Academic Failures in Children

with Communication Disorders

Dennis P. Cantwell, M.D. and Lorian Baker, Ph.D.

Abstract. Twenty-nine of 106 children with communication disorders were identified as aca-
demic failures. Compared to an age- and sex-matched control group, the failing group was
more likely to have a psychiatric disorder. They were more likely to be rated as having
behavioral abnormalities in the classroom but not necessarily at home. The failing group was
more likely to have a language as opposed to a speech problem, and to differ on a number
of other speech and language factors. Implications of the findings are discussed.
Journal of the American Academy of Child Psychiatry, 19:579-591, 1980.

Language makes us uniquely human; a delay in the development

of language might have far-reaching consequences on other areas
of early childhood development. Systematic research has suggested
that language is uniquely and intrinsically related to the develop-
ment of the child's thought, play activities, social-emotional devel-
opment, and learning (Rutter and Martin, 1972). Thus, on purely
theoretical grounds there are reasons to suspect that children with
communication disorders are at risk for the development of other
kinds of problems in development, including learning problems
and behavior problems.
Our previous review of the literature concerning the prevalence
of behavior problems in children with communication disorders
(Cantwell and Baker, 1977) showed that such children have higher
prevalence rates of psychiatric disorders than children in the gen-
eral population. However, our review indicated that firm conclu-
sions were not possible due to many methodological difficulties in
the studies.

Dr. C~ntwell is Joseph Campbell Professor and Dr. Baker is Staff Research Associate, Department of
Child Psyt;hiatry, UCLA Neuropsychiatric Institute (Westwood Plaza, Los Angeles, CA 90024), where
reprints may be requested.
This work was supported by NIMH Grant MH279I9 and NIMH Grant MH08467-I7.
0002-7138/80/1904-0579 $OI.l6 © 1980 American Academy of Child Psychiatry.

579
580 Dennis P. Cantwell and Lorian Baker

Our review also suggested that later school failure, and particu-
larly reading disorder, may be the strongest of all the psychological
effects of early speech and language delay (Rutter, 1972). Thus it is
likely that children with communication disorders are at risk for
both learning disorders and psychiatric disorders and these may be
uniquely related to each other. At the time we began our investiga-
tion, there was no study which consisted of a large number of chil-
dren who presented with a wide variety of speech and language
disorders, representing the general population of communication-
impaired children, who had not been referred to a psychiatric facil-
ity. Moreover, there was no study of a large group of such children
who were systematically evaluated from the standpoint of both
prevalence and types of communication disturbance, and preva-
lence and types of psychiatric and learning disorders. Our study
was designed to eliminate methodological problems found in the
studies we reviewed.
This paper reports a comparison of children having academic
failures and normally achieving children among children with com-
munication disorders.

METHODS

The methodology of this study has been described in detail else-

where (Cantwell et aI., 1979). Briefly, we selected for study chil-
dren presenting to a community speech and hearing clinic in the
San Fernando Valley area of Los Angeles County. The clinic draws
from a population area of over one million with a wide socioeco-
nomic distribution. Each consecutive case presented for speech and
language evaluation was offered the opportunity to take part in the
project which was presented as a free additional evaluation. Re-
fusal rate was less than 3%. We accepted all children above the age
of 2, and excluded only those who had been referred solely for
audiological evaluation. In addition to the regular evaluation which
was done by the clinic staff, each child received an extensive speech
and language evaluation which included a clinical evaluation, the
Goldman-Fristoe test of articulation, the Carrow test of auditory
comprehension of language, the Illinois Test of Psycholinguistic
Abilities, the Peabody Picture Vocabulary Test, and an analysis of a
free speech sample.
Intellectual ability and academic attainment were evaluated with
the WISe or the WPPSI scale of intelligence, the Wide Range
Achievement Test, and the Gray Oral Reading Test.
Children with Communication Disorders 581

A detailed psychiatric evaluation was also done for each child.

This evaluation consisted of a semistructured psychiatric interview
with the parents about the child, a semistructured interview with
the child, and the use of parent-teacher behavior rating scales. The
parent and teacher rating scales developed by Conners (1973) and
those developed by Rutter et al. (1970) were modified slightly.
The psychiatric diagnosis was based on the interview with the par-
ent, the interview with the child, and the parent and teacher rating
scales.
The child was considered to have a psychiatric disorder if he
demonstrated a disorder of behavior, emotions, cognition, or rela-
tionships which was sufficiently prolonged and/or sufficiently se-
vere to cause distress, disadvantage, or disability to the child and/or
disturbance in his or her environment. If a psychiatric disorder was
thought to be present, an attempt was made to make a specific di-
agnosis based on the criteria described in the January 15, 1978
draft of The Diagnostical Manualfor Mental Disorders (DSM-III).
In the teacher questionnaire the teacher indicated what prob-
lems the child had at the time if any; how long the teacher had
known the child; results of any recent standardized intelligence
and academic achievement tests; how well he was achieving in
various school subjects; whether he had special placement, aca-
demic help, referral to a psychologist or a psychiatrist; and the
teacher's overall rating of the child's problem. In addition, the
teacher was asked to rate the severity of the child's problems in
four specific areas: behavior, academic achievement, group partic-
ipation, and attitude toward authority.
In order to pick a subsample of children considered to have
significant academic problems, we chose all children of at least
grade-school age in the first 300 children who were rated by their
teachers as failing at least one academic subject in school: reading,
spelling, or math.

RESULTS

Subjects
Of the first 300 children seen, 106 were in grade school or junior
high school at the time of the evaluation. Their ages ranged from 6
to 15.9 years, with a mean age of 8.6 years (S.D., 2.3 years); 68% of
the school-aged sample was male; 29 of the 106 school-aged chil-
dren were failing at least one academic subject.
582 Dennis P. Cantwell and Lorian Baker

When those 29 children were compared with the 77 children

who were doing well academically in all subjects, it was found that
52% of the failing group was male compared to 74% of the
nonfailing children. This difference in sex ratio was significant
(p < .02).
In order to make a detailed comparison of the failing children
and the achieving children, an age- and sex-matched sample of 29
children with no school failure was identified. The 15 males in the
school-failure group were 7 to 12 years of age; the 14 females were
6 to 13 years of age. The 29 children with school failure were then
compared to the 29 age- and sex-matched children with no school
failure on a variety of factors. The characteristics of these samples
are presented in table 1.
Psychiatric Diagnoses
Axis I: Clinical Psychiatric Syndromes. Eighty-three percent of the
school-failure group received a psychiatric diagnosis, compared to
only 30% of the comparison group, a highly significant difference.
Table 2 reports the psychiatric diagnoses in the two groups of chil-
dren. While 8 of the 24 (33%) children with a psychiatric illness
had a diagnosis of attention-deficit disorder with hyperactivity,
there was a broad range of psychiatric disorders present in the
school failure group.
Axis II: Developmental. Disorders. Only nonlanguage developmental
disorders were recorded on Axis II. These included enuresis,

Table 1
Characteristics of the Samples Studied

School·Failure Comparison
Group Group
Age
Range 6.0-12.9 yrs 6.0-12.9 yrs
Mean &: S.D. 8.6 yrs (2.0) 8.6 yrs (2.0)

Sex 52% males 52% males

Performance IQ
Range 62-156 76-156
Mean &: S.D. 109.8 (26.5) 118.9 (24.6)

Verbal IQ"
Range 55-146 57-143
Mean &: S.D. 97.3 (22.2) 107.6 (18.3)

"p < .05 by t·test.

Children with Communication Disorders 583

encopresis, coordination disorder, and mental retardation. There

were no significant differences between the school-failure group
and the comparison group in the prevalence of any of these Axis II
diagnoses. It should be noted that the mean performance IQ of the
two groups was not different, but the mean verbal IQ for the
school-failure groups was 97.3 (S.D. 22.2), significantly less than
the mean of 107.6 for the comparison group (S.D. 18.3, P < 0.05).
Biological Factors
Medical and neurological disorders that were felt to play a role in
the genesis of the patients' speech and language disorder and/or
psychiatric disorders were systematically recorded. There were no
significant differences between the groups in the presence of at
least one medical or neurological disorder. In fact, more of the
comparison group (63%) had some significant medical or neuro-
logical disorder than the school-failure group (41 %). Ear infections
and hearing problems were the most common in both groups, and
in general the pattern of problems was essentially the same in the
two groups. The two groups did not differ on the number of
abnormalities on the developmental neurological examination as
well.
Psychosocial Factors
The following psychosocial factors were systematically compared in
the two groups: presence and type of psychiatric illness in the par-

Table 2
Clinical Psychiatric Syndromes

Psychiatric Disorder School-Failure Comparison

Group (N = 29) Group (N = 29)
N% N %
No mcntal illncss 5 (17) 19 (70)
Undiagnosed mental illness 3 o
Major affective disorder 3 3
Scparation anxiety disordcr I o
Adjustmcnt disordcr 3 2
Conduct disorder 2 o
Ovcranxious disorder 2 o
Avoidant disorder 2 1
Schizoid disorder I o
Oppositional disordcr 1 2
Attention-deficit disorder with hyperactivity 8 3
Organic personality syndrome o I
584 Dennis P. Cantwell and Lorian Baker

ents, maternal and paternal education, family size, ethnic group,

and whether or not the child came from a broken home. None of
these differences distinguished the school-failure group from the
comparison group. Although twice as many (34%) of the school-
failure group came from broken homes, the difference did not
reach statistical significance.
Likewise, the type and severity of psychosocial stressors were also
compared in the two groups. The type of psychosocial stressor was
rated by means of the scale developed by Ilfeld for a draft of DSM-
III. The severity of psychosocial stressors was rated on a 7-point
scale: 90% of the school-failure group had at least one psychosocial
stressor compared to 70% of the comparison group. This differ-
ence just missed statistical significance. The mean severity rating
of psychosocial stressors did not distinguish the two groups, and in
general the types of psychosocial stressors followed the same pat-
tern in both the school-failure and the comparison groups.
Adaptive Functioning
The highest level of adaptive functioning reached by the child for
at least one month during the previous year was recorded on a
7-point scale according to the criteria developed for DSM-III. Ta-
ble 3 presents these data. Significantly more of the comparison
group were rated as superior or good in functioning, and
significantly more of the school-failure group were rated as fair to
grossly impaired in functioning. This difference was highly
significant (p = 0.0001).
Speech and Language Factors
The total sample of children with communication disorders was di-
vided into three major subgroups with three different types of
communication problems: (1) children with pure speech disorders
(disorders of articulation, fluency, or voice only); (2) children with

Table 3

Highest Level of Adaptive I'unctioning

Adaptive Functioning· School-Failure Group Comparison Group

N % N %
Superior-good 3 (10) 17 (65)
I'air 16 (55) 5 (19)
Poor-grossly impaired 10 (35) 4 (16)

Up =0.0001 by Chi-square test.

Children with Communication Disorders 585

speech and language disorders (disorders of articulation, fluency,

or voice, and of language comprehension, expression, or auditory
processing); and (3) children with pure language disorders (disor-
ders of language comprehension, expression, or auditory pro-
cessing).
Table 4 shows the speech and language diagnoses for the school-
failing and school-achieving groups. It can be seen that significantly
more of the school-failing group had a disorder of language or
speech and language compared to the school-achieving group,
over half of whom had a disorder of speech only. Table 4 also re-
ports specific comparisons of speech and language factors, includ-
ing: presence of an articulation problem, language comprehension,
language expression, language processing, severity of articula-
tion disorder, and severity of language-processing disorder. All
of these significantly differentiate the two groups of children.
Behavioral Ratings
Table 5 reports the results of the teacher's questionnaire. It can be
seen that many individual items significantly differentiated the
groups: a total of 19 out of 50 items. In addition, the school-failure

Table 4

Speech and Language I-actors

School-Failure Group Comparison Group

Speech and Language Diagnoses' N % N '/'o
Speech only 5 (20) 15 (56)
Speech and language 12 (48) 10 (37)
Language only 8 (32) 2 (7)
"p < .01 Chi-square test.

Other Speech and Language I-actors

Normal articulation" 12 (41) 4 (14)
Normal language comprehension" 14 (48) 22 (76)
Normal language expression" 12 (41) 20 (69)
Normal language processing" 8 (30) 18 (62)
Severity
moderate to severe articulation" 17 (59) 25 (86)
language-processing moderate to severe" 21 (72) 1I (38)

Fisher's Exact test

"p < .03.
"p < .02.
• P < .01.
586 Dennis P. Cantwell and Lorian Baker

group was rated as having significantly more of an overall prob-

lem, an academic problem, a behavioral problem, a problem in
group participation, and a problem with attitude toward authority.
All four factors of the Conners teachers' questionnaire--conduct,
inattentive-passive, tension, and hyperactivity-were significantly
higher in the school-failure group. The factor scores for the
school-failure group and for the comparison group are presented
in table 6.
The parent rating scale contained 68 items of behavior rated on
a 4-point scale (0 to 3). Only three items distinguished the school-
failure and the comparison groups: not liked by peers or play·

Table 5
Teachers' Questionnaire Items Significantly
Distinguishing School-Failure Group

School-Failure Comparison
Item Group Group
% with Symptom
very restless' 69 15
disturbs other childrenb 69 36
tearful arrival or school refusal" 14 o
daydreams b 72 21
nervous tics or mannerisms· 35 14
often disobedient b 62 22
short attention span d 93 26
constantly fidgeting' 72 36
hums & odd noises· 52 29
easily frustrated b 72 29
poor coordination" 69 43
quick, drastic mood changes b 55 I4
excitable or impulsive b 62 29
not liked by other children b 46 8
lacks leadershipd 72 36
doesn't get along with same sex" 34 29
unhappyb 48 7
fearful" 34 7
unresponsive, apathetic b 55 7
submissive b 50 29
excessive demands for attention b 62 43
shy' 66 26
overall problem d 89 43
overall academic problem d 97 29
overall behavior problem" 68 36
overall group participation problem' 74 28

Fisher's Exact test

•p < .05. 'p < .001.
b P < .01. d P < .00001.
Children with Communication Disorders 587

Table 6
Total Factor Scores from Tcachers' and Parcnt Questionnaires
School-Failure Group Comparison Group
N = 29 N = 77
Teachers' Qucstionnaire Factors Mean S.D. Mean S.D.
Conduct" 4.7 5.9 1.6 3.7
Inattention" 7.0 3.4 2.9 3.8
Anxiety" 4.2 3.2 1.6 2.3
H yperacti ve b 7.3 5.4 2.7 3.9
Parent Questionnaire Factors
Conduct 2.6 2.5 1.9 2.2
Anxiety 2.9 2.2 2.8 2.3
Tension" 1.2 1.2 0.5 0.7
Learning" 2.5 2.0 0.9 1.5
Psychosomatic 1.9 1.9 1.4 1.2
Perfectionism 0.8 1.1 0.6 0.9
Antisocial 0.1 0.4 0.1 0.2
H yperactive" 4.3 3.7 2.6 2.6
t-test
"p < .05.
"p < .01.

mates, not learning, and will not obey school rules, all of which
were significantly more frequent in the learning-disabled groups.
Conners has factor analyzed the parent questionnaire and found
eight stable factors: conduct, anxiety, tension, learning, psychoso-
matic, perfectionism, antisocial, and hyperactive. The tension,
learning, and hyperactive factors were significantly higher in the
school-failure group.

DISCUSSION

Of 300 consecutive children presenting to a community speech and

hearing clinic, 106 were of grade-school age or above. In this
group 29 (about 25%) were failing at least one subject in school.
When they were comparee! to t.he other 77 children who were not
failing any subjects in school, the first striking finding is that
there were relatively more girls in the school-failure group. Over
70% of the entire 106 children were males, but only 52% of those
with a school failure were males.
Twenty-nine children who were not failing any subjects in school
were randomly selected from the total of 77 children and were
matched for age and sex to the school-failure children. The most
striking finding in this comparison was that the school-failure
588 Dennis P. Cantwell and Lorian Baker

group was characterized by a marked increase in psychiatric disor-

der: 83% of the group had a diagnosable psychiatric disorder com-
pared to 30% of the comparison group. It should be noted that
about 50% of the total sample of children presenting to the com-
munity speech and hearing clinic had a diagnosable psychiatric dis-
order (Cantwell et aI., 1979). The pattern of psychiatric disorder
was essentially similar in the school-failure group and in the com-
parison group. Attention-deficit disorder with hyperactivity was by
far the most common psychiatric disorder in the school-failure
group.
In addition to having a definable psychiatric disorder, the
school-failure group was rated as having considerably more
behavioral problems in the classroom by their teachers. The
behavioral ratings and the psychiatric diagnoses were not, however,
independent measures, insofar as the rating scales were used in
determining the psychiatric diagnoses. Nonetheless, the scales are
important in that they pinpoint the nature of the difficulties that
the children had. The items that distinguished the school-failure
group included both mood and emotional items and behavioral
items. The school-failure group was not rated as significantly more
behaviorally disturbed in the home according to the parental rat-
ings. The items which distinguished the school-failure group,
according to the parental ratings, were items related to school per-
formance and behavior.
In the school-failure group, 2 children were rated by parents as
having behavior problems in school only, 1 in the home only, and 6
in both home and school. In the comparison group, the compar-
able figures were: 0, 0, and 6.
In both groups, 6 children were rated by mothers as having
behavior problems in the home and school, while 11 of the school-
failure children and 4 of the comparison-group children were
rated as having learning problems in school. This latter difference
was statistically significant (p = 0.04, Fisher's Exact test).
Another striking difference was the nature of the speech and
language problem that the school-failure group had compared to
the other children. Significantly more of the school-failure group
had problems with language as opposed to problems with speech.
They also differed on a number of other speech and language fac-
tors, in addition to their major speech and language diagnosis.
It is not surprising that a quarter of children presenting to a
community speech and hearing clinic have significant academic
difficulties. Probably the strongest of all the psychological sequelae
Children with Communication Disorders 589

of speech and language difficulty is educational retardation, par-

ticularly reading retardation (Rutter, 1972).
A number of follow-up studies (Canning and Davies-Eysenck,
1966; Griffiths, 1969; Ingram et aI., 1970) have suggested that
children who are slow in talking also tend to have reading prob-
lems in later life. Likewise, numerous studies of children with read-
ing difficulties and other types of learning problems have shown
that early in life they have a history of language delay. Many older
youngsters with significant difficulties in reading continue to
show problems with language and abstract thinking even in later
life (Blank et aI., 1968; Lytton, 1971; Rutter et aI., 1970). While
children with language difficulties are probably more likely to
have later learning difficulties, a study by Crookes and Green
(1963) shows that children with pure speech problems also have
later difficulties in learning to read. Rutter has suggested that in
the latter case, these children's reading difficulties probably are re-
lated to problems in perception rather than to language problems,
although systematic studies are lacking.
Our finding that 25% of children from a speech clinic have
school failure should be considered to be a minimum figure since
most of our children were only in the first or second grade at the
time we evaluated them. It is likely as they develop further in
school and are required to perform more complex tasks, their aca-
demic problems may become more evident and/or more severe.
It is also not surprising that the learning-disabled group in our
sample was more likely to be psychiatrically disturbed and to have
behavioral abnormalities particularly in the classroom. A number
of epidemiologic studies indicate that children with academic
difficulties of all kinds, particularly reading disability, also are
likely to have significant psychiatric disorder (Rutter, 1974). For
example, in their epidemiological study on the Isle of Wight Rutter
et al. (1970) found that one third of the children who had specific
reading retardation also had psychiatric problems of a conduct-
disorder nature. Likewise, one third of the children with conduct
disorders also had specific reading retardation. When children
with both specific reading retardation and conduct disorder were
compared to those with pure reading retardation and pure con-
duct disorder, it was found that those with both reading retarda-
tion and conduct disorder had much in common with the pure
reading-disorder group. That is, both of them were characterized
by early histories of speech and language difficulties and such
behavioral symptoms as inattentiveness and hyperactivity. Based on
590 Dennis P. Cantwell and Lorian Baker

their data, Rutter et aI. (1970) hypothesized that one of the mecha-
nisms of development of conduct disorder in these children might
be through educational failure. Alternatively they postulated that
some "X factor" might be responsible for both the conduct disor-
der and reading disabilities. It is noteworthy that the majority of
children in our school-failure sample had disorders which would
be labeled conduct disorders by Rutter and his colleagues.
Our previous data (Cantwell et aI., 1977, 1980) suggest that chil-
dren with speech and language disorder are indeed at risk for the
development of psychiatric disorder. They also suggest that the
factors most strongly associated with development of psychiatric
disorder are the nature and severity of the speech and language
factors.
The data presented in this paper suggest that those children in
our speech and language population who have an academic prob-
lem are most at risk for the development of psychiatric disorder.
Follow-up studies should help determine if it is those children with
an academic problem who also not only are more likely to develop
a psychiatric disorder, but persist with the psychiatric disturbance
over time. We believe that our findings have implications not only
for child psychiatrists but also for speech and language therapists
and primary care practitioners. It is the primary care practitioner
who is most likely first to recognize and refer the child with early
speech and language delay. It is speech and language pathologists
who are most likely to intervene early in the speech and language
area. However, the evaluation often done in speech and language
clinics does not encompass learning problems and/or behavioral
problems. Speech and language pathologists need to be alert to the
possibility of either a learning problem and/or a psychiatric prob-
lem in their population.
We also believe our findings may have therapeutic implications.
We believe as others do that one of the mechanisms for the de-
velopment of psychiatric disorders in children with speech and
language disorders is through the development of educational re-
tardation and its accompanying problems. It is possible that early
intervention in the speech and language area may forestall the de-
velopment of both learning problems and the speech and language
problems. Controlled studies over time will help to pinpoint those
children who need educational and psychiatric as well as speech
and language intervention, and those in whom speech and lan-
guage intervention by itself suffices to alter the academic and
behavioral outcome of these children.
Children with Communication Disorders 591

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