Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood

Disclosure: Patricia A. Prelock, PhD, CCC-SLP, has disclosed no relevant financial relationships in addition to her employment.

Disclosure: Tiffany Hutchins, PhD, has disclosed no relevant financial relationships in addition to her employment.

Disclosure: Frances P. Glascoe, PhD, has disclosed no relevant financial relationships in addition to her employment.

Abstract and Introduction

Abstract

Speech-language problems are the most common disability of childhood yet they are the least well detected, particularly in primary care settings. The goal of this article is to: (1) define the nature of speech-language problems, their causes, and consequences; (2) facilitate early recognition by healthcare providers via accurate screening and surveillance measures suitable for busy clinics; and (3) describe the referral and intervention process.

Introduction

Speech-language deficits are the most common of childhood disabilities and affect about 1 in 12 children or 5% to 8% of preschool children.[1] The consequences of untreated speech-language problems are significant and lead to behavioral challenges, mental health problems, reading difficulties,[2] and academic failure including in-grade retention and high school dropout.[3] Yet, such problems are ones that are least well detected in primary care,[4] even though intervention is available and plentiful.

Speech-language impairments embrace a wide range of conditions that have, at their core, challenges in effective communication. As the term implies, they include speech disorders which refer to impairment in the articulation of speech sounds, fluency, and voice as well as language disorders which refer to impairments in the use of the spoken (or signed or written) system and may involve the form of language (grammar and phonology), the content of language (semantics), and the function of language (pragmatics).[5] These may also be described more generally as communication disorders which are typically classified by their impact on a child's receptive skills (ie, the ability to understand what is said or to decode, integrate, and organize what is heard) and expressive skills (ie, the ability to articulate sounds, use appropriate rate and rhythm during speech, exhibit appropriate vocal tone and resonance, and use sounds, words, and sentences in meaningful contexts). There are common conditions in infants, toddlers, and preschoolers that are associated with receptive and expressive communication challenges as presented in Table 1 .[6–17]

Table 1

Disorders in Young Children Commonly Associated With Receptive and Expressive Communication Problems

Condition & Cause	Receptive Communication Problems	Expressive Communication Problems
Psychosocial risk, abuse and neglect	Less talkative and fewer conversational skills than expected; seldom volunteer ideas or discuss feelings; utterances shorter than peers[6]
Autism spectrum disorder	Difficulty analyzing, integrating, and processing information; misinterpretation of social cues[6]	Variability in speech production from functionally nonverbal to echolalic speech to nearly typical speech; use of language in social situations is more challenging than producing language forms (eg, articulating speech sounds, using sentence structure)[7]; tendency to use verbal scripts; difficulty selecting the right words to represent intended meaning; often mechanical voice quality
Brain injury	Difficulty making connections, inferences and using information to solve problems; challenges in attention and memory which affect linguistic processing; challenges in understanding figurative language and multiple meaning words[6]	Greatest difficulty is commonly inpragmatics – using language appropriately across contexts, especially narratives and conversations[8]
Cerebral palsy	Speech sound discrimination, information processing and attention can be areas of challenge; language comprehension is affected by cognitive status	Dysarthric speech – slower rate, with shorter phrases or prolonged pauses; articulation is often imprecise with distorted vowel productions; voice quality can be breathy or harsh, hypernasal with a low or monotone pitch; apraxic speech – sound substitutions that can be inconsistent, groping for sound production and nonfluent volitional speech with more fluent automatic speech[6]; language production is affected by breath support as well as cognitive status
Fetal drug or alcohol exposure	Difficulty comprehending verbal information, especially understanding abstract concepts, multiple word meanings, and words indicating time and space[6]	Fewer vocalizations in infancy, poor use of gestures and delays in oral language[6]; poor word retrieval, shorter sentences, and less well-developed conversational skills[9]
Fluency disorders	Difficulty with the rate and rhythm of speech; false starts; repetitions of sounds, syllables and words; may or may not be accompanied by atypical physical behaviors (eg, grimacing, head bobbing)
Hearing impairment	Difficulty with sound perception and discrimination, voice recognition, and understanding of speech, especially under adverse hearing conditions[6]	Sound productions made until about 6 months; limited oral output depending on degree of hearing loss; for oral communicators, vocal resonance, speech sound accuracy, and syntactic structure often affected
Intellectual Disability	Comprehension of language is often below cognitive ability[10]; difficulty organizing and categorizing information heard for later retrieval; difficulty with abstract concepts; difficulty interpreting information presented auditorily[6]	Production is often below cognitive ability[10]; similar but slower developmental path than typical peers; tendency to use more immature language forms; tendency to produce shorter and less elaborated utterances[11]
Specific language impairment	Slower and less efficient information processing[12,13]; limited capacity for understanding language[14,15]	Shorter, less elaborated sentences than typical peers; difficulty in rule formulation for speech sound, word, and sentence productions[16]; ineffective use of language forms in social contexts sometimes leading to inappropriate utterances[17]; poorly developed vocabulary

It is important to distinguish speech and language impairment from language delay and language difference. Language delay is characterized by the emergence of language that is relatively late albeit typical in its pattern of development. In contrast to an impairment or a delay, a language difference is associated with systematic variation in vocabulary, grammar, or sound structures. Such variation is “used by a group of individuals [and] reflects and is determined by shared regional, social, or cultural and ethnic factors” and is not considered a disorder.[18]

Unfortunately, non-native speakers of English, speakers of various dialects (whose language also varies within dialect), and bilingual or multilingual speakers are frequently classified as language delayed or disordered when, in fact, they are language different[18,19]–although problems of underidentification also occur. This is particularly important in an increasingly pluralistic society such as ours in which 1 of 4 people identify as other than white non-Hispanic, approximately 17% of the population is bilingual (mostly speaking Spanish and English), and where minorities represent more than 50% of the population in several cities and counties.[20]

The overidentification of culturally and linguistically diverse populations commonly occurs when a mismatch is observed and incorrectly interpreted between a language used in a particular community and that of the majority culture. This may be seen most clearly in the improper use of formal tests of speech and language to assess the competencies of speakers who are dissimilar to the sample upon which the test was normed and developed.[21] Similar errors also occur during informal evaluations of language and literacy as when the sound structure of the language influences the spelling or grammatical conventions used in written discourse.[22] With regard to bilingualism, it is commonly assumed that children's acquisition of 1 or both languages is delayed; however, the effects of bilingualism are more complex and differ with the age of the child, the nature of the linguistic input, and the manner and timing of language acquisition. What is clear is that equivalent proficiency in each language should not be expected or assumed as this has the potential to lead to misidentification of a speech and language impairment. (For more information on the effects of bilingualism on language learning, see http://asha.org/public/speech/development/BilingualChildren.htm and http://asha.org/public/speech/development/second.htm) In the case of culturally and linguistically diverse individuals, decisions to intervene and bring language use in line with that of the majority culture or promote proficiency in the dominant language are not inappropriate; however, such decisions must be seen as separate from the language difference vs disorder question.

Lack of effective screening tools that discriminate children with and without speech and language impairment

Lack of accurate parent interview tools that identify clear concerns in speech and language development

All of the following statements about young children with speech and language impairment are true except:

Young children tend to produce words with sounds that are consistent with the words they already know

able to communicate

Answer: Children usually begin to put 2 words together at 30 months. Children usually begin to put 2 words together at 18 months.

Etiology, Neurobiology, and Prevalence of Speech-Language Impairments

The etiology of most cases of speech-language impairments is unknown but diverse causes are suspected. The range of causes or origins includes anatomical abnormalities, cognitive deficits, faulty learning, genetic differences, hearing impairments, neurologic impairments, or physiologic abnormalities.[6] As noted above, language differences as revealed in the communication output associated with diverse cultural, ethnic, regional or social dialects are not considered disorders.[5] Speech and language impairments may be acquired (ie, result from illness, injury or environmental factors) or congenital (ie, present at birth).

Children with speech and language impairment are an under-representation of the broader occurrence of communication disorders,[23] especially considering the co-occurrence of communication disorders with other disabilities (eg, learning disabilities). Approximately 8% to 12% of preschool populations exhibit language impairments.[6] Among children enrolled in early intervention programs, 46% have communication impairments while 26% have developmental delays in multiple areas, usually including language skills.[24] These findings indicate that the most common presentation of disability in preschoolers involves problems with language.

In a family with a child with a speech and language impairment, which of the following would be clinically appropriate?

Discourage the child's parents and sibling(s) from talking for the child as this may be a primary cause of a speech and language impairment

Answer: Advise the parent to have the child's hearing tested. This is appropriate because hearing would be the first condition to rule out as a potential cause of a speech and language delay.

Course and Prognosis

Speech-language impairment sometimes emerges during infancy with challenges in response to sound, atypical birth cries, or limited response to others and progresses through the toddler and preschool age with limited comprehension of spoken language and difficult interactions with peers and others as well as delays in producing first words and word combinations. Speech and language difficulties often persist in school age with difficulties following directions, attending and comprehending oral and written language, and problems producing narratives and using language appropriately in social contexts. Parents are often the first to notice difficulties as they encounter other children with more advanced speech-language skills and thus often wonder if their child is behind.[25] Although many parents raise concerns to primary care providers, many do not. In turn, primary care providers who do not use quality screening tools often dismiss parental concerns with panaceas such as, “He's a boy. Boys talk later.” Or, “Let's give this some time and see if it continues.” Yet, parental concerns about speech and language are associated with developmental disabilities[26] and, thus, careful screening with accurate tools is the requisite response.[27]

The use of a “wait and see” approach underscores the difficulty in distinguishing children who are language delayed from those who have a speech and language impairment. Although most children who have aspeech and language impairment have a history of language delay, only one quarter to one half of late-talkers are eventually diagnosed with a language disorder.[19] In advocating for a more aggressive response for late-talking children, some have argued for careful scrutiny of other risk factors that may guide decisions to refer and intervene.[19] Predictors of a true speech and language impairment that should be considered include poor receptive language skills,[28] limited expressive language skills (eg, small vocabulary, few verbs), and limited development in the sound structure of a language (eg, limited number of consonants, limited variety in babbling structure, vowel errors).[26] Additional predictors include nonspeech (eg, behavioral problems, few gestures, little imitation or symbolic play), environmental (eg, low socioeconomic status, parental use of a directive rather than sensitive and responsive interactional style), and hereditary factors (eg, family history).[26] As a general recommendation, professionals are urged to consider a larger number of risk factors with greater concern.[26]

Often speech-language impairments can be difficult to distinguish from what is considered typical variations in speech and language. For example, disfluencies in speech may be either normal or abnormal. In the nonstuttering child, the most common disfluencies include 1-unit word repetitions (eg, “I… I want that”), interjections (eg, “I saw a… um… picture”), and revisions (eg, “I don't know where… Mommy, help me find my doll”) and, when combined, comprise no more than 10% of words spoken.[29] In the stuttering child, the fluency disorder typically emerges between the ages of 2 and 5 years, is more common among males than females, and is characterized by more than 10% disfluencies in speech, multi-unit syllable (eg, “s-s-s-s-s-September”) and word (eg, “That's my-my-my ball”) repetitions, and may be accompanied by secondary behaviors such as eye-blinking, head-bobbing, or grimacing, as well as feelings of frustration or embarrassment surrounding the stuttering event.[29]

Identification of speech and language impairments is further complicated by the fact that they often masquerade as other diagnostic conditions. For example, children with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) may in fact have an underlying language disorder. Differential diagnosis is challenged by the diagnostic criteria shared between the 2 conditions. Specifically, the diagnostic criteria for ADHD share several characteristics with language disorders including difficulty listening when spoken to, following instructions, talking excessively, blurting out answers, interrupting, and waiting for turns in conversation.[30] Similarly, 50% of preschoolers presenting for psychiatric services were found in several studies to have undiagnosed language impairment.[31,32]

The diagnostic criteria for speech-language impairments are defined both by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)[33,34] and by the Individuals with Disabilities Education Act (IDEA) through the US Department of Education. Table 2 specifies the criteria for communication disorders as described in the DSM-IV. As an example of eligibility criteria for speech-language impairment in response to IDEA guidelines, Vermont indicates that children must demonstrate significant deficits greater than 2 standard deviations below the mean in listening comprehension (eg, measures of auditory (language) processing or comprehension of connected speech including semantics, syntax, phonology, recalling information, following directions and pragmatics) and/or oral expression (eg, measures of oral discourse-syntax, semantics, phonology and pragmatics; voice; fluency; articulation) to qualify as speech or language impaired.[35]

Table 2

Characteristics of Communication Disorders as Described in the DSM-IV[33,34]

Characteristics	Expressive Language Disorder	Mixed Receptive-Expressive Language Disorder
Standardized tests indicate skill area is substantially below what is expected considering chronological age (CA), IQ, and education	Expressive language development (eg, vocabulary, tense errors, word recall, sentence length, and complexity) is below nonverbal IQ and receptive language	Battery of measures of receptive and expressive languagedevelopment (eg, understanding words, sentences, or specific word types-spatial terms) is below nonverbal IQ
Difficulties interfere with academic or occupational achievement or with social communication	X	X
If mental retardation, environmental deprivation, sensory or speech motor deficit is present, difficulties are greater than what is expected	X	X
Criteria not met for mixed receptive-expressive language disorder	X
Criteria not met for pervasive developmental disorder	X	X

Distinguishing children with speech-language deficits from those with other disabilities is often a challenging task as several disabilities share characteristics and have similar diagnostic criteria. For example, an intellectual disability is one in which a child's performance falls at or below 1.5 standard deviations from the mean on a test of intellectual ability with concurrent deficits in adaptive behavior. Children with intellectual disabilities, however, often have significant challenges in receptive and expressive communication as is typical of children with speech and language impairments. Children with learning disabilities have deficits in 1 or more basic skill areas including oral expression and listening comprehension, challenges characteristic of children with speech-language impairments. Children with pervasive developmental disorders/autism exhibit marked impairments in communication and social interaction and restricted and repetitive stereotyped patterns of behavior. Although social impairment is a defining feature of autism, communication impairments are similar to those with a speech-language impairment.

Which of the following is not true of speech-language impairment?

Early intervention is critical as speech-language impairments place children at risk for later academic difficulties