Developmental Language Disorders
Nancy E. Hall
Developmental language disorders are among the most common disorders of childhood referred to the pediatric
neurologist. This article presents an overview of developmental language disorders, a discussion of the definition
of developmental language disorders, potential causal factors, and a description of possible subtypes of language
disorders in children. The article concludes with a review of the pediatric neurologist's role in developmental
language disorders and recommendations for assessment and management.
Copyright 9 1997 by W.B. Saunders Company
EVELOPMENTAL LANGUAGE disorders
D (DLD) are among the most frequent develop-
mental disorders of childhood. Prevalence esti-
mates range from less than 1% to more than 12% of
preschool and early schoolaged children, v3 In most
cases, it is the family members or pediatrician who
first suspect that the child's difficulty learning
language is more than a simple delay. The physi-
cian whose responsibility it is to facilitate the
processes of diagnosis and management must there-
fore possess a solid understanding of the definition,
nature, and causes of DLD.
DEFINITION
Researchers and clinicians have yet to reach
agreement on both the label for and the definition
of the DLD. 4-v Labels have included developmental
aphasia, dysphasia, developmental language delay,
and specific language impairment. Key issues in
the definition and diagnosis of DLD still need
discussion because of different approaches to defin-
ing/diagnosing DLD, such as exclusionary criteria,
discrepancy criteria, and comparisons across linguis-
tic skills.
EXCLUSIONARY CRITERIA
Most clinicians and researchers agree that the
diagnosis of isolated or specific DLD applies only
in the absence of known associated factors, such as
hearing loss, mental retardation, autism, gross
neurological impairment, and sociocommunicative
deprivation. However, differentiating DLD from
autism or mental retardation can be quite difficult.
Although it is important to rule out such factors to
diagnose DLD, this may be unrealistic because
children can have mental retardation or autism and
be language disordered.
DISCREPANCY CRITERIA
A frequent approach to the diagnosis of DLD is
to compare language skills with some measure of
cognitive functioning (preferably nonverbal), such
Seminars in Pediatric Neurology, Vol 4, No 2 (June), 1997: pp 77-85
as the Performance IQ (PIQ) score from a standard
IQ test. The purpose is to determine whether the
impairment is specific to language or one feature of
a more general cognitive deficit. The basis for this
approach is the belief that cognitive development
largely determines language development, yet that
nonverbal cognitive abilities and language abilities
are dissociable) There is lack of agreement on the
size of the discrepancy required for making a
diagnosis of language disorder (ie, the difference
between language skills and nonverbal function-
ing); the discrepancy has ranged from as small as 1
standard deviation (usually 15 points) between
language (low score) and nonverbal skills (high
score), to 2 standard deviations. 4 Basing the diagno-
sis on discrepancy criteria is not problem-free. For
example, a youngster who obtains a score of 80 on
a standardized measure of language and a score of
100 on a standardized nonverbal measure, a discrep-
ancy of just over one standard deviation, may or
may not be identified as having a language disor-
der, depending on the philosophy of the examiner.
The situation is even more controversial in children
with superior PIQs and a large performance-verbal
discrepancy whose language score may be in the
normal or even above-average range, yet out of
keeping with their overall cognitive competence.
Such children may require remedial help for spe-
cific academic problems.
COMPARISONS ACROSS LINGUISTIC SKILLS
In cases such as those just discussed, children
with DLD may obtain composite scores of lan-
From the Department of Communication Disorders, Univer-
sity of Maine, Orono, ME.
Supported in part by NIH grant NS 20489, "Nosology of
Higher Cerebral Function Disorders in Children."
Address reprint requests to Nancy E. Hall, PhD, Department
of Communication Disorders, Conley Speech and Hearing
Center, 5754 North Stevens Hall, University of Maine, Orono,
ME 04469.
Copyright 9 1997 by W.B. Saunders Company
1071-9091/97/0402-000355.00/0
77
78
guage abilities within the average range, yet demon-
strate markedly uneven language abilities. Such
children may have well-developed vocabulary skills
and be able to use their language for a variety of
social functions, yet their phonological and syntac-
tic (grammar) skills may be quite impoverished.
These children's irregular profile of language abili-
ties indicates relative independence in the develop-
ment of individual components of language ability.
A FINAL NOTE ON DEFINITION
Besides ruling out obvious causal factors and
determining the extent of the language disorder in
terms of overall development and profile of linguis-
tic abilities, it is important to take into account
parental/caregiver concern and expert clinician
impressions, each of which is strongly influenced
by societal expectations. Parents or caregivers
possess valuable information regarding a child's
language development that may not be captured
through observation or formal testing. In particular,
parents are able to comment on a child's ability to
use his or her language functionally in a way that
may not be apparent at an office visit or that
standard language measures fail to capture. Most
parents/caregivers are acutely aware of whether or
not their child's social use of language falls within
societal expectations. 9 Research continues to sup-
port the validity of the impressions of expert
clinicians for identifying DLD. 4,1~ Although they
rely on available tools, such as standardized tests
and observational methods, expert clinicians invari-
ably interpret scores within the broad base of their
clinical experience.
NATURE OF DLD
DLD encompasses a variety of deficits across a
range of language functions. For example, some
children with DLD may demonstrate adequate
language comprehension with impairments in lan-
guage expression, or the communicative use of
language, known as pragmatics, or in their use of
higher order language functions involving conver-
sational skills and metalinguistic capabilities (the
ability to think about language, a necessary precur-
sor to reading). Table 1 lists and defines these
different aspects of language.
Not all children with DLD are deficient in all
aspects of language, nor do they demonstrate
identical patterns of language deficits. Clinicians
have identified subgroups among children with
NANCY E. HALL
Table 1. Aspects of Language
Language processes
Receptive language: comprehension
Expressive language: production
Language levels
Phonology: speech sounds and rules by which sounds
are combined
Syntax: grammar and rules by which sentences are con-
structed
Semantics: vocabulary and meaning
Pragmatics: conventions governing the communicative
use of language in social contexts
Metalinguistics: ability to think about language abstractly
DLD with similar language impairments, and inves-
tigators have attempted to define specific DLD
subtypes. ~~ Research on subtyping is ongoing.
In general, DLDs can be categorized into three
basic groups: expressive-only deficits, mixed ex-
pressive-receptive deficits, and deficits in higher
order processing. Expressive and mixed receptive-
expressive disorders involve phonology or phonol-
ogy and syntax, aspects of language that are spared
or largely spared in higher order processing disor-
ders, which mainly affect semantics and pragmat-
ics. Within each of these broad categories, a
number of subtypes or profiles of deficits have been
proposed, such as the subtypes described below
and illustrated in Table 2, which although not yet
empirically validated, are based on the clinical
observations of Rapin and Allen.l~
Expressive-OnlySubtypes
Developmental verbal dyspraxia. Deficits in
the automaticity of expressive language with ex-
tremely impoverished output are seen, as well as
severe deficits in phonology and fluency. The onset
of language is very delayed and speech is labored
once attempted. The disorder is not attributable to
muscle weakness or pseudobulbar palsy, that is, to
dysarthria associated with cerebral palsy.
Phonologic production deficit. This is charac-
terized by impaired phonology and syntax and
compromised intelligibility, with preserved flu-
ency. Compatible with a well-developed vocabu-
lary and appropriate pragmatics. Comprehension is
normal or near normal.
Mixed Receptive-ExpressiveSubtypes
Verbal auditory agnosia (word deafness). Se-
vere impairment of the ability to decode phonology
through the auditory channel is seen, precluding
DEVELOPMENTAL LANGUAGE DISORDERS 79

Table 2. Subtypes of DLD

Developmental Phonologic Verbal Phonologic- Lexical- Semantic-
Verbal Production Auditory Syntactic Syntactic Pragmatic
Dyspraxia Deficit Agnosia Deficit Deficit Deficit
Receptive
Phonology * * ~l l * N
Syntax * * li l l N
Semantics * * li ,[ li ,[l
Expressive
Phonology li 1 l~ N or I * *
Syntax ~ l ~ ~ N or I *
Semantics 1 N or I l l li li
Fluency li N or l l l N or I or T N or I or T
Pragmatics * * N or I l l li
A b b r e v i a t i o n s : *, p r e s u m e d normal; N, normal.

attachment of linguistic meaning to auditory sig-
nals. Severe comprehension and expressive defi-
cits. If child is verbal, phonology is also defective.
Phonologic-syntactic deficit. This is a combi-
nation of receptive and expressive deficits that
interfere with the ability to understand and produce
phonology, syntax, and semantics, often leading to
pragmatic concerns as well. Receptive abilities are
equal to or superior to expressive, the child can
imitate words and simple phrases, and fluency is
impaired.
Lexical-syntactic deficit. Comprehension is de-
fective, but better than production. Characteristics
include immature syntax, severe anomia in dis-
course, although phonology and intelligibility may
be good; the child can imitate phrases; and fluency
varies.
HigherOrderLanguageSubtypes
Semantic-pragmatic deficit. Expressive skills
are often better developed than receptive language.
Children may present as hyperverbal, yet lack
comprehension and pragmatic concepts, in particu-
lar, discourse skills, such as topic initiation and
maintenance, appropriate greeting behavior, and
comprehension and use of conversational tools.
Word retrieval deficits are apparent. Pragmatic
deficits suggest the possibility of a pervasive devel-
opmental disorder (PDD).
Landau-Kleffner syndrome (LKS) or acquired
epileptic aphasia, discussed at length in the article
by Tuchman elsewhere in this issue, is mentioned
here as it may present at an early age and be
mistaken for a developmental language disorder.
LKS is characterized by regression of receptive and
expressive language skills associated with a convul-
sive disorder or epileptiform EEG abnormalities.
The relationship of the seizure disorder to the
language disorder is unclear, with some children
recovering language abilities once the seizures are
controlled and a larger number exhibiting persist-
ing language deficits. Acquired epileptic aphasia in
toddlers is frequently associated with more perva-
sive behavioral regression resulting in autism.
PATHOPHYSIOLOGIC AND ETIOLOGIC
FACTORS
Research into the neurobiological underpinnings
of DLD is expanding as ever more powerful
technologies in neuroimagingl%2~ (also see article
by Semrud-Clikeman, elsewhere in this issue) and
electrophysiology21; (also see article by Neville,
elsewhere in this issue) enable exploration of the
living functioning brain in real time. Although still
mostly speculative, evidence for a neurological
basis of DLD comes from a number of sources,
including parallels between DLD and acquired
disorders of language, I~ neuropathological studies
in related disorders, 22 and the known association of
DLD with other signs of brain dysfunction, such as
attention deficit disorders 23 and seizure disorder24;
(also see article by Tuchman, elsewhere in this
issue).
The search for the etiology of DLD has included
consideration of perinatal factors, genetic factors,
and environmental factors. Perinatal factors play
minor roles as causes of DLD unassociated with
other signs of damage to the brain, such as cerebral
palsy or mental deficiency.25-26
Genetic factors have long been believed to play
an important causal role in DLD. 27 Research has
demonstrated an increased prevalence of DLD or
learning disability among family members of chil-
dren with DLD. Further, DLD occurs in approxi-
80
mately three times as many boys as girls, pointing
to a substantial genetic contribution to the develop-
ment of language impairment. Language deficits
are found in children exhibiting any number of
chromosome abnormalities, including Down's syn-
drome, Fragile-X, Klinefelter's syndrome, and Wil-
liams' syndrome (in which verbal skills are better
preserved than cognitive abilities). 28 It is important
to keep in mind that most of the language disorders
associated with these definable abnormalities exist
in conjunction with a number of other neuropsycho-
logical deficits, including mental retardation, learn-
ing disabilities, and gross and fine motor deficits.
Finally, environmental deprivation, which may
come in the form of too little familial stimulation of
language learning, may result in delayed or disor-
dered development of language. As a specific cause
of DLD, these instances are rare, and when found,
are likely to be associated with other developmen-
tal disturbances. 29 Chronic otitis media (glue ear)
may delay language development and, especially in
children from disadvantaged families, leave subtle
deficiencies in its w a k e . 30
COMORBIDITY WITH OTHER
DEVELOPMENTAL DISORDERS
DLD may occur in conjunction with other devel-
opmental disorders. It may be difficult to determine
whether or not the language impairment is primary,
secondary, or co-occurs with another developmen-
tal disorder. Two of the most closely associated
disorders are mental retardation and autism. It is
crucial to differentiate isolated DLD from mental
retardation and autism as the prognostic and treat-
ment implications are substantial. The nature of
language disorder in mental retardation is briefly
described below. The reader is referred to Rapin
and Dunn's article elsewhere in this issue on the
language disorders in autism.
DLD and Mental Retardation
A diagnosis of mental retardation implies deficits
in language development in conjunction with over-
all cognitive deficits. It is important to point out
that the language difficulties associated with mental
retardation are varied. In many cases, the language
development of a child with mental retardation is
similar to that of a younger normally developing
child, although some language skills tend to be
more severely affected (Table 3).
NANCY E. HALL
Table 3. Language Deficits Observed in Mental Retardation
Comprehension: poorer than expected for mental age level.
Specific difficulties with syntactic recall.
Phonology: persisting phonological errors beyond mental
age expectations.
Syntax: persistent use of less mature forms than capable
of, given mental age.
Semantics: slow growth of vocabulary, reliance on concrete
word meanings.
Pragmatics: poorer conversational skills than expected for
mental age.
*Data from Owens. 31
ASSESSMENT/DIAGNOSIS
The pediatric neurologist's responsibility in the
diagnosis and assessment of DLD is fourfold: (1)
detecting the presence of a language disorder, (2)
characterizing the nature of the language disorder,
including assessing cognitive abilities in relation to
language abilities, (3) exploring potential medical
causes, and (4) developing a medical management
plan when appropriate.
First, determining the presence of DLD involves
comparing developmental history, data from behav-
ioral observations, and scores from screening instru-
ments with normative expectations. Using the
developmental history and observation, the expert
clinician can identify areas of weakness in lan-
guage (involving those areas outlined in Table 1)
and in cognitive development. Further, use of a
standardized scale affords the clinician a more
systematic method for obtaining and interpreting
language and cognitive skills. Four instruments
suitable for physicians are as follows: the Denver
Developmental Screening Test, 32 an observational
screening tool designed to assess a child's overall
development; the Early Language Milestone Scale-
Revised, 33 a screening instrument for early lan-
guage abilities in the same format as the Denver;
the Clinical Linguistic and Auditory Milestone
Scale, 34-35 a well-studied questionnaire that evalu-
ates early language development based on parental
report; and the well-standardized MacArthur Com-
munication Development Inventories, 36 which also
assess language comprehension and expression
through parent report and which is the most de-
tailed scales for evaluating language children youn-
ger than 30 months of age.
Knowing when to be concerned with inadequate
language development and what signs to look for
are critical components for determining the pres-
ence of a language disorder. Developmental mile-
DEVELOPMENTAL LANGUAGE DISORDERS 81

Table 4. Preschool Language Milestones

Fourth Year
First Year Second Year Third Year and Beyond

Receptive Develops understanding Develops comprehen- Comprehends large Begins to understand

of single words based
on environmental con-
text
Expressive Syllabic babbling occurs
Develops hi/bye routines
Points to express needs
or draw attention
First words expressed
Begins using words to
manipulate environ-
ment
sion of words out of vocabulary multiple meaning
context (points to pic- Begins to understand vocabulary words
tures) Wh-questions Uses sentence word
Follows two-word com- Answers yes/no ques- order to understand
mands tions agent-object relation-
ships
Points to pictures repre-
senting sentences
Develops novel one- Expansion of vocabulary, Uses complex language
word utterances syntax, functions of Talks about remote expe-
Begins use of two-word language riences
utterances Is able to express any Uses language to relate
Asks simple "What's idea intelligibly to experiences
that?" questions familiar and unfamiliar Able to converse appro-
Morphological markers listeners priately
begin to develop Articulation skills nor-
malize

stones in language and warning signs of disordered
language are outlined in Tables 4 and 5, respec-
tively.
Second, careful characterization of the nature of
the DLD falls under the purview of the speech-
language pathologist; however, the pediatric neu-
rologist should be able to differentiate receptive,
Table 5. Warning Signs of Disordered Language
in Preschoolers
Limitations in expressive language
Produces little to no creative utterances of three words or
more by age 3 years.
Limitations in vocabulary
Has small repertoire of words understood and/or used
and acquires new words slowly or with difficulty.
Limitations in comprehending language
Relies too much on contextual cues to understand lan-
guage.
Limitations in social interaction
Rarely interacts socially, except to have needs met.
Limitations in play
Has not developed symbolic, imaginative play by age 3
years. Does not play interactively with peers.
Limitations in learning speech
Expressive speech contains numerous articulation errors
or is unintelligible to unfamiliar listeners.
Limitations in using strategies for language learning
Uses unusual or inappropriate strategies for age level,
eg, overuses imitation (echolalia), does not imitate ver-
balizations of others (dyspraxia), does not use ques-
tions for learning ("Why" questions).
Limitations in attention for language activities
Shows little interest in book reading, talking, communi-
cating with peers.
Data from Nelson. 37
expressive, and more global language deficits. With
the exception of very severe verbal dyspraxia,
children exhibiting expressive-only impairments
generally have better prognoses than those with
receptive-expressive or global deficits. 38-39To make
such determinations, one should rely on informed
observations guided by the information in Tables 1,
2, 4, and 5, and the use of standardized scales or
batteries.
Third, the exploration of potential medical causes
of DLD will, in large measure, be driven by the
data obtained through behavioral observations,
history taking, and the medical/neurological exami-
nation. As mentioned earlier, a diagnosis of specific
or pure DLD is reserved for children with language
impairment in the absence of hearing loss, mental
retardation, frank neurological involvement, au-
tism, social-environmental deprivation, or elective
mutism. During the assessment process, such con-
ditions must be ruled out, as management and
prognosis vary depending on the diagnosis. The
general physical and neurological examinations
rarely uncover a specific cause for the language
disorder, although observations from these exami-
nations may provide valuable information on asso-
ciated signs or behaviors, such as subtle motor
involvement, oromotor deficits, or attention defi-
cits. Likewise, diagnostic tests, such as neuroimag-
ing, electrophysiology, or metabolic studies will
rarely contribute substantially to the understanding
of the disorder; however, there are exceptions. A
definitive test of hearing acuity is necessary for all
82
children believed to have or diagnosed with DLD,
particularly those with poor comprehension or
significant impairment in phonology. In some chil-
dren, behavioral audiometry may not yield reliable
results and brainstem auditory evoked response or
cochlear emission testing is required. Additionally,
a prolonged sleep-deprived sleep EEG is recom-
mended for children with severe mixed receptive-
expressive deficits, especially those with verbal
auditory agnosia or language regression. Further
testing involving chromosomal studies may be
indicated in children with features suggestive of a
syndromic condition. Finally, in the case of sus-
pected elective mutism, it is critical to obtain proof,
such as a tape recording, that the youngster speaks
or has spoken in other environments, bearing in
mind that some children with elective mutism also
have DLD.
Finally, medical management is generally re-
served for those children who might benefit from
pharmacological (eg, anticonvulsants), surgical, or
prosthetic (eg, hearing aids) intervention. Most
children with DLD will require language interven-
tion provided by a speech-language pathologist.
MANAGEMENT
Referral Process
Beyond ruling out potential causative factors and
associated neurological conditions, the pediatric
neurologist who evaluates a child with DLD will be
providing the families with essential referral infor-
mation. If DLD is suspected, the most appropriate
referral is to a speech-language pathologist who
will be able to specify the nature and severity of the
disorder and provide appropriate recommendations
for intervention. Opinions differ on how early to
refer for early intervention, with some advocating
delaying referrals until age 4 years for expressive-
only impaired children, 4~ and others recommend-
ing early identification and prompt interven-
tion. 39,42 This decision is usually made by the
speech-language pathologist. If mental retardation
or autism is suspected, the referral process should
involve both a psychologist or neuropsychologist
and a speech-language pathologist. Working to-
gether, these professionals will be able to specify
the relationship between cognition and language;
that is, they will be able to determine whether or
not language is more impaired than cognition,
commensurate with cognition, or better developed
than cognition. The role of the physician is to
NANCY E. HALL
participate and interpret the results of such pluridis-
ciplinary evaluations for the family and decide
whether further medical tests or pharmacological
intervention are indicated.
Intervention Principles
The type of intervention a youngster receives
depends on the nature and severity of the disorder.
Knowing basic intervention principles will help the
pediatric neurologist make appropriate recommen-
dations and referrals. Typically, DLD is diagnosed
in toddlers or preschool children; thus, many of
these children do not have the benefit of a school
structure within which to receive services. Never-
theless, federal guidelines require that states pro-
vide appropriate services to all identified children,
regardless of age. Thus, states have adopted poli-
cies whereby public school districts or separate
state agencies are responsible for making sure
preschool children receive adequate services. To
facilitate the processes of referral and obtaining
appropriate intervention, the pediatric neurologist
must become knowledgeable about the state's poli-
cies and must obtain the names of appropriate
contact personnel.
Intervention can be provided in a number of
settings, such as individual, small group, special
classroom, and consultation interventions. Chil-
dren with expressive language deficits only or less
severe DLD may benefit maximally from direct
individual intervention. Those with more involved
disorders, such as mixed receptive-expressive DLD,
verbal auditory agnosia, verbal dyspraxia, or con-
comitant cognitive or behavioral deficits are best
served through individual intervention in conjunc-
tion with a special classroom or integrated class-
room environment. The consultation model focuses
on teaching family members basic language stimu-
lation and intervention techniques to foster lan-
guage growth throughout the child's day. None of
these interventions need be provided in isolation.
An integrative model of direct intervention and
consultation has the added benefit of providing
support and direction to family members as well as
individual work with the child.
In children with severe receptive deficits, it is
important to provide visual referents for spoken
words, and in the most severe cases it is appropriate
to use gestures, sign language, and alternative
devices such as communication boards. Interven-
tion in DLD focuses on the entire communcative
DEVELOPMENTAL LANGUAGE DISORDERS
act, not on speech articulation errors per se. More
details on general methods appropriate for use in
preschool children with the various language disor-
ders described earlier can be found in Allen et al.43
Counseling Families
Regardless of the role each professional plays in
the processes of identifying and managing DLD,
each member of the team is responsible for provid-
ing information, support, and counseling to the
families of these children. Most families approach
a visit with a professional with a combination of
anticipation, fear, and hope. The foremost ques-
tions in the minds of parents of children with DLD
are: (1) What is wrong with my child? (2) Why has
this happened (the tacit form of " A m I responsible
for the problem?") (3) What can be done about it?
and (4) What does the future hold? Honest and
consistent responses to these questions from all
professionals involved with the child will go a long
way toward helping the family adjust to and accept
the disorder, and move toward helping the child. It
is common not to reach a definitive diagnosis in
very young children given the complexities of
language and cognitive development. Family mem-
bers will need assurances that the most important
goal will be finding appropriate intervention, regard-
less of diagnostic status, and that response to
intervention is likely to yield more reliable diagnos-
tic information than initial impressions.
To the second question, the answer is almost
invariably "No, you had nothing to do with this
problem." In most cases, family members provide
adequate language models and they frequently
develop healthy strategies for fostering communica-
tion. These efforts should be recognized and encour-
aged.
The response to the third question is intimately
tied to the other two. A child with multiple needs
may require further diagnostic assessments, and the
family may be in for an extended period of
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provided with appropriate intervention.
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Pediatricians and pediatric neurologists are regu-
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