatic impairment —is-a→ language disorder — 'SPCD IS SEEN…' Two manuals, one phenomenon, and the disagreement is about WHICH TREE IT HANGS FROM rather than about the child - and the practical consequence given is which intervention the child is routed to — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concept_edges[3] |
| relation | pragmatic impairment —is-a→ language disorder — CATALISE treats pragmatic impairment as a TYPE of language disorder, where DSM-5 makes social (pragmatic) communication disorder a separate neurodevelopmental category — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” — “First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder.” | concept_edges[3] |
| weight | pragmatic impairment —is-a→ language disorder — 0.95 — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concept_edges[3] |
| note | pragmatics —part-of→ language — 'we regard pragmatics as part of language.' The paper's own reason for declining the DSM-5 term, and it is a MEREOLOGICAL claim doing diagnostic work: if pragmatics is part of language then a pragmatic impairment is inside DLD, and if it is a separate social faculty then it is not. The child's route through the service depends on a part-whole judgement about a construct — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concept_edges[4] |
| relation | pragmatics —part-of→ language — pragmatics is part of language, which is why pragmatic impairment is a language disorder rather than a communication disorder — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” — “whereas we regard pragmatics as part of language” | concept_edges[4] |
| weight | pragmatics —part-of→ language — 0.95 — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concept_edges[4] |
| outcome | control — partial — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” — “Of the original panel, two declined to take part in CATALISE‐2 for personal reasons, leaving a panel of 57 individuals, whose characteristics are shown in Table 1 . Nine panel members had a close relative with impaired language development.” | controls[0] |
| outcome | control — held — “The percentage agreement (combining strongly agree with agree) ranged from 30% to 98% for the 16 items, with a median value of 74%.” — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” | controls[1] |
| outcome | control — failed — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” — “Finally, although it was generally agreed that there is considerable heterogeneity in children with DLD, we failed to reach consensus about possible terminology for linguistic subtypes of DLD. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLD do not neatly divide into subtypes along linguistic lines.” | controls[2] |
| limitation | THE PANEL IS ENGLISH-ONLY AND SAYS SO: `An obvious limitation of this study is that we restricted our focus to the English language because of the difficulties of devising terms that would be applicable across different language and cultures.` The recommended remedy is the method, not the terms - `We recommend the use of the Delphi method to researchers working with language disorders in other languages` — “An obvious limitation of this study is that we restricted our focus to the English language because of the difficulties of devising terms that would be applicable across different language and cultures. We recommend the use of the Delphi method to researchers working with language disorders in other languages, as a good way to achieve better consensus.” | limitations[0] |
| limitation | AND THE PANEL IS DOMINATED BY ONE PROFESSION: 57 individuals, of whom 31 are speech-language therapists or pathologists and 7 more are joint SLT/psychologists - so two thirds of the raters share a training. `Nine panel members had a close relative with impaired language development`, which is disclosed and not adjusted for — “Of the original panel, two declined to take part in CATALISE‐2 for personal reasons, leaving a panel of 57 individuals, whose characteristics are shown in Table 1 . Nine panel members had a close relative with impaired language development.” | limitations[1] |
| limitation | AND THE CENTRAL BOUNDARY IS CONCEDED NOT TO EXIST: `there is no clear dividing line between normality and disorder; third, within the domain of language, children's problems do not neatly segregate into subtypes, and there may be overlap between problems in speech, language and communication.` The definition that follows is therefore built on PROGNOSIS and FUNCTIONAL IMPACT rather than on a cut-off — “Despite the geographical and professional diversity of the panel, there were some points of broad agreement, as follows: first, some children have language problems that are severe and persistent enough to create long‐term functional challenges, in daily communication and/or educational attainment; second, there is no clear dividing line between normality and disorder; third, within the domain of language, children's problems do not neatly segregate into subtypes, and there may be overlap between problems in speech, language and communication.” | limitations[2] |
| limitation | AND THE ALTERNATIVE THE DEFINITION REFUSES IS NAMED: `it cautions against defining language disorder solely in terms of statistical cut-offs on language tests. Note also that we reject any attempt to use discrepancy scores to draw a distinction between `disorder` and `delay`: the term `LANGUAGE DELAY` was widely rejected by our panel members as confusing and illogical.` A second term abolished, in one clause, with no vote reported for it — “In particular, it cautions against defining language disorder solely in terms of statistical cut‐offs on language tests. Note also that we reject any attempt to use discrepancy scores to draw a distinction between ‘disorder’ and ‘delay’: the term ‘language delay’ was widely rejected by our panel members as confusing and illogical.” | limitations[3] |
finding · quantity · variable · definition · key-term — grounded in the full text| finding | — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | content_tags.findings[0] |
| finding | — “There is no agreed criterion for when a Delphi consensus is deemed adequate for an item – in the literature, values from 51% to 80% agreement have been used (Hasson et al., 2000 ). We aimed for 75% agreement as a reasonable goal.” | content_tags.findings[1] |
| finding | — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” | content_tags.findings[2] |
| finding | — “Finally, although it was generally agreed that there is considerable heterogeneity in children with DLD, we failed to reach consensus about possible terminology for linguistic subtypes of DLD. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLD do not neatly divide into subtypes along linguistic lines.” | content_tags.findings[3] |
| finding | — “The terminology used for neurodevelopmental disorders can create the impression that there is a set of distinct conditions, but the reality is that many children have a mixture of problems. Indeed, the same problems may be labelled differently depending on the professional the child sees. For example, the same child may be regarded as having DLD by a SLT/P, dyslexia by a teacher, auditory processing disorder by an audiologist, or ADHD by a paediatrician.” | content_tags.findings[4] |
| finding | — “Use (and misuse) of exclusionary factors in definitions of language disorder was a major issue leading to dissatisfaction with terminology in this field. Panel members were concerned that, instead of being used for diagnostic differentiation, exclusionary criteria were sometimes interpreted as criteria for denying services to children.” | content_tags.findings[5] |
| finding | — “Some panel members noted specific meanings of ‘developmental’ that were not intended: for example, that this was something that the child might ‘grow out of’, or – quite the converse – that a developmental problem meant that the child would be unable to develop language.” | content_tags.findings[6] |
| quantity | at least 78% on 19 of 21 statements, within two rounds; 21 statements collapsed to 12 — — “We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ ( DLD ) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD , (b) DLD can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLD does not require a mismatch between verbal and nonverbal ability.” | content_tags.quantities[0] |
| quantity | 68% and 46%, both about terminology for subtypes of language disorder — — “The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorder, had 68% and 46% agreement respectively, indicating a need for further revision or omission.” | content_tags.quantities[1] |
| quantity | median agreement 74% in round 1 (range 30-98%) to 90% in round 2 (range 46-98%) — — “The percentage agreement (combining strongly agree with agree) ranged from 30% to 98% for the 16 items, with a median value of 74%.” | content_tags.quantities[2] |
| quantity | 57 individuals across six English-speaking countries and eight professions; response rates 93% and 91% — — “Of the original panel, two declined to take part in CATALISE‐2 for personal reasons, leaving a panel of 57 individuals, whose characteristics are shown in Table 1 . Nine panel members had a close relative with impaired language development.” | content_tags.quantities[3] |
| value source note | quantity — THE VALUE DRAWS ON THE PAPER BEYOND THIS QUOTE: part of it is printed elsewhere in the paper, not in this quote ('members for Round 1 was 93%…'; 'members for Round 2 was 91%…'). | content_tags.quantities[3] |
| variable | prognosis — “In particular, it cautions against defining language disorder solely in terms of statistical cut‐offs on language tests. Note also that we reject any attempt to use discrepancy scores to draw a distinction between ‘disorder’ and ‘delay’: the term ‘language delay’ was widely rejected by our panel members as confusing and illogical.” | content_tags.variables[0] |
| definition | DLD — “We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorder’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosis. The term, ‘Developmental Language Disorder’ ( DLD ) was endorsed for use when the language disorder was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factors (neurobiological or environmental) does not preclude a diagnosis of DLD , (b) DLD can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLD does not require a mismatch between verbal and nonverbal ability.” | content_tags.definitions[0] |
| definition | differentiating conditions — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | content_tags.definitions[2] |
| definition | risk factors — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | content_tags.definitions[3] |
| definition | co-occurring conditions — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | content_tags.definitions[4] |
| concept | DLD — not defined in this paper's own words; developmental language disorder - language disorder with no known differentiating biomedical condition — “Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLD is nested within the broader SLCN category” | concepts[0] |
| concept | SLCN — not defined in this paper's own words; speech, language and communication needs - the superordinate service-planning category DLD sits inside — “Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLD is nested within the broader SLCN category” | concepts[1] |
| concept | Specific Language Impairment — not defined in this paper's own words; the abolished predecessor term, the most frequent in the prior research literature — “The principal recommended term, DLD, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorder) used in DSM‐5. It was one of four possible terms considered in Bishop's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairment, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.” | concepts[2] |
| concept | differentiating conditions — not defined in this paper's own words; biomedical conditions in which language disorder occurs as part of a more complex pattern - the ONLY one of the three that excludes a DLD diagnosis — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concepts[3] |
| concept | risk factors — not defined in this paper's own words; biological or environmental factors statistically associated with language disorder whose causal role is unclear - recorded, and NOT exclusionary — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concepts[4] |
| concept | co‐occurring conditions — not defined in this paper's own words; impairments in other domains that co-occur with DLD and do not preclude it - the third leg of the split that replaced exclusionary criteria — “Rather than using exclusionary criteria in the definition of language disorder, we draw a threefold distinction between differentiating conditions, risk factors and co‐occurring conditions.” | concepts[5] |
| concept | pragmatic impairment — not defined in this paper's own words; difficulty with the appropriate production or comprehension of language in context - treated here as a TYPE OF language disorder, not a separate category — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concepts[6] |
| concept | language disorder — not defined in this paper's own words; the superordinate diagnostic term this paper defines by prognosis and function — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concepts[7] |
| concept | pragmatics — not defined in this paper's own words; language use in context - claimed here as PART OF language rather than as a separate social-communication domain — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concepts[8] |
| concept | language — not defined in this paper's own words; the domain whose boundary with social communication this paper draws differently from DSM-5 — “We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmatics as part of language, and hence pragmatic impairment as a type of language disorder. Second, the label SPCD emphasises social communication, rather than language; in contrast, our focus is on linguistic problems.” | concepts[9] |
| a significance test applied to a DEFINITIONAL process | — “Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.” | content_tags.statistics[0] |
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J Child Psychol Psychiatry J Child Psychol Psychiatry 379 blackwellopen JCPP Journal of Child Psychology and Psychiatry, and Allied Disciplines 0021-9630 1469-7610 pmc-is-collection-domain yes pmc-collection-title Wiley Open Access Collection PMC5638113 PMC5638113.1 5638113 5638113 28369935 10.1111/jcpp.12721 JCPP12721 1 Original Article Original Articles Phase 2 of CATALISE: a multinational and multidisciplinary Delphi consensus study of problems with languageterm development: Terminology Dorothy V.M. BishoppersName et al. BishoppersName Dorothy V.M. dorothy.bishoppersName@psy.ox.ac.uk 1 SnowlingpersName Margaret J. 1 ThompsonpersName Paul A. 1 GreenhalghpersName Trisha 2 and the CATALISE‐2 consortium Adams Catherine Archibald Lisa Baird Gillian Bauer Ann Bellair Jude Boyle Christopher Brownlie Elizabeth Carter Glenn Clark Becky Clegg Judy Cohen Nancy Conti‐Ramsden Gina Dockrell Julie Dunn Janet Ebbels Susan Gallagher Aoife Gibbs Simon Gore‐Langton Emma Grist Mandy Hartshorne Mary Hüneke Alison Joanisse Marc Kedge Sally Klee Thomas Krishnan Saloni Lascelles Linda Law James Leonard Laurence Lynham Stephanie Arnold Elina Mainela Mathura Narad McCartney Elspeth McKean Cristina McNeill Brigid Morgan Angela Murphy Carol‐Anne Norbury Courtenay O'Hare Anne Cardy Janis Oram O'Toole Ciara Paul Rhea Purdy Suzanne Redmond Sean Restrepo Laida Rice Mabel Slonims Vicky Snow Pamela Speake Jane Spencer Sarah Stringer Helen Tager‐Flusberg Helen Tannock Rosemary Taylor Cate Tomblin Bruce Volden Joanne Westerveld Marleen house Andrew 1 Department of Experimental Psychology University of Oxford Oxford UK 2 Nuffield Department of Primary Care Health Sciences University of Oxford Oxford UK * Correspondence Dorothy V.M. BishoppersName, Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford, OX1 3UD, UK; Email: dorothy.bishoppersName@psy.ox.ac.uk 30 3 2017 10 2017 58 10 299768 10.1111/jcpp.2017.58.issue-10 Developmental Language Disordersterm 1068 1080 22 2 2017 12 10 2017 25 10 2017 25 06 2025 © 2017 The Authors. Journal of Child Psychology and Psychiatry published by John Wiley & Sons Ltd on behalf of Association for Child and Adolescent Mental Health. https://creativecommons.org/licenses/by/4.0/ This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. Background Lack of agreement about criteria and terminology for children's languageterm problems affects access to services as well as hindering research and practice. We report the second phase of a study using an online Delphi method to address these issues. In the first phase, we focused on criteria for language disorderterm. Here we consider terminology.
Methods The Delphi method is an iterative process in which an initial set of statements is rated by a panel of experts, who then have the opportunity to view anonymised ratings from other panel members. On this basis they can either revise their views or make a case for their position. The statements are then revised based on panel feedback, and again rated by and commented on by the panel. In this study, feedback from a second round was used to prepare a final set of statements in narrative form. The panel included 57 individuals representing a range of professions and nationalities.
Results We achieved at least 78% agreement for 19 of 21 statements within two rounds of ratings. These were collapsed into 12 statements for the final consensus reported here. The term ‘Language Disorderterm’ is recommended to refer to a profile of difficulties that causes functional impairment in everyday life and is associated with poor prognosisterm·var. The term, ‘Developmental Language Disorderterm’ ( DLDterm ) was endorsed for use when the language disorderterm was not associated with a known biomedical aetiology. It was also agreed that (a) presence of risk factorsterm (neurobiological or environmental) does not preclude a diagnosis of DLDterm , (b) DLDterm can co‐occur with other neurodevelopmental disorders (e.g. ADHD ) and (c) DLDterm does not require a mismatch between verbal and nonverbal ability.
Conclusions This Delphi exercise highlights reasons for disagreements about terminology for language disordersterm and proposes standard definitions and nomenclature.
Developmental language disorderterm specific language impairmentterm terminology risk factorsterm definitions Wellcome Trust 082498/Z/07/Z pmc-status-qastatus 0 pmc-status-live yes pmc-status-embargo no pmc-status-released yes pmc-prop-open-access yes pmc-prop-olf no pmc-prop-manuscript no pmc-prop-legally-suppressed no pmc-prop-has-pdf yes pmc-prop-has-supplement yes pmc-prop-pdf-only no pmc-prop-suppress-copyright no pmc-prop-is-real-version no pmc-prop-is-scanned-article no pmc-prop-preprint no pmc-prop-in-epmc yes pmc-license-ref CC BY source-schema-version-number 2.0 component-id jcpp12721 cover-date October 2017 details-of-publishers-convertor Converter:WILEY_ML3GV2_TO_NLMPMC version:5.2.1 mode:remove_FC converted:12.10.2017 Conflict of interest statement: No conflicts declared.
Introduction Languageterm problems are common in children, with prevalence estimates ranging from 3% to 7%, depending on age and definition (Norbury et al., 2016 ; Tomblin, Records et al., 1997 ; Weindrich, Jennen‐Steinmetz, Laucht, Esser, & Schmidt, 2000 ). In relation to their severity and prevalence, children's languageterm problems receive considerably less research funding than other conditions such as attention deficit hyperactivity disorder (ADHD) or autism spectrum disorder (ASD), with which they frequently co‐occur (BishoppersName, 2010 ). The term Specific Language Impairmentterm (SLI) has been widely used to refer to children whose languageterm development is not following the usual course despite typical development in other areas. However, professionals and lay people alike appear to be far less familiar with SLI compared with dyslexia or autism (Kamhi, 2004 ). Of more concern, Ebbels ( 2014 ) described how use of the term SLI had become controversial, because it seemed not to reflect clinical realities and excluded many children from services.
BishoppersName, SnowlingpersName, ThompsonpersName, GreenhalghpersName and The CATALISE Consortium ( 2016 ) used an online version of the Delphi technique (Hasson, Keeney, & McKenna, 2000 ) with the aim of achieving consensus on these issues. Because of the complexity of the subject matter, we divided the task into two phases: the first, described by BishoppersName et al. ( 2016 ) focused on criteria for identifying significant languageterm problems in children. Here we describe the second phase, where the same panel focused on the issue of terminology for children's languageterm problems. Here we describe this second phase.
Materials and methods Ethics approval This research was approved by The Medical Sciences Interdisciplinary Research Ethics Committee, University of Oxford (approval number: MS‐IDREC‐C1‐2015‐061). Panel members gave written consent for their ratings to be used to derive a consensus statement.
Delphi panel We approached the same panel members who had formed part of the CATALISE consortium for our previous Delphi on criteria. As detailed by BishoppersName et al. ( 2016 ), we restricted consideration to English‐speaking countries, and there was a predominance of speech‐languageterm therapists/pathologists (SLT/Ps). Of the original panel, two declined to take part in CATALISE‐2 for personal reasons, leaving a panel of 57 individuals, whose characteristics are shown in Table 1 . Nine panel members had a close relative with impaired languageterm development.
Table 1 Professional group and country a of panel members Profession N and Country Gender Speech‐Languageterm Therapist/Pathologist 31 (15 UK, 6 USA, 3 NZ, 3 Ire, 1 Can, 3 Aus) 6 M, 25 F Joint SLT/SLP and Psychologist 7 (3 Can, 2 Aus, 2 UK) 1 M, 6 F Psychologist/Educational Psychologist 8 (3 UK, 1 US, 3 Can, 1 Aus) 3 M, 5 F Paediatrician 3 (3 UK) 1 M, 2 F Psychiatrist 1 (1 Can) 1 F Audiologist 1 (1 NZ) 1 F Specialist teacher 2 (2 UK) 2 F Charity representative 4 (4 UK) 4 F Total 57 57 a Country where panel member was based at start of Delphi studies.
John Wiley & Sons, Ltd The first two authors (DVMB and MJS), both psychologists with considerable experience in the area of children's languageterm problems, acted as moderators: they did not contribute rankings, but agreed on modifications to statements on the basis of feedback from the panel. The third author (PT) set up the online Delphi, controlled the anonymisation and analysed responses to produce reports for panel members. The fourth (TG), an expert in primary health care who was familiar with the Delphi method acted, as methodological advisor.
Delphi consensus process We started with a set of statements about terminology accompanied by a background document (Appendix S1 ) that put these in context. These were new statements that were different from those in the prior Delphi exercise on criteria, though they were informed by issues that arose in that study (BishoppersName et al., 2016 ). Panel members were asked to rate the statements on a 5‐point scale from 1 (strongly disagree) to 5 (strongly agree).
Participant responses to Round 1 were collated. The distribution of responses and associated anonymised comments were then fed back to all panel members and scrutinised by the moderators. One difference from our previous Delphi was that we held a 1‐day meeting to present and discuss preliminary results from CATALISE‐2 before proceeding to Round 2. All panel members were invited to this, as well as additional stakeholders. The meeting was attended by the first four authors and 22 of the CATALISE‐2 consortium, as well as 23 individuals representing a range of fields: eight from speech and languageterm therapy, eight from psychology, one paediatrician, two representatives from charities, one expert in special educational needs, one geneticist, one general practitioner and one psychiatrist.
On the basis of ratings, qualitative comments and discussions at the meeting, the two moderators agreed on rewording of some items and revision of the background document. The set of items and background document used in Round 2 are shown in Appendix S2 .
There is no agreed criterion for when a Delphi consensus is deemed adequate for an item – in the literature, values from 51% to 80% agreement have been used (Hasson et al., 2000 ). We aimed for 75% agreement as a reasonable goal.
After Round 2, the moderators made some further revisions to the statements to improve clarity and readability, to take into account specific comments provided by the panel, and to reconsider the two problematic items. Some statements with good agreement were consolidated to give a single longer statement (see Appendix S3 ), giving a total of 13 statements. A draft of the current paper, including finalised statements in the Results section, was circulated for comments and approval by the panel. Further revisions were made to address points raised by reviewers, including the dropping of one redundant statement, and the paper was again circulated to all panel members for comment. The current paper represents the final agreed version.
Results and discussion Round 1 The response rate by panel members for Round 1 was 93%. Appendix S4 shows quantitative and qualitative responses to the Round 1 statements; a personalised copy of this report containing these data was sent to all panel members, showing how their own responses related to the distribution of responses from other (anonymised) panel members. The percentage agreement (combining strongly agree with agree) ranged from 30% to 98% for the 16 items, with a median value of 74%.
Kruskal–Wallis tests were conducted on each item to test whether agreement was related to either geographical location (six countries) or professional status (SLT/P vs. others), using a Bonferroni‐corrected p ‐value of .001. None of these comparisons was statistically significant after correction for multiple comparisons. Given the small sample size, we cannot rule out an effect of these two factors on ratings, but the analysis offers some reassurance that responses did not simply pattern according to professional background or geographical location.
Round 2 The response rate by panel members for Round 2 was 91%. Appendix S5 contains the data that were incorporated in a personalised report sent to all panel members for Round 2. The percentage agreement (combining ratings of strongly agree with agree) ranged from 46% to 98% across items, with a median value of 90%. Of the 21 items, 19 had agreement of 78% or more, which we regarded as adequate to accept that statement. Items 19 and 20, both concerned with terms for subtypes of language disorderterm, had 68% and 46% agreement respectively, indicating a need for further revision or omission.
Consensus statements In this section, we present final statements, with supplementary comments that reflect reasoning behind them, based on qualitative comments and discussion, supported by references where appropriate.
Statement 1 It is important that those working in the field of children's languageterm problems use consistent terminology.
Supplementary comment In Round 2, a version of this statement was included to orient the panel to our common goal. Although the terminology we propose is not novel, its adoption will require many people to change their practices, which will be difficult where there is a long‐standing preference for other terms. Nevertheless, panel members were strongly motivated to achieve a consensus, because the lack of consistency was recognised as a major problem for the field.
Statement 2 The term ‘language disorderterm’ is proposed for children who are likely to have languageterm problems enduring into middle childhood and beyond, with a significant impact on everyday social interactions or educational progress.
Supplementary comment This statement clarifies that prognosisterm·var should be a key factor in the definition of language disorderterm; that is, the term should include those with languageterm problems that lead to significant functional impairments unlikely to resolve without specialist help. There is no sharp dividing line between language disorderterm and typical development, but we can use relevant information from longitudinal studies to help determine prognosisterm·var (see Statement 3 ).
Arguments for preferring the term ‘disorder’ to ‘impairment’ included the greater seriousness and importance associated with the term; consistency with other neurodevelopmental disorders (autism spectrum disorder, developmental coordination disorder, attention deficit hyperactivity disorder); and compatibility with the two main diagnostic systems, DSM‐5 (American Psychiatric Association, 2013 ) and ICD‐11 (Baird, personal communication).
Some panel members expressed concerns that the term ‘disorder’ had medical connotations and placed the problem ‘inside the child’, when it might be contextually dependent. It was thought to have negative associations for teachers and there were concerns that such a label could lead to low expectations. For this reason, our definition explicitly excludes children who have limited languageterm skills because of lack of exposure to the languageterm of instruction, or are likely to grow out of their problems. These children often benefit from educational interventions, and may require monitoring, but they should not be identified as languageterm disordered.
Another objection to the term ‘disorder’ is that historically it has been interpreted as referring to a large mismatch between languageterm and nonverbal ability. This interpretation has been widely adopted in some circles, but is discredited and is not part of our definition (BishoppersName et al., 2016 ) (see also Statement 8 ).
Statement 3 Research evidence indicates that predictors of poor prognosisterm·var vary with a child's age, but in general languageterm problems that affect a range of skills are likely to persist.
Supplementary comment Prognostic indicators will vary with age. Our focus here is on what we know about learning English.
Under 3 years Prediction of outcome is particularly hard in children under 3 years of age. Many toddlers who have limited vocabulary at 18–24 months catch up, and despite much research, it can be difficult to identify which late talkers are likely to have long‐term problems (Reilly et al., 2010 ). Children who fail to combine words at 24 months appear to have worse outcomes than those who do not produce any words at 15 months, though this is still a far from perfect predictor (Rudolph & Leonard, 2016 ). Prognosisterm·var is also poorer for children with comprehension problems, those who do not communicate via gesture (Ellis & Thal, 2008 ), or do not imitate body movements (Dohmen, BishoppersName, Chiat, & Roy, 2016 ). Roy and Chiat ( 2014 ) administered a preschool measure of social responsiveness and joint attention to 2‐ to 4‐year olds referred for speech‐languageterm therapy, and found it was predictive of persisting problems, and indicative of social communication problems at 9 years. A positive family history of languageterm or literacy problems is an additional risk factorterm (Rudolph & Leonard, 2016 ; Zambrana, Pons, Eadie, & Ystrom, 2014 ). Overall, however, the prediction from late languageterm emergence to subsequent language disorderterm at school age is surprisingly weak: in part because many late talkers catch up but also because some school‐aged children with language disorderterm were not late to talk (SnowlingpersName, Duff, Nash, & Hulme, 2016 ; Zambrana et al., 2014 ).
Three to four years Prediction improves as children grow older; in 4‐year olds, the greater the number of areas of languageterm functioning that is impaired, the higher the likelihood that the problems will persist into school age (BishoppersName & Edmundson, 1987 ). Note that this finding contradicts the idea that intervention should be focused on children with a ‘spiky’ languageterm profile rather than a more even pattern of impairment. When individual languageterm tests are considered, sentence repetition has been identified as a relatively good marker for predicting outcomes (Everitt, Hannaford, & Conti‐Ramsden, 2013 ).
In contrast, there is generally a good prognosisterm·var for preschoolers whose problems are restricted to expressive phonology (Beitchman, Wilson, Brownlie, Walters et al., 1996 ; BishoppersName & Adams, 1990 ).
Five years and over Languageterm problems that are still evident at 5 years and over are likely to persist (Stothard, SnowlingpersName, BishoppersName, Chipchase, & Kaplan, 1998 ). Children who start school with oral languageterm problems are at risk of reading problems and poor academic attainment (BishoppersName & Adams, 1990 ; Catts, Fey, Tomblin, & Zhang, 2002 ; ThompsonpersName et al., 2015 ) with little evidence that the languageterm gap closes over time (Rice & Hoffman, 2015 ). Prognosisterm·var appears particularly poor when receptive languageterm is impaired (Beitchman, Wilson, Brownlie, Walters, & Lancee, 1996 ; Clark et al., 2007 ), and when nonverbal ability is relatively low (Catts et al., 2002 ; Johnson, Beitchman, & Brownlie, 2010 ; Rice & Hoffman, 2015 ).
Family factors There has been some debate over the predictive value of family factors. As noted above, several studies found that a positive family history of languageterm problems is a predictor (albeit weak) of persisting problems in late talkers, and family history is also associated with poor literacy outcomes (SnowlingpersName & Melby‐Lervåg, 2016 ). It is less clear whether social background is independently predictive, once other risk factorsterm have been taken into account (Botting, Faragher, Simkin, Knox, & Conti‐Ramsden, 2001 ).
For further discussion of the range of languageterm skills under consideration, see Statement 11 .
Statement 4 Some children may have languageterm needs because their first or home languageterm differs from the local languageterm, and they have had insufficient exposure to the languageterm used by the school or community to be fully fluent in it. This should not be regarded as language disorderterm, unless there is evidence that the child does not have age‐appropriate skills in any languageterm.
Supplementary comment This statement makes it clear that a low score on a languageterm test does not necessarily mean that a child has any kind of disorder. It is important to consider whether the child has adequate proficiency in any languageterm. In general, multilingualism does not lead to languageterm problems (Paradis, 2016 ), but where there has been limited experience with the languageterm used at school, the child may require extra help (Cattani et al., 2014 ). This also applies to hearing‐impaired children whose native languageterm is a signed languageterm. In practice, however, for many languagesterm, we lack suitable (normed) assessments (Jordaan, 2008 ).
Statement 5 Rather than using exclusionary criteria in the definition of language disorderterm, we draw a threefold distinction between differentiating conditionsterm, risk factorsterm and co‐occurring conditionsterm.
Supplementary comment Use (and misuse) of exclusionary factors in definitions of language disorderterm was a major issue leading to dissatisfaction with terminology in this field. Panel members were concerned that, instead of being used for diagnostic differentiation, exclusionary criteria were sometimes interpreted as criteria for denying services to children. On the other hand, grouping together all children with a languageterm problem, regardless of cause, and without regard to type of intervention required, would, in many contexts, be counterproductive.
Statements 6–10 explain how we draw the distinction between differentiating conditionsterm, risk factorsterm and co‐occurring conditionsterm.
Statement 6 Differentiating conditionsterm are biomedical conditions in which language disorderterm occurs as part of a more complex pattern of impairments. This may indicate a specific intervention pathway. We recommend referring to ‘Language disorderterm associated with X’, where X is the differentiating conditionterm, as specified above.
Supplementary comment Differentiating conditionsterm include brain injury, acquired epileptic aphasia in childhood, certain neurodegenerative conditions, cerebral palsy and oral languageterm limitations associated with sensori‐neural hearing loss (Tomblin et al., 2015 ) as well as genetic conditions such as Down syndrome. We also include here children with autism spectrum disorder (ASD) and/or intellectual disability (Harris, 2013 ) because these conditions are commonly linked to genetic or neurological causes (Fitzgerald et al., 2015 ; Shevell, Majnemer, Rosenbaum, & Abrahamowicz, 2001 ), with the numbers of known aetiology increasing with advances in genetic methods (Bourgeron, 2015 ; Fitzgerald et al., 2015 ; Shevell et al., 2001 ).
These are all cases where an association between a biomedical condition and language disorderterm is commonly seen. In such cases, the child requires support for the languageterm problems, but the intervention pathway will need to take into account the distinctive features of the biomedical condition. It should be noted, however, that there is little research directly comparing languageterm intervention approaches across conditions, so this inference is based on clinical judgement rather than research evidence.
Statement 7 The term Developmental Language Disorderterm (DLDterm) is proposed to refer to cases of language disorderterm with no known differentiating conditionterm (as defined in Statement 6). Distinguishing these cases is important when doing research on aetiology, and is likely also to have implications for prognosisterm·var and intervention.
Supplementary comment The term ‘Developmental Language Disorderterm’ is consistent with ICD‐11 (Baird, personal communication), though our definition does not include any nonverbal ability criteria.
‘Developmental’ in this context refers to the fact that the condition emerges in the course of development, rather than being acquired or associated with a known biomedical cause. Although many panel members endorsed it, some objections to the term ‘developmental’ were encountered. It was noted that ‘developmental’ can become less useful, or even confusing, as individuals grow older. One proposed solution was to drop the ‘developmental’ part of the term in adulthood – this is how this issue is typically handled in the case of (developmental) dyslexia, where affected adults usually refer to themselves as ‘dyslexic’. Some panel members noted specific meanings of ‘developmental’ that were not intended: for example, that this was something that the child might ‘grow out of’, or – quite the converse – that a developmental problem meant that the child would be unable to develop languageterm. It was also suggested that this term might be hard for parents to understand – though similar objections were made for other alternatives that were offered, namely ‘primary’ and ‘specific’ language disorderterm.
Statement 8 A child with a language disorderterm may have a low level of nonverbal ability. This does not preclude a diagnosis of DLDterm.
Supplementary comment It is important to recognise that languageterm can be selectively impaired in a child with normal nonverbal ability, but this statement confirms that a large discrepancy between nonverbal and verbal ability is not required for a diagnosis of DLDterm. In practice, this means that children with low nonverbal ability who do not meet criteria for intellectual disability (Harris, 2013 ) can be included as cases of DLDterm.
Statement 9 Co‐occurring disorders are impairments in cognitive, sensori‐motor or behavioural domains that can co‐occur with DLDterm and may affect pattern of impairment and response to intervention, but whose causal relation to languageterm problems is unclear. These include attentional problems (ADHD), motor problems (developmental coordination disorder or DCD), reading and spelling problems (developmental dyslexia), speech problems, limitations of adaptive behaviour and/or behavioural, and emotional disorders.
Supplementary comment The terminology used for neurodevelopmental disorders can create the impression that there is a set of distinct conditions, but the reality is that many children have a mixture of problems. Indeed, the same problems may be labelled differently depending on the professional the child sees. For example, the same child may be regarded as having DLDterm by a SLT/P, dyslexia by a teacher, auditory processing disorder by an audiologist, or ADHD by a paediatrician. Given our focus on DLDterm, our aim with this statement was to make it clear that presence of another neurodevelopmental diagnosis does not preclude DLDterm.
Some panel members noted that a case could be made for including ASD as a co‐occurring disorder, rather than a differentiating factor. One reason for keeping it as a differentiating factor is that a substantial minority of children with ASD have a clear genetic aetiology: changes in chromosomes, copy number variants or specific mutations are estimated as accounting for around 25% of cases (Bourgeron, 2015 ), a figure likely to increase with advances in genetic methods. This is in contrast with the other neurodevelopmental disorders listed here, where, although there is evidence for heritability, the aetiology appears to be complex and multifactorial (see e.g. BishoppersName ( 2015 ) on dyslexia). In addition, communication problems are a core diagnostic feature of ASD, albeit with wide variation in the severity and nature of the languageterm problems (Williams, Botting, & Boucher, 2008 ). Finally, the co‐occurring social and behavioural difficulties suggest the need for a distinctive intervention approach for ASD.
There was discussion about including auditory processing disorder (APD) as a co‐occurring conditionterm. This category is controversial (Moore, 2006 ), but this should not lead to it being ignored. Children who are given this diagnosis often have co‐occurring languageterm problems which require expert evaluation (Dawes & BishoppersName, 2009 ; Sharma, Purdy, & Kelly, 2009 ).
Some panel members noted that relatively pure cases without co‐occurring problems might be more common in epidemiological than in clinical samples. However, that this may in part reflect the criteria used to define cases in epidemiological studies, who may not be screened for difficulties in domains beyond languageterm and IQ. A focus on ‘pure’ cases has been traditional in research settings, because it can clarify which features of a disorder are specific to languageterm. However, this can make it difficult to generalise research findings to many children seen in clinical settings, where co‐occurring conditionsterm are more commonly observed. Most panel members agreed that the term DLDterm should apply whether or not co‐occurring problems are documented.
Statement 10 Risk factorsterm are biological or environmental factors that are statistically associated with language disorderterm, but whose causal relationship to the languageterm problem is unclear or partial. Risk factorsterm do not exclude a diagnosis of DLDterm.
Supplementary comment These are factors that are not robust predictors of individual children's languageterm status or outcome, but which are more common in children with language disordersterm than typically developing children (Zubrick, Taylor, & Christensen, 2015 ). A systematic review found that commonly documented risk factorsterm include a family history of language disordersterm or dyslexia, being male, being a younger sibling in a large family and fewer years of parental education (Rudolph, 2016 ). Prenatal/perinatal problems do not seem to be an important risk factorterm for language disordersterm (Tomblin, Smith, & Zhang, 1997 ; Whitehouse, Shelton, Ing, & Newnham, 2014 ).
It is important to note that associated risk factorsterm may differ depending on the age of the child, and whether epidemiological or clinical samples are considered.
Statement 11 Developmental language disorderterm is a heterogeneous category that encompasses a wide range of problems. Nevertheless, it can be helpful for clinicians to pinpoint the principal areas for intervention, and researchers may decide to focus on children with specific characteristics to define more homogeneous samples for study. We suggest here some guidelines for more in‐depth analysis of languageterm problems.
Supplementary comment The panel members did not reach good agreement on terminology for subgroups, and this may reflect the fact that, although attempts have been made to develop a classification of subtypes, these have not in general been validated as categories that are stable over time (Conti‐Ramsden & Botting, 1999 ). The traditional distinction used in DSM, between receptive and expressive language disorderterm, is rather gross, and fails to indicate which aspects of languageterm are proving problematic. We have therefore opted for an approach that uses specifiers indicating the principal dimensions of languageterm difficulty, with a recommendation that assessment focus on identifying which areas are most impaired. We outline these briefly below. Note: our focus here is on oral rather than written languageterm, though reading and writing are commonly affected in DLDterm.
Phonology Phonology is the branch of linguistics concerned with the organisation of speech sounds into categories. Different languagesterm use different articulatory features to signal contrasts in meaning, and when learning languageterm, the child has to learn which features to ignore and which to focus on (Kuhl, 2004 ).
In both research and clinical practice, most emphasis has been placed on expressive phonological problems: difficulties with speech production that are linguistic in origin, rather than due to motor impairment or physical abnormality of the articulators. This kind of problem is identified when a child fails to make a speech distinction between sounds that are used to contrast meaning in the languageterm being learned, as when a child says ‘tea’ rather than ‘key’, substituting/t/for/k/. Phonological errors of this kind are common in early development, but can persist and, when numerous, impair intelligibility of speech. Phonological problems in preschoolers that are not accompanied by other languageterm problems are a relatively common reason for referral to a SLT/P and often respond well to specialist intervention (Law, Garrett, & Nye, 2003 ). Thus, they would not meet our criteria for DLDterm because the prognosisterm·var is good. The more general term ‘Speech Sound Disorder’ (SSD) can be used for such cases: this is an umbrella term that also includes problems with speech production that have motor or physical origins, or involve misarticulations such as a lisp, where a sound is produced in a distorted way without losing the contrast with other sounds. The classification of and terminology for disorders of speech sound production is a subject of considerable debate (Waring & Knight, 2013 ). In practice, even for those with specialist skills, it is not always easy to distinguish between phonological disorders and other types of speech production problem.
Where phonological problems continue beyond 5 years of age it is important to assess the child's broader languageterm skills, as persisting phonological difficulties are usually accompanied by other languageterm problems and have a poorer prognosisterm·var (Bird, BishoppersName, & Freeman, 1995 ; BishoppersName & Edmundson, 1987 ; Hayiou‐Thomas, Carroll, Leavett, Hulme, & SnowlingpersName, 2017 ), so would merit a diagnosis of DLDterm. Where the child has a mixture of language disorderterm and motor or structural problems with speech production, a dual diagnosis of DLDterm with SSD is appropriate.
Some children have impairment affecting phonological awareness, that is they have difficulty explicitly categorising and manipulating the sounds of languageterm. For instance, they may be unable to identify the three phonemes constituting the word ‘cat’, or to recognise that ‘cat’ and ‘car’ begin with the same phoneme. Phonological awareness has been studied extensively in children with reading disability, where it is commonly impaired, even in children with normal speech production. Although phonological awareness is often deficient in children with DLDterm, we would not diagnose DLDterm on the basis of poor phonological awareness alone, because it is a metalinguistic skill that can be as much a consequence as a cause of literacy problems (Wimmer, Landerl, Linortner, & Hummer, 1991 ).
Syntax A considerable body of research has focused on documenting syntactic impairments in children with DLDterm (Van der Lely, 2005 ). Expressive problems with morpho‐syntax are of particular theoretical interest, and there have been contrasting attempts to account for them in terms of linguistic and processing theories (Leonard, 2014 ). Receptive languageterm impairments affecting syntax can also occur, with children failing to interpret meaning conveyed by grammatical contrasts (Hsu & BishoppersName, 2014 ), or showing problems in distinguishing grammatical from ungrammatical sentence forms (Rice, Wexler, & Redmond, 1999 ).
Word finding and semantics Some children struggle to produce words despite having some knowledge of their meaning – these are known as ‘word finding difficulties’ (Messer & Dockrell, 2006 ). Others have limited knowledge of word meanings – a problem that comes under the domain of lexical semantics. The child may be poor at understanding multiple word meanings and/or use a restricted vocabulary. The latter problem has been particularly noted in verb use, where the term ‘general all‐purpose verbs’ has been coined to describe this phenomenon (Kambanaros & Grohmann, 2015 ; Rice & Bode, 1993 ). Semantic impairments also encompass problems with expressing or understanding meaning from word combinations; for example, understanding the scope of the quantifier (all/none) in sentences such as ‘all the pens are in the boxes’ or ‘none of the pens are in the boxes’ (Katsos, Roqueta, Estevan, & Cummins, 2011 ).
Pragmaticsterm/languageterm use Pragmaticterm difficulties affect the appropriate production or comprehension of languageterm in a given context. They include such characteristics as providing too much or too little information to a conversational partner, insensitivity to social cues in conversation, being over‐literal in comprehension and having difficulty understanding figurative languageterm (Adams, 2002 ). Prosodic abnormalities, in which cues such as intonation and stress are used idiosyncratically, so speech sounds robotic, stereotyped or otherwise atypical to the context, can also be disruptive to social communication. These difficulties are hallmarks of the communicative problems seen in ASD, but are also found in children who do not meet criteria for autism.
Specific terminology has been proposed for nonautistic children with pragmatic impairmentsterm. In ICD‐11, the term pragmaticterm languageterm impairment is used as a descriptive qualifier within DLDterm. In DSM‐5, a new category of social (pragmaticterm) communication disorder (SPCD) has been introduced – see Baird and Norbury ( 2016 ).
We considered adopting the DSM‐5 term in CATALISE, but decided against this for several reasons. First, in DSM‐5, SPCD is seen as a new category of neurodevelopmental disorder, whereas we regard pragmaticsterm as part of languageterm, and hence pragmatic impairmentterm as a type of language disorderterm. Second, the label SPCD emphasises social communication, rather than languageterm; in contrast, our focus is on linguistic problems.
Interventions are being developed that address linguistic as well as social aspects of such communication problems (Adams, 2008 ), and a focus on pragmaticterm languageterm as a feature of DLDterm should help direct children to appropriate intervention.
Discourse In contexts such as narrative, children must learn to process sequences of utterances, so that they form a coherent whole. Children who lack this ability may produce sequences of utterances that appear disconnected and hard to follow. They may also experience comprehension failure if they interpret one sentence at a time, without drawing the necessary inferences to link them together (Karasinski & Weismer, 2010 ).
Verbal learning and memory The research literature has shown that many children with DLDterm have problems in retaining sequences of sounds or words over a short delay (verbal short‐term memory), learning associations between words and meaning, or learning statistical patterns in sequential input (Archibald & Gathercole, 2006 ; BishoppersName, North, & Donlan, 1996 ; Campbell, Dollaghan, Needleman, & Janosky, 1997 ; Conti‐Ramsden, 2003 ; Ellis Weismer, 1996 ; Gillam, Cowan, & Day, 1995 ; Leonard 2007 ; Lum, Conti‐Ramsden, Page, & Ullman, 2012 ; Lum & Zarafa, 2010 ; Montgomery, 2002 ). Their languageterm limitations are different from those due to poor hearing or auditory discrimination, or to lack of knowledge due to unfamiliarity with the ambient languageterm.
Statements 2–11 are synthesised in Figure 1 .
Figure 1 Flow chart illustrating pathways to diagnosis of language disorderterm. Numbers in square brackets refer to Statements in the Results section Statement 12 It can be useful to have a superordinate category for policymakers, because the number of children with specific needs in the domain of speech, languageterm and communication has resource implications. The term Speech, Languageterm and Communication Needs (SLCNterm), already in use in educational services in the United Kingdom, is recommended for this purpose.
Supplementary comment DLDterm can be viewed as a subset within a broad category that covers the whole range of problems affecting speech, languageterm and communication, regardless of the type of problem or putative aetiology.
As shown in Figure 2 , this is a very broad category that encompasses children with DLDterm (as defined above), and also includes cases where problems have a clear physical basis (e.g. dysarthria), or affect speech fluency or voice. Also included here are children who have needs due to limited familiarity with the languageterm used in the classroom, and those who have communication difficulties as part of other differentiating conditionsterm.
Figure 2 Venn diagram illustrating relationship between different diagnostic terms. DLDterm is nested within the broader SLCNterm category It is not anticipated that this terminology will be useful for those doing research on the nature or causes of language disordersterm, nor will it be helpful in explaining a child's difficulties to parents or in determining a treatment pathway. It could, however, serve a purpose for those who need to plan services, who may need to estimate how many children are likely to require additional support and to bridge across professional divides (McKean et al., 2017 ). In addition, it recognises children who have languageterm needs that may require extra help or accommodations in the classroom, even if they do not have a language disorderterm. These would include those who are shown in pathways terminating in a bullet in the flow chart in Figure 1 , that is children with milder difficulties who should respond well to classroom modification, children with hearing loss who use sign languageterm or children who have had limited exposure to the ambient languageterm.
General discussion Despite the geographical and professional diversity of the panel, there were some points of broad agreement, as follows: first, some children have languageterm problems that are severe and persistent enough to create long‐term functional challenges, in daily communication and/or educational attainment; second, there is no clear dividing line between normality and disorder; third, within the domain of languageterm, children's problems do not neatly segregate into subtypes, and there may be overlap between problems in speech, languageterm and communication.
A complicating factor in the nosology of language disordersterm is that it has in the past been based on information from a mixture of different levels of description: information about the severity and type of presenting problems with languageterm; co‐occurring problems in nonlanguage domains, such as nonverbal ability, social interaction or attention; and putative biological and environmental causes, such as brain damage, a genetic syndrome or social disadvantage. This approach implies that the constellation of verbal and nonverbal skills will map onto natural subtypes with distinct causes, such that we can use the linguistic, cognitive and behavioural profile to distinguish the child whose languageterm problems have environmental or genetic origins. However, this approach has not worked. As research has progressed, it has become evident that causes of language disordersterm are complex and multifactorial, and there is no neat one‐to‐one mapping between aetiology and phenotype.
In many ways, the results of this consensus exercise may seem unsurprising. The principal recommended term, DLDterm, has a long history in the field, and is compatible with planned usage in ICD‐11 and close to the term (Language Disorderterm) used in DSM‐5. It was one of four possible terms considered in BishoppersName's ( 2014 ) original review of terminology, and already had reasonable representation in a Google Scholar search. For many of those working in this area, however, this represents quite a radical departure from previous practice. The term Specific Language Impairmentterm, which was the most frequent in the research literature, was the subject of substantial disagreement among the panel, with strong arguments being put forward both for its retention and its rejection. Ultimately, the decision was made to reject the term. A major drawback of this decision is that it creates a discontinuity with prior literature, which could affect future meta‐analyses and systematic reviews. On balance, however, it was concluded that the term ‘specific’ had connotations that were misleading and confusing and that, rather than redefining the term, it would be better to abolish it.
There are other aspects of terminology where the Delphi process exposed points of disagreement, but also clarified reasons for these and so allowed us to identify ways forward. Discussions about the term ‘disorder’ revealed principled objections by those who were concerned about medicalisation of normal developmental variation. At the same time, concerns were expressed that other terminology might trivialise the challenges experienced by children who had persistent problems that interfered with their social and educational development. The solution we adopted was to retain ‘disorder’ but define it in a way that required functional problems with a poor prognosisterm·var. This may seem a small change, but it does have major implications. In particular, it cautions against defining language disorderterm solely in terms of statistical cut‐offs on languageterm tests. Note also that we reject any attempt to use discrepancy scores to draw a distinction between ‘disorder’ and ‘delay’: the term ‘languageterm delay’ was widely rejected by our panel members as confusing and illogical.
The main challenge facing those attempting to use the concept of language disorderterm that we advocate is that there are few valid assessments of functional languageterm and relatively limited evidence regarding prognostic indicators. More longitudinal research is needed, using designs that allow us to predict individual outcomes rather than just characterise group averages.
A further case where the Delphi process helped identify sticking points was the treatment of ‘exclusionary factors’. We hope that our distinction between differentiating conditionsterm, risk factorsterm and co‐occurring disorders will be helpful here. Only differentiating conditionsterm, which correspond to biomedical disorders that are clearly associated with languageterm problems, are distinguished diagnostically from DLDterm. Risk factorsterm and co‐occurring disorders are noted but do not preclude a diagnosis of DLDterm. This contrasts with prior practice in some quarters, where a child's social background or presence of problems in other developmental areas could leave a child without a diagnosis, and hence without access to support.
Finally, although it was generally agreed that there is considerable heterogeneity in children with DLDterm, we failed to reach consensus about possible terminology for linguistic subtypes of DLDterm. It is possible that as research advances the situation may change, but another possibility is that it is a consequence of the phenomenon of interest: quite simply, children with DLDterm do not neatly divide into subtypes along linguistic lines. It is likely that there is substantial aetiological as well as linguistic heterogeneity, just as has been found for the related conditions of ASD (Coe, Girirajan, & Eichler, 2012 ) and developmental dyslexia (Raskind, Peter, Richards, Eckert, & Berninger, 2012 ). In addition, the boundaries between DLDterm and other neurodevelopmental disorders are not clearcut (BishoppersName & Rutter, 2008 ). In our current state of knowledge, we propose that the appropriate course of action is to document the heterogeneity rather than attempting to apply a categorical nosology that fails to accommodate a large proportion of children.
An obvious limitation of this study is that we restricted our focus to the English languageterm because of the difficulties of devising terms that would be applicable across different languageterm and cultures. We recommend the use of the Delphi method to researchers working with language disordersterm in other languagesterm, as a good way to achieve better consensus.
As with our previous Delphi study, this exercise has revealed the urgent need for further research on children's language disordersterm, including studies on intervention, models of service delivery, epidemiology, prognosisterm·var, linguistic profiles and functional limitations over time. We hope that by clarifying terminology in this area we will also make it easier to raise awareness of children's languageterm problems.
Key points Some children have problems with languageterm development that cause significant interference with everyday life or educational progress. Terminology for describing such problems has been inconsistent, hampering communication, leading to inequity over access to services and confusion in synthesising research.
A group of experts representing a range of professions and English‐speaking countries using the Delphi method, came to a consensus that ‘Developmental Language Disorderterm’ (DLDterm) is the preferred term for languageterm problems that are severe enough to interfere with daily life, have a poor prognosisterm·var and are not associated with a clear biomedical aetiology.
We replace the traditional exclusionary criteria in the definition of language disorderterm, with a threefold distinction between differentiating conditionsterm, risk factorsterm and co‐occurring conditionsterm.
We provide guidelines about terminology in this area that can be used in clinical and research contexts.
Supporting information Appendix S1. Background document, with the statements for round 1.
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Appendix S2. Background document, with the statements for round 2.
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Appendix S3. Relationship between Round 2 statements and final statements reported in Results section.
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Appendix S4. Report showing quantitative and qualitative responses to Round 1 statements.
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Appendix S5. Report showing quantitative and qualitative responses to Round 2 statements.
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Acknowledgements This work was supported by Wellcome Trust Programme Grant no. 082498/Z/07/Z. The authors thank Holly Thornton and Denise Cripps for their help in running the CATALISE project and Pauline Frizelle, Helen Murrell and Yvonne Wren for comments on an earlier draft. CATALISE stands for Criteria and Terminology Applied to Languageterm Impairments: Synthesising the Evidence. This paper was handled by the Editor‐in‐Chief and has undergone the normal external peer review.
Members of the CATALISE‐2 consortium include Catherine Adams (University of Manchester, UK), Lisa Archibald (University of Western Ontario, Canada), Gillian Baird (NHS, UK), Ann Bauer (Languageterm Resource Provision, Vyne Community School), Jude Bellair (NHS, UK), Christopher Boyle (University of Exeter), Elizabeth Brownlie (University of Toronto, Canada), Glenn Carter (NHS, UK), Becky Clark (RALLI, ClarkSLT, UK), Judy Clegg (University of Sheffield, UK), Nancy Cohen (University of Toronto, Canada), Gina Conti‐Ramsden (University of Manchester, UK), Julie Dockrell (Institute of Education, University College London, UK), Janet Dunn (Meath School, Surrey, UK), Susan Ebbels (Moor House School and College, Surrey, UK; University College London), Aoife Gallagher (University of Limerick, Ireland), Simon Gibbs (Newcastle University, UK), Emma Gore‐Langton (University College London, UK), Mandy Grist (ICAN, UK), Mary Hartshorne (ICAN, UK), Alison Hüneke (Afasic, UK), Marc Joanisse (University of Western Ontario, Canada), Sally Kedge (University of Auckland, New Zealand), Thomas Klee (University of Hong Kong, Hong Kong), Saloni Krishnan (University of Oxford, UK), Linda Lascelles (Afasic, UK), James Law (Newcastle University, UK), Laurence Leonard (Purdue University, USA), Stephanie Lynham (NHS, UK), Elina Mainela Arnold (University of Toronto, Canada), Narad Mathura (NHS, UK), Elspeth McCartney (University of Strathclyde, Scotland), Cristina McKean (Newcastle University, UK), Brigid McNeill (University of Canterbury, New Zealand), Angela Morgan (Murdoch Children's Research Institute, Australia), Carol‐Anne Murphy (University of Limerick, Ireland), Courtenay Norbury (Royal Holloway University of London, UK), Anne O'Hare (University of Edinburgh, Scotland), Janis Oram Cardy (University of Western Ontario, Canada), Ciara O'Toole (University College Cork, Ireland), Rhea Paul (Sacred Heart University, USA), Suzanne Purdy (University of Auckland, New Zealand), Sean Redmond (University of Utah, USA), Laida Restrepo (Arizona State University, USA), Mabel Rice (University of Kansas, USA), Vicky Slonims (NHS, UK), Pamela Snow (La Trobe University, Australia), Jane Speake (NHS, UK), Sarah Spencer (University of Sheffield, UK), Helen Stringer (Newcastle University, UK), Helen Tager‐Flusberg (Boston University, USA), Rosemary Tannock (University of Toronto, Canada), Cate Taylor (University of Western Australia, Australia), Bruce Tomblin (University of Iowa, USA), Joanne Volden (University of Alberta, Canada), Marleen Westerveld (Griffith University, Australia), and Andrew Whitehouse (Telethon Kids Institute, University of Western Australia, Australia).
The authors have declared that they have no competing or potential conflicts of interest in relationship to this article.