"When I can't find words it feels like I have scrambled eggs in my brain. My brain just tells my mouth the wrong thing to say."

—Eric, third grade

Eric's metaphoric expression of what it feels like to access words is compelling. His voice tells us that although he is very aware of the mismatch between the words he verbalizes and the thoughts he wants to express, he is unable to prevent his word-finding (WF) errors. Eric is not alone in his frustration with his expressive language difficulties. The prevalence of child word-finding difficulty is high among learners with specific language impairment (25%; Dockrell, Messer, George, & Wilson, 1998) and learning disabilities (49%; German, 1998). Clinical reports also document WF difficulties among learners with reading (Faust, Dimitrovsky, & Shacht, 2003) and written (Scott, 2002) language difficulties. Earlier research literature (Johnson & Myklebust, 1967; Wiig & Semel, 1976) suggests that previous generations of students also struggled with word finding.

Professionals agree that difficulties in WF can result in significant expressive language problems that can profoundly affect one's life. As Eric's poignant words indicate, WF difficulties in young people can impede learning and interfere with interpersonal communication.

Word finding refers to the ability to retrieve a desired word in single-word or discourse contexts. Learners with these WF difficulties have problems either storing or accessing lexical representations (Messer & Dockrell, 2006). There are different types of WF difficulties for learners who find it challenging to access or retrieve known words (i.e., lexical-access difficulties) as well as corresponding assessments, interventions, and accommodations for each of those difficulties.

Definition of WF Difficulties

"I know it, I know it, it's a, it's a ..." (ornament)

—Brian, second grade

One might assume that Brian and other learners who cannot answer questions do not know the answer. Yet WF errors are defined as a failure or significant delay manifested by a learner who attempts to say a known word, one that he or she comprehends and may have spoken previously. Although Brian's overt word search might first suggest that the word "ornament" was not stored in his lexicon, his metacognitive comments and his later verbalization of "ornament" challenge this assumption. Brian demonstrates that even though a learner possesses a word's conceptual structure and has stored its semantic, syntactic, and phonological features, he or she may still be unable to access that word for spontaneous usage.

Learner Characteristics

"You find the range by putting the first, you subtract the first, from the last... No, you..."

—Daniel, fifth grade

Difficulties in WF or lexical access have been reported to affect oral expressive language in three contexts:

• single-word or discrete-naming contexts (German, 2000), demonstrated by Brian's struggle to retrieve the word "ornament"
• discourse contexts (German, 1991), observed in Daniel's efforts to retrieve the word "number"
• serial naming tasks (Wiig, Zureich, & Chan, 2000).

In single-word or discrete-naming contexts, learners demonstrate one or more of the following characteristics: inaccurate word selection, no responses, unique substitutions, and/or extended delays when attempting to say a word. An inability to retrieve words in discourse contexts results in reformulations, repetitions, substitutions, insertions, time fillers, and/or empty words in a learner's sentences. WF difficulties on serial naming tasks are characterized by slower naming times.

Theoretical Underpinnings

Retrieval of a word when naming a picture, for example, is thought to involve four stages of lexical access (Levelt, 1989, 1999, 2001): 1) a word's conceptual structure is elicited; 2) activation spreads to access the word's semantic and syntactic features (the word's lemma); 3) elicitation of corresponding phonological features occurs (the word's lexeme); 4) execution of a motor plan is created for word production.

Difficulties in lexical access, possibly due to blocking or competition from other words (Blanken, Dittman, & Wallesch, 2002; Gaskell & Dumay, 2003), can result in either slow speed (Wiig et al., 2000), poor selection, or both. Lexical selection difficulties are thought to involve disruptions at two potential access stages in the speech production trajectory described in the previous paragraph. These disruptions result in either inaccessible semantic features, making the phonological features also unavailable (Messer et al., 2004), or accessible semantic features with subsequent blockage of retrieval of phonological features.

Error Patterns

Learners with WF difficulties may show any one or a combination of the following three semantic or form-based error patterns in oral language (McGregor & Appel, 2002).

Pattern 1 ("Slip of the Tongue" error): "Red, no yellow, blue, it's blue!"

—Sadia, kindergarten

Sadia could be demonstrating a lemma-related semantic error, which may be a failure in accessing the word's semantic or syntactic features (commonly known as a "slip of the tongue" error).

Pattern 2 ("Tip of the Tongue" error): "It is just caught in my throat."

—Evan, second grade

Evan could be struggling with a form-related blocked error, which may be a disruption at the juncture between a word's semantic and phonological properties, resulting in a failure to access any of the word's form information (e.g., no response or "I don't know," commonly known as a "tip of the tongue" error).

Pattern 3 ("Twist of the Tongue" error): "It's like I got marbles in my mouth, I just can't always say those long words."

—Lisa, fifth grade

Lisa may be describing a word-form segment-related phonologic error, which may be a disruption resulting in an incomplete access to the word's form, syllabic frame, or segmental sound content. This error is associated with the word's lemma (e.g., "subrine" for "submarine," commonly known as a "twist of the tongue" error).

Assessment and Differential Diagnosis

To maximize the efficacy of intervention, WF assessment in discrete naming contexts needs to go beyond accuracy scores on picture-naming tasks. To identify the three potential WF error patterns above, in-depth WF assessment is required in both single-word naming and discourse contexts. Deep assessment should focus on naming words that the examiner is reasonably sure the learner knows (stored in her or his semantic and phonological lexicons) and on words selected because of their potential to draw out the semantic or form-based WF disruptions in learners with weak lexical access systems.

To differentiate among the three WF error patterns, the diagnostic information gathered by the clinician needs to include the learner's speed and accuracy profile; responsiveness to phonemic cueing; nature of erred responses (semantic errors, phonemic errors, or no response); ability to imitate erred multisyllabic words; and the presence of gestures or extra verbalizations when engaged in WF blocks. (See the Test of Word Finding, Second Edition [German, 2000] for a detailed description of how to address these areas.)

Intervention

It is not unusual to review a learner's school folder and find he or she has a diagnosis of WF difficulties but no 504 plan or Individualized Education Program to treat her or his WF challenges. If left untreated, however, WF problems can continue throughout the school years, impeding learning and fluent expression in both oral and written language. Intervention for WF difficulties offers an opportunity to support learners' overall learning as well as their ability to express themselves effectively through speaking and writing.

Intervention for WF should be directed in three areas: retrieval strategy instruction, WF accommodations, and self-advocacy (German, 2005). These interventions can be implemented in both curriculum-relevant and response-to-intervention (RTI) environments (see VanSlyke, 2008, and Wallach, 2007, for a detailed discussion of service delivery models).

Retrieval Strategy Instruction

Automatic retrieval of vocabulary is expected in school, yet typical classroom instruction focuses only on teaching word meanings with little attention to enhancing lexical access, which leaves learners with WF difficulties at a disadvantage. Most learners are able to bridge conceptual knowledge and corresponding lexical access, but learners with WF difficulties are not able to do so. Without intervention, these learners face difficulties in gaining automatic fluency in using learned words.

This phase of intervention thus focuses on developing WF-sensitive vocabulary instruction for learners with WF difficulties. Encouraged by the improvement reported for learners in previous WF intervention studies (Best, 2005; German, 2002; McGregor, 1994), a dual-focused approach to vocabulary instruction is recommended for students with WF difficulties. This approach provides instruction in word meanings as well as retrieval strategies to enhance lexical access (German, 2007). The dual-focused approach is based on the concept that all words in memory have both a storage strength (i.e., the extent and depth of knowledge available for that word) and a retrieval strength (i.e., the ease with which an item can be accessed from one's lexical memory system); thus, meanings and retrieval strategies need to be taught to establish word knowledge and automatic usage (Bjork, R., & Bjork, L., 1992; Nippold, 1992).

Interventions for teaching word knowledge typically stress methodologies for semantic mapping and identifying semantic features, synonyms, and multiple-meaning words. Word selection for these lessons is usually based on semantic and contextual features, with an emphasis on words that are frequently encountered across the curriculum (Montgomery, 2008; Wallach, 2007) or that emerge from thematic-based written language instruction (Nelson & Van Meter, 2004).

In contrast, retrieval strategy instruction reinforces learners' metalinguistic knowledge of known words while teaching mnemonic strategies for recalling word parts. In this approach, word forms are first segmented by syllables and phonological features are then used to create mnemonic cues (similar-sounding familiar words) to aid word retrieval (German, 2002; Mastropieri, Sweda, & Scruggs, 2000). Word selection for retrieval strategy instruction is based on those target words predicted to be challenging for a particular learner to retrieve. Rather than focusing on word meanings, the phonological properties of words are emphasized (e.g., frequency of usage, length, phonological neighborhood, and phonological probability) because these lexical factors have been reported to influence the lexical access skills of learners with WF difficulties (German & Newman, 2004). For example, Lisa's self-reflection would suggest that she may have difficulty retrieving the long, low-frequency words in her math curriculum such as "circumference" or "hypotenuse."

In linking assessment to intervention, retrieval strategies can be matched to learners' WF error patterns. For example, phonological mnemonics can be used to anchor rarer, lower-frequency words in the curriculum to reduce the occurrence of form-related blocked errors ("tip of the tongue" errors). Specifically, one might link "circus" to "cirrus" or "strap" to "stratus" to enhance retrieval of cloud names in science.

Similarly, to support retrieval of difficult-to-access multisyllabic words with a low frequency, few phonological neighbors, and/or low phonological probability, the clinician would teach segmenting strategies, such as syllable dividing, by pairing evasive syllables with same-sound mnemonic cues to anchor the word's phonological schema (German, 2002). For example, in the photo (below), SLP Jan Schwanke links "X is gone" to "hexagon" to support retrieval of this shape name in math class. These mnemonic strategies have been shown to reduce the occurrence of word-form segment-related phonologic errors ("twist of the tongue" errors) on multisyllabic words (German, 2002). Rehearsal strategies would include embedding treated words in sentences and discourse contexts as a way to anchor word forms and to stabilize pathways for word usage in meaningful contexts.

Figure 1 [PDF] presents a worksheet to guide clinicians in implementing a dual-focus vocabulary lesson. In the lesson shown, retrieval strategy instruction for science words moves from teaching word meanings and associations of the target words—"ventricle," "blood," and "circulation"—to applying retrieval strategies, which include segmenting, developing phonological mnemonic cues, and rehearsing to aid automatic usage of the learned words (see German, 2005, for specific instructional steps).

Technology can make dual-focus vocabulary instruction more appealing to learners. To provide learners with an on-demand retrieval strategy, icons on a learner's computer desktop can be hyperlinked to various Internet sites (like http://www.dictionary.com/)that define, pronounce, and segment words. Additional computer desktop icons can be hyperlinked to Web sites (like www.rhymezone.com) that provide similar-sounding words (such as homophones and words beginning with the same sound as the target word) to help learners link mnemonic cues to words or word parts. Learners are taught to embed retrieval strategy instruction into the curriculum on an as-needed basis. As learners encounter evasive words or learn new vocabulary they anticipate will be difficult to retrieve, they can apply segmenting, WF mnemonics, and rehearsal strategies to anchor these words.

Classroom Accommodations

"I was doing so bad that I had to excuse myself and go throw up before I could finish. Even after hours of studying, I could not come up with the answers on the test."

—Michael, ninth grade

To help learners with WF difficulties gain equal access to the general education curriculum, WF accommodations are focused on reducing the retrieval load—not the workload—in academic work.

Classroom implementation of WF accommodations, which are rooted in universal design, may require a paradigm shift, as typical accommodations (such as reduced workload, test readers, or extended time) are not linguistic in nature and do not support the language needs of learners, like Michael, with WF difficulties. These learners need specific linguistic accommodations to succeed. Implementing WF accommodations early in a learner's schooling can prevent a downward spiral of failure that otherwise may occur.

"I hate Mr. Phillip's class. When he starts questioning, I hide my book and say, I hope, I hope he doesn't call on me. Then when someone else answers, I think, I knew that."

—José, ninth grade

WF accommodations, designed to match task formats to learners' WF abilities, are examples of differentiated instruction (Schwarz & Kluth, 2007) for learners with expressive language difficulties. Differentiated instruction would help José in Mr. Phillip's class by reducing the retrieval load inherent in classroom discourse. The use of recognition task formats such as multiple choices, cueing, or question priming, and the provision of specific materials that offer cues or aid retrieval (such as procedural cue cards, electronic resource files, or discourse scaffolding) would be very beneficial.

Differentiated assessment for learners with WF difficulties reduces the retrieval load inherent in the test-response format by providing learners like Michael with open-book or take-home exams, multiple-choice frames, and/or "select," "circle," or "highlight the answer" response formats.

Reading Accommodations

Latisha, a sixth grader, read, "usually...no, it's useful...no, it's useless!" Upon reflection, she said: "I really knew the word was 'useless' from the beginning. I looked at it and knew what it was, but my mouth read the other two words first."

WF accommodations are also needed in reading because oral reading errors produced by children with WF difficulties like Latisha result from lexical access or WF disruptions rather than poor decoding skills (German & Newman, 2007). Replacing an oral reading assessment with a silent reading assessment would prevent underestimating the reading skills of learners with WF difficulties because of their inability to retrieve written words during an oral reading task.

How do we begin to help students with WF difficulties like Eric, Latisha and others? What are their voices telling us and what are they asking us to do? The answers to these questions are multifold, but no one is in a better position to respond than the speech-language pathologist. The SLP understands the nature of WF difficulties and their impact on student learning. It is recommended that SLPs carry out differential diagnosis in word finding as well as lead tier 2 interventions in response-to-intervention that incorporate both retrieval strategy instruction and WF accommodations for learners with WF difficulties.