The Clinical Spectrum of Developmental Language Impairment in School-Aged

Children: Language, Cognitive, and Motor Findings

Richard I. Webster, Caroline Erdos, Karen Evans, Annette Majnemer, Eva Kehayia,
Elin Thordardottir, Alan Evans and Michael I. Shevell
Pediatrics 2006;118;e1541
DOI: 10.1542/peds.2005-2761

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ARTICLE

The Clinical Spectrum of Developmental Language

Impairment in School-Aged Children: Language,
Cognitive, and Motor Findings
Richard I. Webster, MBBS, MSc, FRACPa,b, Caroline Erdos, MScc, Karen Evans, MScc, Annette Majnemer, PhD, OTa,d,e, Eva Kehayia, PhDe,
Elin Thordardottir, PhDc, Alan Evans, PhDf, Michael I. Shevell, MD, CM, FRCPCa,d

aDepartment of Neurology/Neurosurgery, cSchool of Communications Sciences and Disorders, dDepartment of Pediatrics, eSchool of Physical and Occupational Therapy,
f
McConnell Brain Imaging Centre, McGill University, Montreal, Quebec, Canada; bDepartment of Neurology and Children’s Hospital Education Research Institute,
Children’s Hospital at Westmead, Westmead, New South Wales, Australia

The authors have indicated they have no financial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. Our goal was to evaluate detailed school-age language, nonverbal cogni-
tive, and motor development in children with developmental language impair-
www.pediatrics.org/cgi/doi/10.1542/
ment compared with age-matched controls. peds.2005-2761
METHODS. Children with developmental language impairment or normal language doi:10.1542/peds.2005-2761
development (controls) aged 7 to 13 years were recruited. Children underwent Key Words
cognitive development, language
language assessment (Clinical Evaluation of Language Fundamentals-4, Peabody disorders, developmental delay, motor
Picture Vocabulary-3, Goldman-Fristoe Test of Articulation-2), nonverbal cogni- development, language development
tive assessment (Wechsler Intelligence Scale for Children-IV), and motor assess- Abbreviations
ment (Movement Assessment Battery for Children). Exclusion criteria were non- SLI—specific language impairment
DLI— developmental language
verbal IQ below the 5th percentile or an acquired language, hearing, autistic impairment
spectrum, or neurologic disorder. CELF-4 —Clinical Evaluation of Language
Fundamentals-4
RESULTS. Eleven children with developmental language impairment (7:4 boys/girls; PPVT-3—Peabody Picture Vocabulary Test,
3rd Edition
mean age: 10.1 ⫾ 0.8 years) and 12 controls (5:7 boys/girls; mean age: 9.5 ⫾ 1.8 GFTA-2—Goldman-Fristoe Test of
years) were recruited. Children with developmental language impairment showed Articulation-2
WISC-IV—Wechsler Intelligence Scale for
lower mean scores on language (Clinical Evaluation of Language Fundamentals- Children, 4th Edition
4 — developmental language impairment: 79.7 ⫾ 16.5; controls: 109.2 ⫾ 9.6; PRI—Perceptual Reasoning Index
Goldman-Fristoe Test of Articulation-2— developmental language impairment: M-ABC—Movement Assessment Battery
for Children
94.1 ⫾ 10.6; controls: 104.0 ⫾ 2.8; Peabody Picture Vocabulary-3— developmen-
Accepted for publication May 30, 2006
tal language impairment: 90.5 ⫾ 13.8; controls: 100.1 ⫾ 11.6), cognitive (Wech- Address correspondence to Michael I. Shevell,
sler Intelligence Scale for Children-IV— developmental language impairment: 99.5 MD, CM, FRCPC, Montreal Children’s Hospital,
⫾ 15.5; controls: 113.5 ⫾ 11.9), and motor measures (Movement Assessment 2300 Tupper St, Room A-514, Montreal,
Quebec, Canada H3H 1P3. E-mail: michael.
Battery for Children percentile— developmental language impairment: 12.7 ⫾ shevell@muhc.mcgill.ca
16.7; controls: 66.1 ⫾ 30.6) and greater discrepancies between cognitive and PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2006 by the
language scores (Wechsler Intelligence Scale for Children-IV/Clinical Evaluation of American Academy of Pediatrics
Language Fundamentals-4 — developmental language impairment: 17.8 ⫾ 17.8;

PEDIATRICS Volume 118, Number 5, November 2006 e1541

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controls: 1.2 ⫾ 12.7). Motor impairment was more com-
mon in children with developmental language impair-
ment (70%) than controls (8%).
CONCLUSIONS. Developmental language impairment is char-
acterized by a broad spectrum of developmental impair-
ments. Children identified on the basis of language im-
pairment show significant motor comorbidity. Motor
assessment should form part of the evaluation and fol-
low-up of children with developmental language im-
pairment.
D EVELOPMENTAL DISORDERS LEADING to language im-
pairment are probably the most common form of
childhood developmental disability. The prevalence of
language delay in preschool-aged children has been es-
timated to be 7.6%.1 In kindergarten-aged children,
7.4% were found to meet criteria for specific language
impairment (SLI).2,3 The term SLI has been used to iden-
tify children with language impairment in the context of
normal nonverbal cognitive function; however, evi-
dence is increasing that SLI is associated with a range of
impairments in other developmental domains.4–6 Thus,
in this article, we use the term developmental language
impairment (DLI) to describe children who would oth-
erwise meet criteria for SLI. Children with an acquired
language disorder or language impairment secondary to
an autistic spectrum disorder, a hearing disorder, or a
known neurologic disorder are usually not considered to
have DLI.
Previous studies that examined the clinical pheno-
types of children with DLI have identified a range of
impairments in domains other than language. There is
an increased incidence of attention-deficit disorders
among children with DLI7 and an increased incidence of
language impairment among children with attention-
deficit disorders.5 Children with DLI are frequently
found to have impairments in socialization skills.8 More-
over, despite the requirement for normal nonverbal cog-
nitive function, nonverbal cognitive impairments have
been reported at school-age follow-up in children with a
diagnosis of DLI made at preschool age.9 Despite the
range of impairments seen in children with DLI, it is
unclear whether these deficits are secondary to the ef-
fects over time of the underlying communication disor-
der or whether they are a separate but intrinsic part of
the underlying disorder that leads to language impair-
ment.
There is increasing evidence that motor impairment is
a common comorbidity in children with DLI.4,6,10,11 Mo-
tor impairment is less likely to be secondary to a com-
munication disorder than the impairments in other de-
velopmental domains. Among children with DLI, motor
impairment has been found to correlate most strongly
with the observed severity of the child’s language disor-
e1542 WEBSTER et al
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der.5 Consistent with this, in studies that have recruited
children with greater degrees of language impairment, a
higher incidence of motor disorders has been reported.12
However, it is still unclear whether motor impairment in
children with DLI is the result of a more global develop-
mental impairment or reflects a biological function that
has greater effects on language and motor function than
nonverbal cognition.
Most previous studies that have evaluated motor per-
formance in DLI have used measures of isolated motor
functions (eg, rate of tapping or peg-moving10,13,14) or
have used combined measures of neurologic soft signs
that are not standardized and do not necessarily predict
a child’s functional motor ability.15,16 Four studies have
used standardized measures of motor function to evalu-
ate children with DLI.4,6,11,12 In one of these studies a
proportion of children would not meet criteria for DLI,12
and the other studies focused on the motor findings of
children with DLI but provided limited data on the chil-
dren’s language and cognitive skills.4,6,11 To our knowl-
edge, no study has evaluated the developmental profiles
of children with DLI across language, nonverbal cogni-
tive, and motor domains.
With this study we aimed to further the understand-
ing of DLI by evaluating the developmental profiles (ie,
phenotypes) of children with DLI across language, mo-
tor, and nonverbal cognitive domains using standardized
instruments with relevance for clinicians.
METHODS
Population
Children between the ages of 7 and 13 years who were
considered to have DLI and controls were prospectively
recruited for this study. Children were recruited through
the neurology and developmental clinics of Montreal
Children’s Hospital, private speech/language patholo-
gists, and from a class for children with language disor-
ders. For the DLI group, clinicians were asked to refer
children if they had an impairment in language but were
considered to have otherwise-normal nonverbal cogni-
tive development. For the control group, clinicians were
asked to refer children with headache disorders (ie, mi-
graines, considered unlikely to have a structural basis)
who were considered to have normal development in all
developmental domains. Children with headache disor-
ders were selected as the comparison group because
these children are regularly assessed through the hospi-
tal’s neurology clinics. These children had already un-
dergone assessment by a neurologist and, thus, were
unlikely to have unrecognized developmental problems.
Given that the normative data for the language and
cognitive measures were available for English-speaking
children, only children with English as their dominant
language were recruited.
Children were excluded from this study if they were
known to have an underlying neurologic or autistic
spectrum disorder per Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Revised criteria (ie, per-
vasive developmental disorder or pervasive develop-
mental disorder-not otherwise specified), a hearing im-
pairment, or on subsequent testing were found to have
a nonverbal IQ below the 5th percentile. Approval was
obtained from the hospital’s institutional review board
before commencing the study. Written informed con-
sent from the children’s parents and the child’s assent
were necessary preconditions for participation in this
study.
Clinical Assessment and Measures Used
Before assessment, the parents of all children were in-
terviewed by telephone by a research assistant to con-
firm that they met broad eligibility criteria. All children
underwent screening audiometry with a portable audi-
ometer. A threshold of 20 dB (at least in 1 ear) at all
frequencies tested was considered to represent adequate
hearing for conversational speech. A neurologic exami-
nation was performed by a pediatric neurologist to iden-
tify signs suggestive of possible underlying structural
neurologic disease. Parents were asked to complete a
questionnaire providing details about the child’s medical
and developmental history as well as the Pragmatics
Profile from the Clinical Evaluation of Language Funda-
mentals-4 (CELF-4).17 All speech/language, psychologi-
cal, and occupational therapy assessments were per-
formed by appropriately qualified therapists who were
blinded to the children’s group assignment (suspected
DLI or control) and to clinical information.
Language was assessed by using the CELF-4 and the
Peabody Picture Vocabulary Test, 3rd Edition (PPVT-3).18
The CELF-4 is an instrument that was designed to iden-
tify language disorders or delays in children ⬎5 years of
age. The CELF-4 shows excellent split-half and interrater
reliability, and detailed evidence supporting its validity is
presented in its published manual.17 The PPVT-3 is a
well-established measure of receptive vocabulary for
children and adults aged ⬎21⁄2 years. It shows excellent
internal consistency and test-retest reliability, and valid-
ity is supported by strong correlations with other mea-
sures of language.18 The core subtests and the Pragmatics
Profile of the CELF-4 were administered. The core
subtests of the CELF-4 involve 2 tests of receptive lan-
guage (concepts and following directions, word classes
[receptive, for children ⬎8 years old]) and 3 tests of
expressive language (word structure [children ⬍8 years
old], word classes [children ⬎8 years old], formulated
sentences and recalling sentences). A parent-completed
questionnaire, the Pragmatics Profile, was used to iden-
tify children who had evidence of pragmatic impairment
(ie, the rules that determine how language is used in
different social contexts and environments). Speech was
assessed by using the “sounds-in-words” section of the
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Goldman-Fristoe Test of Articulation-2 (GFTA-2).19 This
test is a systematic means of assessing each child’s spon-
taneous articulation of the consonant sounds of standard
American English in single words. The GFTA-2 has ex-
cellent test-retest, interrater, and internal reliability and
is intended for use in children ⬎2 years of age.19
The children’s nonverbal cognition was assessed by
using the block-design, matrix-reasoning, and picture-
concepts subtests of the Wechsler Intelligence Scale for
Children, 4th Edition (WISC-IV).20 These 3 subtests al-
low the calculation of a child’s Perceptual Reasoning
Index (PRI), which is a measure of nonverbal and fluid
reasoning (the ability to deduce the relationship be-
tween stimuli and to draw conclusions from this infor-
mation). It shows excellent reliability and convergent
validity with the previously validated 3rd edition of the
WISC.20
Children’s motor function was measure by using the
Movement Assessment Battery for Children (M-ABC).21
The M-ABC is a commonly used instrument for the
identification of motor impairment in children and pro-
vides measures of movement competence and manual
dexterity as well as ball skills and static and dynamic
balance. The M-ABC represents a minor revision of a
previously validated test of motor impairment (Test of
Motor Impairment [Henderson Revision])22; this test had
a minimum test-retest reliability for any item of 0.75 and
a minimum interrater reliability of 0.70. A recent vali-
dation study of the M-ABC in Chinese preschool-aged
children reported a mean intraclass correlation coeffi-
cient of 0.96 across items and a test-retest reliability of
0.77.23 The M-ABC has demonstrated validity in identi-
fying motor impairments in at-risk24 populations and has
previously been reported to be a useful instrument for
detecting motor difficulties in children with SLI.4
Normative values were taken from the data set pro-
vided by the tests’ publishers. The CELF-4, WISC-IV, and
the GFTA-2 allow the calculation of standard scores
(mean: 100; SD: 15). The M-ABC generates an age-
standardized impairment score from which a child’s per-
centile can be calculated.
Statistical Analysis
Statistical analysis was performed by using SPSS 11.5
software.25 Descriptive statistics were used to describe
the population characteristics and the range of scores on
the measures used. The distributions of scores are shown
graphically by using box plots (see Figs 1– 4). Compari-
sons between children with DLI and controls were per-
formed by using t tests for normally distributed data (age
at assessment, CELF-4 language scores, GFTA-2 scores,
WISC-IV PRI scores, nonverbal cognitive discrepancy)
and the Mann-Whitney tests (M-ABC impairment
scores) for data that were not normally distributed.
Given the difficulties inherent in comparing percentile
ranks, statistical tests on the M-ABC were performed by
PEDIATRICS Volume 118, Number 5, November 2006 e1543
using the total impairment score. To compare the distri-
bution of scores with expected normative values, the
sign test was used because of the relatively low sample
size. The ␹2 statistic (or Fisher’s exact test) was used to
compare parental income brackets, the reported fre-
quency of a family history of language disorders, and the
frequency of motor impairments.
RESULTS
Thirty children (16 DLI, 14 controls) were originally
recruited to participate in this study. Five children re-
ferred with a diagnosis of DLI were excluded from the
study: 2 children did not undergo complete clinical test-
ing, 1 child was found to have a PRI below the 5th
percentile, 1 child had an acquired language disorder,
and 1 child was considered to have normal language
after assessment. Two other children (1 with DLI, 1
control) who met criteria for inclusion in the study but
were the older siblings of children assessed were ex-
cluded to avoid biasing the data as a result of familial
factors. Thus, 11 children with DLI (7 boys) and 12
controls (5 boys) met eligibility criteria for this study.
The demographic details and parental assessment of
the children’s attention, social, and reading skills for
each child are presented in Table 1. A comparison of
controls and children with DLI at the time of their clin-
ical assessment is shown in Table 2. The age range of
control children (9.5 ⫾ 1.8 years) was more widely
distributed than that of the children with DLI (10.1 ⫾
0.8 years), although the mean values did not differ sig-
nificantly. Children with DLI were significantly more
likely that control children to have a family history of
language disorders (DLI: 6 of 11; controls: 0 of 10; P ⫽
.006), which is consistent with previous studies. All chil-
dren passed screening audiometry. No child had clinical
findings suggestive of a focal neurologic disorder (other
than language impairment).
All parents of children referred with a diagnosis of DLI
considered their children to have problems with speech
and language. The mother of 1 child in the control group
reported that her child had difficulties with articulating
some words. The majority of children (10 of 12) in the
control group had a clinical diagnosis of migraine. Three
children with DLI (3 of 11) had infrequent headaches;
none were considered to have migraine. Data on the
combined parental income were available for 9 children
with DLI and 10 controls. The families of controls tended
to have higher incomes than that of the families of
children with DLI, although this did not reach statistical
significance (P ⫽ .11).
The distributions of language (CELF-4), vocabulary
(PPVT-3), and articulation (GFTA-2) scores for the DLI
and control groups are shown in Figs 1–3. The test and
subtest scores for the CELF-4 and the PPVT-3 for indi-

TABLE 1 Demographic Characteristics and Parental Assessment of Children Studied

ID Gender Age, y Referring Family Attentionb Social Reading Problemsd Parental Incomee
Diagnosis Historya Problemsc
1 F 7.7 Control ND ND ND ND ND
2 M 11.0 Control ND ND ND ND ND
3 F 10.5 Control ⫺ Normal None Mild 20 000–39 000
4 M 8.2 Control ⫺ Normal None Normal 40 000–59 000
5 F 8.1 Control ⫺ Normal Minor ND 60 000–79 000
6 M 10.9 Control ⫺ Normal None Normal 60 000–79 000
7 F 8.6 Control ⫺ Normal None Normal 60 000–79 000
8 F 7.0 Control ⫺ Normal None Normal 60 000–79 000
9 M 9.2 Control ⫺ Normal None Normal 60 000–79 000
10 M 10.7 Control ⫺ Normal Minor Normal 60 000–79 000
11 F 9.1 Control ⫺ Normal None Normal ⬎80 000
12 F 13.2 Control ⫺ Normal None Normal ⬎80 000
13 M 10.6 DLI ⫹ Normal Minor Mild ND
14 M 8.8 DLI ⫹ Normal None Moderate/Severe ND
15 F 8.8 DLI ⫹ Poor Minor Moderate/Severe ⬍20 000
16 M 9.1 DLI ⫺ Poor None Moderate/Severe 20 000–39 000
17 M 10.8 DLI ⫺ Normal None Normal 40 000–59 000
18 F 10.7 DLI ⫺ Normal None Moderate/Severe 40 000–59 000
19 M 10.0 DLI ⫹ Normal Minor Moderate/Severe 40 000–59 000
20 M 10.8 DLI ⫺ Poor Minor Mild 60 000–79 000
21 M 9.8 DLI ⫹ Poor Major Moderate/Severe 60 000–79 000
22 F 10.1 DLI ⫹ Normal Minor Mild ⬎80 000
23 F 11.1 DLI ⫺ Normal Minor Mild ⬎80 000
Shown is a summary of the demographic characteristics of the children included in this sample. Included are data from a questionnaire given to the children’s parents. ND indicates data not supplied.
a Family history: parents were asked if there were other family members who had problems with speech and language.

b Attention: parents were asked if their child’s general ability to pay attention was normal/good or poor for their age.

c Social problems: parents were asked if their child had difficulties making friends with children of the same age.

d Reading problems: parents were asked to rate their child’s reading skills, allowing for their age.

e Parental income: parents were asked in which income bracket their total family income was.

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 TABLE 2 Comparison of Children With DLI and Controls
DLI (n ⫽ 11) Controls (n ⫽ 12) P
Age, mean ⫾ SD, y 10.1 ⫾ 0.8 9.5 ⫾ 1.8 .36
Boys, n/N (%) 7/11 (64) 5/12 (42) .29
Family income more than $60 000, n/N (%) 4/9 (44)a 8/10 (80)a .11
Family history of language disorders, n/N (%) 5/11 (55) 0/10 (0)a .006
a Not all parents responded to these items on the questionnaires.

FIGURE 1
Scores on language measures. A, Core language score, CELF-4; B, articulation, Goldman-Fristoe Test of Articulation-2; C, receptive vocabulary, PPVT-3. Shown are box plots of scores on
language and articulation measures. The box shows the 25th to 75th percentile ranges, the solid line within the box is the median score, and the range is illustrated by the horizontal
lines at the ends of the range bars.

vidual children are shown in Table 3. Children with DLI 109.2 ⫾ 9.6; P ⬍ .001). They also had significantly lower
showed significantly lower total language scores on the scores on tests of articulation (GFTA-2—DLI: 94.1 ⫾
CELF-4 than did controls (DLI: 79.7 ⫾ 16.5; controls: 10.6; controls: 104.0 ⫾ 2.8; P ⫽ .003). Children with DLI

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FIGURE 2
Nonverbal cognition: PRI (WISC-IV). Shown are box plots of scores on the WISC-IV PRI. The
box shows the 25th to 75th percentile ranges, the solid line within the box is the median
score, and the range is illustrated by the horizontal lines at the ends of the range bars.
FIGURE 3
Discrepancy between language and nonverbal cognitive scores (WISC-IV PRI/CELF-4
core language score). Shown are box plots of children’s nonverbal cognitive/language
discrepancy (WISC-IV PRI/CELF-4 total score). The box shows the 25th to 75th percentile
ranges, the solid line within the box is the median score, and the range is illustrated by the
horizontal lines at the ends of the range bars.
tended to have poorer receptive vocabulary scores, al-
though this did not reach statistical significance (PPVT-
3—DLI: 90.5 ⫾ 13.8; controls: 100.1 ⫾ 11.6; P ⫽ .06).
Children with DLI had significantly poorer scores on all
the administered subtests of the CELF-4 other than word
classes (P ⫽ .10). The subtest that caused the greatest
difficulty was recalling sentences (DLI: 5.2 ⫾ 3.2; con-
trols: 10.9 ⫾ 2.8; P ⫽ .001). Two children, both with a
diagnosis of DLI, met the criterion for pragmatic impair-
ment on the CELF-4 Pragmatics Profile.
When compared with expected normative values,
children with DLI had significantly poorer core language
scores (P ⫽ .001). Although the mean vocabulary score
e1546 WEBSTER et al
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(PPVT-3) was lower than expected on the basis of nor-
mative values, the distribution of scores did not differ
significantly from normative data (P ⫽ .11). By contrast,
the language scores of controls were significantly higher
than would be expected on the basis of normative data
(P ⫽ .04); however, scores on the PPVT-3 did not differ
significantly from normative data.
The distributions of nonverbal cognitive testing scores
and the results for individual children are shown in Fig
2 and Table 3, respectively. Children with DLI had sig-
nificantly lower WISC-IV PRI scores than did controls
(DLI: 99.5 ⫾ 15.5; controls: 113.5 ⫾ 11.9; P ⫽ .009).
When compared with controls, children with DLI
showed significantly poorer performance on the matrix-
reasoning (DLI: 9.1 ⫾ 3.2; controls: 12.7 ⫾ 1.9; P ⫽ .002)
and block-design (DLI: 9.3 ⫾ 3.5; controls: 11.9 ⫾ 2.6; P
⫽ .05) subtests of the WISC-IV. However, the total PRI
scores and subtest scores of children with DLI did not
differ significantly from published normative values. By
contrast, control children had significantly higher total
PRI scores (P ⫽ .01) and higher scores on the picture-
concepts subtests than would be expected on the basis of
normative data. Children with DLI showed significantly
greater discrepancies between nonverbal cognitive and
core language scores than controls (WISC-IV [PRI]/
CELF-4 [core language score]—DLI: 17.8 ⫾ 17.8; con-
trols: 1.2 ⫾ 12.7; P ⫽ .02) (see Fig 3).
The distribution of children’s scores on the M-ABC is
shown in Fig 4, and results for individual children are
shown in Table 3. One child in the DLI group did not
complete assessment with the M-ABC. The mean im-
pairment score for children with DLI was 14.1 ⫾ 5.3 and
for controls was 3.9 ⫾ 5.2 (P ⫽ .001). When percentile
ranks were considered, the mean M-ABC percentile for
children with DLI was 12.7 ⫾ 16.7, whereas for controls
the mean was 66.1 ⫾ 30.6. Using an M-ABC score below
the 15th percentile to identify impairment, 70% of chil-
dren with DLI met criteria for motor impairment,
whereas 8% of controls met this criteria (P ⫽ .003).
More than half of the children (6 of 10) with DLI had
M-ABC scores that fell below the 5th percentile.
DISCUSSION
Despite a history of delayed language development and
ongoing language difficulties in all children with DLI,
not all children had abnormal results on the core lan-
guage tests of the CELF-4. The mean language score fell
1.25 SDs below the expected population mean on the
basis of normative data. This corresponds to the 10th
percentile cutoff that has been suggested to correlate
well with the clinical identification of meaningful lan-
guage impairment.26 However, several children had core
language scores that fell within the reference range, just
short of the population mean. Consistent with the clin-
ical diagnosis of DLI, children with DLI showed much
greater degrees of discrepancy between language and
 TABLE 3 Test and Subtest Scores of the Participants: CELF-4, WISC-IV, and M-ABC
ID Group Age, y CELF-4 PPVT-3 WISC-IV M-ABC
CFD WS/WC RS FS Total BD PC MR PRI Percentile IS
1 Control 7.7 10 12 11 13 109 85 11 10 11 104 65 3
2 Control 11.0 10 10 10 12 102 114 9 7 9 90 36 6
3 Control 10.5 9 7 7 10 90 87 14 13 12 119 79 2
4 Control 8.2 13 13 12 12 115 112 9 13 14 112 93 0.5
5 Control 8.1 12 11 10 13 109 98 15 11 8 108 29 7
6 Control 10.9 12 9 5 13 98 83 11 12 12 110 89 1
7 Control 8.6 14 13 15 13 123 93 15 11 18 129 84 1.5
8 Control 7.0 11 11 13 10 108 103 12 11 16 119 96 0
9 Control 9.2 10 9 14 15 112 115 14 12 13 119 49 4.5
10 Control 10.7 11 11 13 13 112 107 14 16 15 131 79 2
11 Control 9.1 11 10 10 10 108 102 7 13 10 100 1 19
12 Control 13.2 12 14 11 14 124 111 12 13 15 121 93 0.5
13 DLI 10.6 8 10 8 12 97 89 12 15 8 110 1 23
14 DLI 8.8 7 2 1 5 62 100 8 13 11 104 1 19
15 DLI 8.8 3 1 1 1 44 65 6 6 6 75 1 18
16 DLI 9.1 4 8 5 9 79 94 7 9 9 90 4 14.5
17 DLI 10.8 6 10 9 9 91 91 13 10 9 104 29 7
18 DLI 10.7 12 7 3 6 82 79 13 15 11 119 13 10.5
19 DLI 10.0 11 8 9 11 99 102 10 12 10 104 2 16.5
20 DLI 10.8 9 10 7 9 93 98 7 5 10 84 49 4.5
21 DLI 9.8 6 9 5 3 75 87 14 10 12 112 26 7.5
22 DLI 10.1 4 8 8 10 85 115 3 9 7 77 ND ND
23 DLI 11.1 11 5 1 3 70 76 9 11 7 94 1 20.5
Presented are the scores of the individual participants on the tests and subtests of the CELF-4, WISC-IV, and M-ABC. CFD indicates concepts and following directions; WS/WC, word structure (⬍9
years)/word classes (⬎9 years); RS, recalling sentences; FS, formulated sentences; BD, block design; PC, picture concepts; MR, matrix reasoning; IS, impairment score (higher scores are associated
with greater degrees of motor impairment); ND, no data.

ceptive vocabulary are less sensitive in identifying chil-

FIGURE 4
Distribution of children’s motor scores (M-ABC percentiles). Shown are box plots of per-
centiles on the M-ABC. The box shows the 25th to 75th percentile ranges, the solid line
within the box is the median score, and the range is illustrated by the horizontal lines at
the ends of the range bars.
nonverbal cognitive scores than control children. For a
number of children, this discrepancy was the major
marker of language impairment.
The PPVT-3 (a test of receptive vocabulary) proved to
be a less sensitive instrument for the identification of
language impairment than the CELF-4. This is consistent
with previous studies that have shown that tests of re-
dren with language impairment than more broadly
based tests of language.9 Although the PPVT-3 is a rela-
tively easy instrument to administer, it is likely to miss
problems with syntax and word structure that are com-
monly seen in children with DLI.
The range of language findings in this group of chil-
dren illustrates the heterogeneity of language disorders
in school-aged children. The profile of the language abil-
ities of children with DLI has been shown to evolve.27 As
children age, earlier problems in areas such as phonol-
ogy and morphosyntax may improve; however, more
detailed testing may show problems with higher-level
language (eg, understanding of humor and idioms28).
The core language subtests of the CELF-4 (which test
receptive and expressive morphosyntax, verbal memory,
and verbal working memory and the relationship be-
tween words) are insufficient to identify problems with
these higher-level language functions. Tests of reading
potentially would have an increased sensitivity for de-
tecting language disorders; however, given considerable
variability in classroom exposure to reading between
families and school environments, we decided not to
include these tests.
In this study, articulation was assessed by using the
GFTA-2.19 Most of the control children were performing
at a ceiling level on this test. Although children with DLI
did more poorly than controls, most did not have major
problems with their production of individual speech

PEDIATRICS Volume 118, Number 5, November 2006 e1547

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sounds. The sounds-in-words section of the GFTA-2
only examines a child’s ability to produce individual
speech sounds. A more demanding test of verbal se-
quencing may be required to demonstrate oromotor lan-
guage impairments in these children.
For children with DLI, the mean PRI (99.5) was on
the 50th percentile on the basis of normative data. The
PRI scores of children with DLI had an almost normal
distribution and ranged from the 5th percentile to the
90th percentile. This finding is not surprising and is
consistent with our recruitment criteria (language im-
pairment in the context of normal nonverbal intelli-
gence). Although the scores of children with DLI were
significantly poorer than those of the control population,
there was evidence to suggest that the control children
were “supernormal.”
Motor impairment proved to be a common comor-
bidity in this group of children. The identification of a
group of children on the basis of language impairment
also identified a group of children with considerable
motor impairment. When the mean percentiles were
plotted for the domains tested (Fig 5), levels of motor
performance were commensurate with language perfor-
mance in children with DLI; however, these were unre-
lated to nonverbal cognitive function. This lends further
support to the hypothesis that common biological factors
critical to language and motor function (but of relatively
less importance for nonverbal cognition) may be the
etiologic factors in DLI.14 The number of children en-
rolled in this study was relatively small; thus, further
exploration of the correlation between language, non-
verbal cognitive, and motor variables was not possible.
The relatively high frequency of motor impairments
in this cohort is consistent with previous research in this
area.4,6,11,12,29 Motor impairment has important conse-
quences for a child’s elementary school academic per-
formance (writing, drawing, and coloring) and for a
FIGURE 5
Comparison of mean percentiles. The mean language (CELF-4 core language score),
nonverbal cognitive (WISC-IV PRI), and motor (M-ABC) scores of children with DLI and
controls are plotted as percentiles. It can be seen that although both groups have relative
strengths in their nonverbal cognitive skills, there is almost a 40-percentile difference
between language and cognitive scores and cognitive and motor scores in the group of
children with DLI.
e1548 WEBSTER et al
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child’s ability to participate in sporting and playground
activities. Children with language disorders are fre-
quently relatively socially isolated. Motor competence is
important for the participation in normal playground
activities (eg, ball games, running, and climbing). Chil-
dren with motor impairments have been found to have
lower self-worth and higher levels of anxiety than con-
trols.30 As such, it is possible that comorbid motor im-
pairments exacerbate the social isolation commonly seen
in children with DLI. Although the effectiveness of ther-
apy for motor impairment in DLI is uncertain, there is
some evidence that treatment can lead to improvements
in a child’s motor skills.11 Moreover, knowledge of po-
tential motor impairments in children with DLI may lead
to targeted surveillance of areas that may cause potential
difficulties (ie, pen grip) and guidance regarding physical
activities that present fewer motor challenges.
CONCLUSIONS
This study illustrates the considerable clinical heteroge-
neity seen in school-aged children with DLI. Although
motor impairment proved to be a common and signifi-
cant comorbidity, it was by no means universal. The
range of developmental impairments seen in this group
of children suggests that the care of children with DLI
would be enhanced by multidisciplinary developmental
surveillance (eg, speech/language, educational psychol-
ogy, and occupational therapy). However, given the rel-
atively low number of children with DLI assessed, there
is need for additional studies with larger sample sizes to
determine if these findings are generally applicable to
children with DLI.
ACKNOWLEDGMENTS
Dr Webster was a research fellow supported by the Mon-
treal Children’s Hospital Research Institute and the John
Yu Scholarship (Children’s Hospital at Westmead, Syd-
ney, Australia). Dr Shevell is a chercheur boursier cli-
nicien (clinical research scholar) of the Fonds de Recher-
che en Santé du Québec. Dr Shevell is also grateful for
the support of the Montreal Children’s Hospital Foun-
dation. This project was supported by the Réseau Pro-
vincial de Recherche en Adaptation-Réadaptation.
We acknowledge the contributions of Nancy Marget,
Cynthia Pearlman, Rina Birnbaum, Nicholas Hall, and
Lisa Steinbach to this study.
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PEDIATRICS Volume 118, Number 5, November 2006 e1549
The Clinical Spectrum of Developmental Language Impairment in School-Aged
Children: Language, Cognitive, and Motor Findings
Richard I. Webster, Caroline Erdos, Karen Evans, Annette Majnemer, Eva Kehayia,
Elin Thordardottir, Alan Evans and Michael I. Shevell
Pediatrics 2006;118;e1541
DOI: 10.1542/peds.2005-2761
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