t t p

t ss:
p t t p
t ss:
p
hht hht
r ss r
kke s s
b
eebooook53
kee r
/
e
e b
r
Developmental Language Disorders
o
b
oo
o / e b o
b o
m ee e
Doris A. Trauner and Ruth D. Nass
/ m ee / e
: / /
/ t
/ .
t . m : / /
/ t
/ .
t . m
t t p
t ss
p : t t p
t ss
p :
An expanded version of this chapter is available on www.expertconsult.com. See inside cover for registration details.

INTRODUCTION
hht hht
deficit in auditory attention or in general attentional resources
at the basis of SLI. Rapid processing of sensory information,
Developmental language disorders (DLDs) include a number particularly in the auditory modality, may also be a contribut-
of conditions that adversely affect language development. The ing factor to impaired language development. Efficient pro-

k eer ss
most common DLD is specific language impairment (SLI), a
r
neurodevelopmental disorder (NDD) that affects 2% to 11%
k ee rrss cessing of auditory stimuli has been shown to be impaired in

b ooook b o oook
of the population, making it one of the most common NDDs.
many children with SLI. It is as yet unclear whether the primary

o
deficit is in the ability to focus attention to process auditory
b o
eeb ee/ e
/ e b
The hallmark of SLI is that a child with normal intelligence
and hearing fails to develop language in an age-appropriate
e e
/ e b
information or whether the processing deficit is the principal
/
causal factor. In either event, basic sensory processes are dis-
e
: / / t
/ t m
fashion. SLI is a clinical diagnosis, based on the presence of a
. . m
normal nonverbal IQ, evidence of expressive and/or receptive
: / / t
/ .
t m
rupted in SLI, leading to impaired language development.
. m
t p ss
p : /
language significantly below expected for age and intelligence
NEUROANATOMY OF SPECIFIC
LANGUAGE IMPAIRMENT ttp
(SLI is often defined by scoring at least 1.5 standard deviations ss
p : /
t
hht t
below the mean for age on standardized, age-appropriate tests
of language), and absence of other specific conditions such
as autism, global intellectual disability, metabolic or genetic
hht t
Although SLI has been an important area of research and
clinical focus for many years, there have been relatively few
disorders, or severe environmental deprivation. Although this
studies of brain structure in this condition, and those reported
condition is commonly called “specific” language impair-
have not been consistent. Clinical neuroimaging scans (mag-

k ee rss k eerrs
ment, there is controversy as to how specific the condition is
r
and whether the terminology should be changed to a more
s netic resonance imaging [MRI]) generally yield normal results,
although a higher-than-expected incidence of abnormal find-

b ooook o ook
generic term, such as language impairment. Despite this con-
troversy, however, at present the terminology remains the
b o
ings, including ventriculomegaly, central volume loss, and

b oo
white-matter hyperintensities, has been described, suggestive
eeb e e
/ b
same. Other forms of DLD include stuttering, selective mutism,
/ e
verbal apraxia, and epileptic aphasia. Box 53-1 lists normal
e ee/ e
/ e b
of possible disruption of normal white-matter structure.
Quantitative neuroimaging techniques have focused primarily
oping language competence.
: / / / m
.t.m
language milestones as a baseline for assessing a child’s devel-
t : / / t
/ m
.t.m
on the frontal and temporal regions thought to be important

t pp ss : / t ppss : / for language and have demonstrated abnormal gyrification in

the inferior frontal gyrus, the absence of the normal left-right
t
hhtt
NEURAL SUBSTRATES OF LANGUAGE t
hhtt
In adults, specific brain regions, primarily in the left hemi-
asymmetry of the planum temporale, or atypical right-greater-
than-left asymmetry of both anterior and posterior temporal
lobes. Arguments for atypical lateralization of the developing
sphere, are believed to mediate language, based primarily on brain for language as a cause for SLI have been made based
studies of adults with strokes and more recently on neuro- on the differences in brain symmetry observed in some of the
physiological and functional imaging studies. The neural sub- imaging studies (Badcock et al., 2012). Functional neuroimag-

k e rrss
e k
defined, and in fact may differ markedly from those that
e rrss
strates of language during early development are not as clearly

e
ing studies have also demonstrated lack of the expected left
lateralization of activation on linguistic tasks.

o o
o o k o o o k
mediate language once it has developed. Children who had a
o o
Diffusion-tensor imaging techniques have demonstrated
o
eebb e / b
e b
left-hemisphere stroke in early life do not typically demon-
/ e
strate aphasia, or even a functional language impairment. A
e e / / b
e b
white-matter structural changes in the superior longitudinal
e
fasciculus (SLF) of adolescents with SLI. The SLF is a major
e
/ t m
classic study by Bates et al. (2001) demonstrated the differ-
.t.m
ences between children with perinatal stroke and adults with
: / / : / / t m
white-matter tract that is thought to be crucial for language
.t.m
processing because it connects the anterior areas of the cortex
/
t ss:
p /
late-acquired stroke in the left hemisphere, showing that chil-

p
dren performed equally well as their typically developing
t p ss:
p /
to the posterior areas and, among other areas, the Broca’s area
to the Wernicke’s area. Differences in SLF structure provide a
t
hht t
counterparts on multiple aspects of language, unrelated to the
hemispheric side of the lesion, whereas adults who had a
t
hht t possible structural explanation for the language-processing
problems found in SLI.
later-onset left-hemisphere stroke showed significant impair- Other types of imaging studies have demonstrated func-
ments on the same tasks. Such findings suggest that language tional changes in the brains of children and adults with SLI.
is not “hardwired” into specific brain regions, but that the Single-photon emission-computed tomography (SPECT)

k e r
e s
process of language acquisition requires more widely distrib-

r s k e r
e s
r
uted neural networks. Studies of very early language awareness
s
studies have shown reduced cerebral blood flow in the left
hemisphere of children with SLI compared with controls.

o o
o o k o o
o k
in the first few months of life indicate that infants learn very
o
early to attend to the linguistic traits that are relevant to the
With the use of transcranial ultrasound to examine blood flow

o o
to each hemisphere during a word-generation task, aberrant

eebb e e
/ b
e b
language to which they are exposed. Typically developing chil-
/
dren attend more to speech sounds when their attention is
e e / e
/ b
e b
hemispheric blood-flow responses have been demonstrated in
adults with SLI. Magnetoencephalography was used to track
e
: / / / .
t m m
directed to auditory rather than visual stimuli, whereas chil-
t .
dren with SLI are unable to sufficiently attend to speech
: / / / .
t m m
the spatiotemporal course of brain response to real words and
t .
pseudowords in children with SLI compared with typically

t p ss
p : /
sounds in the same setting, suggesting that there may be a

t p ss
p : /
developing children. Bilateral superior temporal cortex regions

t
hht t t
hht t 431
 t t p
t ss:
p t t p
t ss:
p
432
hht
PART VII Neurodevelopmental Disorders
hht
GENETICS

k e r
e s
BOX 53-1 Normal Language Milestones
r s k e r
e s
r s Heritability rates for SLI run as high as 0.5, but they are vari-

o o
o o k RECEPTIVE

o o
o o k o
able and are affected by the criteria used to diagnose the dis-
o
eebb b b
• Some words understood by 9 months

cued by a gesture
ee/ e
/ e b
• Follows one-step commands by 12 months without being
ee/ e
/ e b
order (SLI vs. more general DLDs that may be associated with
known genetic syndromes) (Bishop and Hayiou-Thomas,

EXPRESSIVE
: / / t
/ .
t m
. m : / / t
/ t m
2008). The median incidence rate for language difficulties in
. . m
the families of children with language impairment is up to
• Cooing—2 months

t p ss
p : / t p ss
p : /
35%, compared with a median incidence rate of 11% in
control families. Increased concordance rates in monozygotic
• Babbling—6 months
t
hht t
• Variable babble—8 months
• One word other than dada and mama—12 months
t
hht t
versus dizygotic twins indicate that heredity, not just shared
environment, is responsible for familial clustering.
Studies using genome-wide scanning have implicated a
• 10 to 50 words used meaningfully—16–20 months
• Two-word phrases—20–24 months
number of gene loci, but the same loci have not been found
• Points to at least one body part and to named objects and
in a reproducible fashion (Vernes et al., 2008). Isolated fami-

k eerrss
people on command—20 months
• Vocabulary greater than 200 words—2 years
k eerrss
lies with specific mutations have been studied. In the three-
generation KE family, half the members are affected with a

b ooook • Two-word combinations—2 years

• Follows two-part commands—2 years
b o ook
o
severe speech and language disorder that is transmitted as an

o
autosomal-dominant monogenic trait involving the FOXP2
b o
eeb • Sentences of three to four words—3 years
• Compound and complex sentences—4 years
ee/ e
/ e b e / e
/ e b
forkhead-domain gene. Notably, however, a screening of 270
4-year-olds with SLI was negative for the FOXP2 mutation.
e
• Passive voice—6 years

: / / t
/ .
t m
. m / / t
/ .
t m
Recently HLA alleles have been associated with SLI. Mater-
. m
nally but not paternally inherited HLA-B B8 and HLA-
:
t p ss
p : / ss : /
DQA1*0501 were associated with impaired receptive language.

t p p
t
hht t
were activated to word and pseudoword presentations, but in
t
hht t
HLA-A A2 was associated with expressive language ability.
HLA-DRB1 was found with greater frequency in individuals
with SLI than in controls. In other studies, the calcium-
contrast to controls, children with SLI showed equally strong transporting ATPase 2C2 (ATP2C2) gene on chromosome 16
activation to both words and pseudowords. Further, children has been considered as a candidate gene for SLI.
with SLI did not show the typical attenuation of activation the It is unlikely that there will be one specific gene whose

k eerrss k eerrs
second time the same word was presented, indicating that the
s
linguistic activation that underlies word recognition may be
function would be restricted to forming the genetic basis for
language acquisition. It is more likely that there are many

b oo k
ooFACTORS
defective in SLI.

b o ook
o
genes that contribute to a variety of functions, and that these

b oo
genes form networks that are recruited in the process of lan-

eeb LANGUAGE DISORDERS

ASSOCIATED WITH DEVELOPMENTAL
ee/ e
/ e b ee/ e
/ e b
guage acquisition. The issue of pleiotropy, or the influence of
the same genes on multiple phenotypes, has also been dis-

: / / t
/ m
.t.m : / / t
/ m
.t.m
cussed in the literature on SLI, given the substantive overlap

p ss : /
As with many neurodevelopmental disorders, there is a higher

p
incidence of SLI in males (1.6 : 1 males : females). The cause
t p t pss : /
in regions of linkage for a variety of developmental disorders,
such as speech and sound disorders (SSD) and developmental

t
hhtt t
hhtt
for the gender differences is not known. Numerous biological
and environmental risk factors for SLI have been identified.
Low birth weight, prematurity, and prenatal exposure to drugs
dyslexia, and SLI and autism. Whether these are true examples
of pleiotropy or outcomes of the imprecision of phenotype
definitions is yet to be determined.
(e.g., cocaine) and to cigarettes have been reported to adversely
affect language development, although no single perinatal
complication has been definitively associated with SLI; rather,
DIAGNOSIS

k e rrss
an aggregate of perinatal complications could contribute to

e
later language impairment.
k e rrss
e
SLI is a clinical diagnosis based on a delay in language
development for expected age, in the absence of intellectual

o o
o o k o o o k
Although frequent episodes of otitis media have been sug-
o o
disability, autism, hearing impairment, or environmental
o
eebb e / b
e b
gested as causing language impairment, there is little evidence
/ e
from controlled studies to indicate a causal relationship. Inter-
e e / / b
e b
deprivation. In children for whom formal language assess-
e
ments are conducted, a score of 1.5 or more standard devia-
e
/ t m
mittent hearing loss may interfere with language development
.t.m
in at-risk children, but is not likely to cause long-term lan-
: / / : / / t m
tions from the normative mean on a standardized test of
.t.m
language is considered diagnostic for SLI.
/
t ss:
p /
guage issues in otherwise normally developing children.

p
Language impairment is seen in association with specific
t p ss:
p /
Box 53-3 lists warning signs that suggest a DLD during the
first 3 years. Language delay can be diagnosed very early. The
t
hht t
neurologic and genetic disorders. For example, perisylvian
polymicrogyria (or congenital bilateral perisylvian syndrome)
t
hht t
developmental history provides strong evidence for language
delay when the child does not meet expressive language mile-
is a disorder of defective neuronal migration that has a spec- stones, does not seem to understand directions without associ-
trum of neurologic impairments that include severe epilepsy ated gestures (e.g., “get your ball” without pointing to the
and cognitive impairment. In some children with this condi- ball), or does not point on command. During the examina-

k e r s
tion, language impairment is the most prominent feature.

r s
Language impairment is also prominent in a number of chro-
e k e r
e s
r s
tion, similar instructions can be given to the young child, and
the child can be asked to point to various body parts or to

o o
o o k o o
o k
mosomal disorders, including Down, Klinefelter, and fragile
o
X syndromes. Epileptic encephalopathies, particularly Landau–
point to pictures of common objects in a book. If there is a

o o
suspicion of language delay, the young child can undergo

eebb e e
/ b
e b
Kleffner syndrome (LKS), may have language impairment
/
(often receptive greater than expressive impairment) as an
e e / e
/ b
e b
more formal language testing, such as with the MacArthur-
Bates Communicative Development Inventory (normed for
e
: / / / .
t m m
isolated or primary symptom. Rolandic epilepsy, often consid-
t .
ered to be “benign,” may be complicated by language impair-
/ / / .
t m m
8–30 months) or the Preschool Language Scale–4 (normed for
t .
birth to 6 years 11 months), both of which assess receptive
:
t p ss
ment and learning disabilities.

p : / ss : /
and expressive language at young ages.

t p p
t
hht t t
hht t
 t t p
t ss:
p t t p
t ss:
p
hht hht
Developmental Language Disorders 433

k e r
e s
BOX 53-3 Warning Signs of a Developmental
r s Language Disorder
k e r
e s
r s BOX 53-4 Glossary of Terms Used in Describing
Linguistic Functions
53

o o
o o k o o
o o k o o
eebb b b
LIMITATIONS IN EXPRESSIVE LANGUAGE Functors The small words of the language, such as

ee/ e
/ e b
• Early problems with sucking, swallowing, and chewing
ee/ e
/ e b
prepositions, conjunctions, and articles;
also called closed-class words because
• Excessive drooling

: / / t
/ .
t
• Failure to vocalize to social stimulim
. m : / / t
/ .
t m
. m they are limited in number

ss : /
• Failure to vocalize two syllables at 8 months

t p p
• Few or no creative utterances of three words or more by
t p p :
Lexicon
ss / The words in a language; the dictionary of
word meanings
age 3
t
hht
LIMITATIONS IN VOCABULARY
t t
hht t
Mean length of
utterance (MLU)
Morpheme
The number of morphemes per utterance

The smallest meaningful unit in a

• Limited repertoire of words understood or used language, occurring either in a word or
• Slow or difficult new-word acquisition as a word. (For example, the compound
LIMITATIONS IN COMPREHENDING LANGUAGE word compounding is made up of three

k eerrss k e rrss
• Excessive reliance on contextual cues to understand language

e
morphemes: com-pound-ing.) Prefixes,

ook ook
suffixes, and inflected endings such as
LIMITATIONS IN SOCIAL INTERACTION

b
eeboo b o o
• Reduced social interaction, except to have needs met

/ e b Phoneme

/ e b o
-ed, -s, and -ly are also morphemes

b o
A distinct sound unit in a language (In
LIMITATIONS IN PLAY

m ee / e m ee / eEnglish, there are 46: 9 vowels and 37

consonants.)

/
• No interactive play with peers
: /
/ t
/ .
• No symbolic, imaginative play by age 3

t . m : / / t
Phonology

/ / .
t . m The rules a speaker follows when

t p
t ss
LIMITATIONS IN LEARNING SPEECH

t p : t t p
t ss
p :
Pragmatics
combining speech sounds
The communicative intent of speech

hht
• Numerous articulation errors in expressive speech
• Unintelligible to unfamiliar listeners
LIMITATIONS IN USING STRATEGIES FOR LANGUAGE
hht rather than its content (e.g., asking a
question at the right time and in the
right way)
LEARNING Prosody The melody of language; the tone of voice
• Use of unusual or inappropriate strategies for age level, e.g., used to ask questions, for example, or

k eerrss eerrs
overuses imitation (echolalia), does not imitate verbalizations
s
of others (dyspraxia), does not use wh- questions for learning
k
Semantics
to show emotion
The meaning of words; their definition

b ooook (why, what, where, etc.)

b
LIMITATIONS IN ATTENTION FOR LANGUAGE ACTIVITIES
o ook
o
Syntax

b
The grammar of a language; the

oo
acceptable relationship between

eeb e / e
/ e b
• Little interest in book reading, talking, or communicating with

e ee/ e
/ e bwords in a sentence

peers

: / / t
/ m
.t.m : / / t
/ m
.t.m
t p : /
(Modified with permission from Nelson NW. Childhood Language

ss
Disorders in Context: Infancy through Adolescence. New York:

p t ppss : /
identify apraxia in severe cases. Milder forms may require a
t
hhtt
Macmillan, 1993; Hall N. Semin Pediatr Neurol 1997;4:77–85.)
t
hhtt more extensive oral-motor assessment by a speech pathologist
or pediatric occupational therapist.

Before the age of 2 years, delay may not always equal dis-
order. Research on late-talking toddlers suggests that about NOSOLOGY OF DEVELOPMENTAL
40% of children retained the diagnosis of SLI at ages 3 and 4 LANGUAGE DISORDERS

k rrss
e k rrss
years. This is particularly true if the early language delay is
e e e
primarily expressive. However, many children with early lan-
There is not uniform agreement on the proper nosology of the

o o
o o k o o o k
guage delay who appear to “catch up” go on to have language-
o
DLDs. The fifth edition of the Diagnostic and Statistical Manual
o o
eebb b b
of Mental Disorders (DSM-V) of the American Psychiatric

e / / e b
based learning disabilities (e.g., dyslexia). It is therefore
e
important to recommend periodic reassessment of a child’s
e / e e b
Association (2013) includes DLD under Communication Dis-
ee /
orders, and specifies subcategories of language disorder (“lan-
delay has been diagnosed.
: / / t
/ m
language and academic functioning after an early language
.t.m : / / t
/ m
.t.m
guage disorder” combines expressive and mixed receptive–

t ss:
p /
Children with receptive language impairments are more

p
likely to have a persistent SLI. These children are more likely
t p ss: /
expressive language disorders—this is synonymous with SLI
in common usage), speech-sound disorder (i.e., phonological
p
t
hht t
to have academic and social problems as a result of poor
comprehension of language, and in some cases slowed pro-
t
hht tdisorder), childhood-onset fluency disorder (i.e., stuttering),
and social (pragmatic) communication disorder (in the
absence of autistic features). These constitute general subtypes
cessing of auditory information, which makes it difficult for
of DLDs. A more specific nosology has been proposed by
them to follow a conversation or to follow a spoken lecture.
Rapin (1996) based on psycholinguistic features. The subtypes
Thus concern for poor language prognosis should be height-
are named for the linguistic areas that are most problematic

k e e s
ened when receptive language deficits are identified.
r r s
Speech articulation disorders may be found in isolation or
k e e r rss
(see Table 53-1 and the glossary of terms in Box 53-4).

o o
o o k o o
in association with language disorders. Early articulation
o k
Articulation
o
errors are common and usually mild. However, if there are and Expressive Fluency Disorders
o o
eebb e e
/ b
e b
other features (e.g., excessive drooling or inability to chew
/ Pure Articulation Disorders
food properly) or if a child is not able to be understood virtu-
e ee/ e
/ b
e b
/ / / .
t m m
ally 100% of the time by age 4 years, this should raise concern
t .
about a more serious condition, such as oral-motor apraxia.
: : / / / .
t m m
Articulatory skills improve with age, and as with language
t .
development, the normal range is considerable. Most children

ss : /
A thorough oral-motor examination by the physician will

t p p t p ss
p : /
speak intelligibly by age 2 years. Unintelligible speech is the

t
hht t t
hht t
 t t p
t ss:
p t t p
t ss:
p
434
hht
PART VII Neurodevelopmental Disorders
hht

k e e s
TABLE 53-1 Subtypes of Developmental Language Disorders

r rs Receptive Expressive
k eers
r s Expressive Higher Order

o o
o o k Verbal Auditory
o oo k
Phonological
o Verbal
o
Phonological
o Semantic Lexical

eebb Comprehension—Receptive
Agnosia

ee/ e
/ebb Syntactic Dyspraxia

ee/ e
/ b
e b
Programming Pragmatic Syntactic

Phonology

: / /
↓↓
t
/ .
t m
. m ↓

: / / t
/ .
t m
. m
Syntax
Semantics

t p ss
p : /
↓↓
↓↓
↓
?

t p ss
p : / ↓↓
↓
↓
Production—Expressive
Semantics (lexical)
Syntax
t
hht t ↓↓
↓↓ ↓↓
t
hht t ? ?
↓↓ ↓
↓
Phonology ↓↓ ↓↓ ↓↓ ↓
Repetition ↓↓ ↓ ↓ ↑ ↓
Fluency ↓↓ ↓ N1 or ↓ N1 or ↓ N1 or ↑ ↓

k rss
Pragmatics

ee r
N1 or ↓ N1 or ↓

k ee r rss ↓↓ ↓

ook ook
Nl = normal; ↓ = impaired; ↓↓ = very impaired; ↑ = atypically enhanced; ? = unknown

b
eeboo b o
b o b o
(Modified from Nass R, Ross G. Disorders of higher cortical function in the preschooler. In: David R, ed. Child and Adolescent Neurology. St. Louis,

b
MO: Mosby, 1997; Rapin I. Preschool Children with Inadequate Communication. London: Mackeith, 1996.)

/ e / e o
m ee / e m ee / e
: ///t/.t. m : / /
/t/.t . m
t ss
p :
exception at age 3 years. However, almost 50% of children at

t p
age 4 years still have mild articulation difficulties, primarily
t t tptpss :
mediation paired-associate learning task may help select the
best remediation method for each child because some are

hht
defective use of th or r sounds. At kindergarten entry, one third
of children still have minor to mild articulation defects, but
speech is unintelligible in less than 5%. Verbal Dyspraxia
hht better with symbols and some with signs.

Children with verbal dyspraxia, also called dilapidated speech,

Stuttering and Cluttering are extremely dysfluent. These children are unable to convert

keerrss keerrs
Stuttering is a disorder in the rhythm of speech. The speaker
s an abstract phonological representation into a set of motor
commands to the articulators (i.e., there is a deficit in

b ooook o ook
knows what to say but is unable to say it because of an invol-
untary repetitive prolongation or cessation of a sound. Some
b o oo
phonology–motor conversion). Utterances are short and labo-

b
eeb e e/e b
degree of dysfluency is common as language skills evolve
/
during the preschool years, particularly as the mean length of
e ee/e/e b
riously produced. Phonology is impaired and includes incon-
sistent omissions, substitutions, and distortions of speech

/ / t m
utterance (MLU) reaches 6 to 8 words between ages 3 and 4
.t.m
years. However, stuttering, in contrast to developmental dys-
: / : / / t m
sounds. Children with dysarthria make voicing errors that
.t.m
distort, whereas children with dyspraxia make place substitu-
/
t ppss : /
fluency, is probably a linguistic disorder (errors occur at gram-

t ppss : / tion errors. In conversation, they make phrasal errors. Syntac-

tic skills are difficult to assess in the face of dysfluency.
t
matically important points in the sentence) and a motor

hhtt
planning problem. Typically, onset of stuttering is between the
ages of 3 and 6 years, and reports indicate unassisted recovery
t
hhtt Language comprehension is relatively preserved, but many
children have receptive language problems. Children with
rates of 75%. Thus the prevalence of stuttering as a lifetime verbal dyspraxia who do not develop intelligible speech by
disorder is much lower than its incidence (0.5%–1% vs. age 6 years are unlikely to acquire it later. The frequency with
4%–5%). However, persistence of stuttering may be associated which nonverbal praxis deficits—buccal-lingual dyspraxia

rrss rrss
with other aspects of language impairment, such as difficulty (e.g., positioning muscles of articulation) and generalized

o e
with processing of syntactic information.
k k e o k e
k e
Stuttering is often a genetic trait. Although the cause of
dyspraxia—coexist with verbal dyspraxia is unknown. The
presence of a more diffuse disorder of praxis has significant

o
eebb o o o o o
developmental stuttering is unknown, the main theories are

e b b e b o
therapeutic implications because children with verbal dys-

b o
praxia may depend on signing and writing skills for commu-

ee/
anomalous dominance and abnormalities of interhemispheric
/ e
connections. Cluttering, by contrast, as seen in fragile X syn-
m m e / / e
nication. Developmental coordination disorder (DCD) is
e
: / / t
/ .t.m
drome, is characterized by incomplete sentences and short
outbursts of two- to three-word phrases, along with echolalia,
/ : / /
/ t
/ .t.m
commonly comorbid with speech/language learning disabili-
ties. Young children who are in early intervention programs

t t p
t pss:
palilalia (compulsive repetition reiterated with increasing
rapidity and decreasing volume), perseveration, poor articula-
t t p
t ss:
p
for speech/language delays may have significant coordination
difficulties that will become more evident at kindergarten
hht
tion, and stuttering.
hht age, when motor deficits begin to affect self-care and
academic tasks.
Phonological Programming Disorder
Children with the phonological programming disorder have Disorders of Receptive and
Expressive Language

k e e s
fluent speech, and their MLU approaches normal. Despite
r rs k eers
rs
initially poor intelligibility, serviceable speech is expected.
Phonological Syntactic Syndrome
o o
o o k o o
Language comprehension is relatively preserved. Most such

o
children show delayed rather than deviant phonology and
o k oo
Phonological syntactic syndrome (also called mixed receptive

eebb e e
/ b
e b
improve during school years. It is debatable whether this dis-
/
order is a severe articulation problem or a mild form of verbal
e e /e/ebb
expressive disorder, expressive disorder, and nonspecific
formulation-repetition deficit) is probably the most common
e
: / / / .
tm m
dyspraxia. The fact that patients with phonological program-
t .
ming disorder have more difficulty learning manual signs than
: / / /.tm m
DLD. The phonological disturbances consist of omissions,
t .
substitutions, and distortions of consonants and consonant

t p ss
p : /
do controls supports an association with dyspraxia. A prere-

t p ss
p : /clusters in all word positions. The production of unpredictable

t
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 t t p
t ss:
p t t p
t ss:
p
hht hht
Developmental Language Disorders 435

and unrecognizable sounds makes speech impossible to autistic children. Comprehension is generally acceptable,

k e r s
rs
understand. The syntactic impairment consists of a lack of
e k ee rrss although complex questions and other linguistic forms taxing 53

o o
o o k o oo k
functors and an absence of appropriate inflected endings.
Plurals, third-person singulars, past tense, the auxiliary verb
o
higher-level receptive syntactic skills are often deficient.

o o
eebb e e
/ebb
be, the and a, infinitives (to), and case markings on pronouns
/ OUTCOME OF DEVELOPMENTAL
are particularly vulnerable. Grammatical forms are atypical,
e LANGUAGE DISORDERS ee/ e
/ b
e b
/ / t t m
not just delayed. Whereas a typically developing young child
. . m
may say “baby cry” or “a baby crying,” children with phono-
: / : / / t
/ .
t m
. m
ss : /
logical syntactic syndrome produce deviant constructions,

t p p t p ss : /
Many children with SLI, particularly those with expressive
language impairment, appear to improve in their language
p
t
such as “the baby is cry.” Telegraphic speech is common.

hht t
Comprehension is relatively spared. Semantic skills tend to be
intact. Repetition, pragmatics, and prosody may be normal.
t
hht t
ability by early school age. Others have persistent language
impairment that remains throughout life. There is a high inci-
dence of other problems associated with SLI, including aca-
Autistic children with this DLD subtype produce a significant
demic, behavioral, social-emotional, and psychiatric issues,
amount of jargon.
and these may occur even when language appears to have
Neurologic dysfunction is especially frequent in this
reached the normal range.

k ee s
rs k er
ers
subtype. Sucking, swallowing, and chewing difficulties are
r s
common, and drooling is often persistent. The neurologic
Attention deficit disorder occurs in about 40% of children
with SLI and may cause additional challenges.

b ooook nia, and incoordination.

b ooook
examination may reveal signs of oral motor apraxia, hyperto-

b o
Dyslexia is present in approximately 65% of children with
o
eeb Verbal Auditory Agnosia ee/ e
/ e b / e
/ e b
SLI. Written composition may also be a challenge for these
children. These problems lead to poorer-than-expected school
ee
: // t/.tm
. m
Children with verbal auditory agnosia (VAA) are unable to
: / /t/ tm
performance and a higher dropout rate.
. . m
Adolescents with a history of SLI have a higher likelihood

t p ss
p : / t
VAA may be a developmental condition, apparent from early
p pss
discern meaning from spoken language, despite intact hearing.
: / of peer problems, emotional symptoms, and conduct prob-
lems (Snowling et al., 2006; Conti-Ramsden et al., 2013).

hhtt t t
hht t
life, or an acquired disorder, as in Landau–Kleffner syndrome.
VAA is common in low-functioning children with autism. The
outcome from the developmental form of VAA is generally
Poor receptive language raises the likelihood of emotional and
behavioral difficulties. Anxiety disorder, social phobia, and
depression occur at a high rate in children and adolescents
poor. The outcome from the acquired disorder is somewhat (20%–50%) with a history of SLI. Adolescents with SLI have
better, with approximately one third of patients having a good a lower level of academic achievement than their typically

k e errs
outcome with specific treatment.
s keerrss
developing peers. It is important to note that subtle language
and communication problems may persist into adult life in

b ooookSemantic Pragmatic Syndrome

Higher-Order Language Disorders
b ooook up to 90% of cases and may cause the affected individuals to

oo
be shy in social situations and reluctant to enter into conversa-
b
eeb ee/e/e b e /e/e b
tions with others because of their language problem.
Preschool language skills are the best single predictor of
e
/ / m
.t.m
Children with the semantic pragmatic syndrome (also called

/ t
repetition strength and comprehension deficit, language
: : / / / m
.t.m
later reading ability and disability. Even children with good
t
receptive skills who speak late may be at risk for continuing

t pps s : /
without cognition, cocktail party syndrome) are fluent and

t ppss : /
subtle language difficulties and later reading- and language-

hhttt t
hhtt
often verbose speakers. Vocabulary is often large and some-
what formal. Parents are often encouraged by the child’s size-
able vocabulary, only to find later that the verbosity did not
based academic difficulties. Thus both screening and follow-up
studies of children with SLI are important. Follow up of 112
individuals with SLI into adult life demonstrated lower levels
indicate superior cognitive skills. Many children have trouble of functioning in the areas of communication, educational
with meaningful conversation and informative exchange of attainment, and occupational status compared with their
ideas. Pragmatic skills are lacking. They often show deficits in typical peers. Such studies indicate the need for continued

k e rrss
song quality. They cannot convey the additional pragmatic
e k errss
prosody; their speech has a monotonous, mechanical, or sing-

e
surveillance of individuals with SLI and adequate guidance in
terms of academic and career choices (Young et al., 2002;

o o
o o k o ooo k
intentions that prosody affords, such as speaking with the Johnson et al., 2010).
o o
eebb b b
proper emotion or indicating by tone of voice that they are Early intervention, not only with speech/language therapy

ee/ e
/ e b
asking a question. Comprehension may be impaired. Phono-
logical and syntactic skills are generally intact. / e e b
but also with social skills training and, when indicated, psy-
ee /
chological and career counseling, may help to reduce the long-

Lexical Syntactic Syndrome

: / / t
/ m
.t.m : / / t
term morbidity of SLI.

/ m
.t.m
t p ss:
p / EVALUATION OF THE CHILD WITHs
Lexical syntactic syndrome (LSS) occurs in approximately 15%
t p p : /
AsSUSPECTED
hhtt t
of children with DLD. Speech is generally dysfluent, even to
DEVELOPMENTAL
the point of stuttering, because of word-finding difficulties hhtt
LANGUAGE t
DISORDER
and poor syntactic skills. Both literal and semantic parapha- The workup of the child with a DLD (Box 53-6) must include
sias are common. Most children have delays in word acquisi- an assessment of hearing and an assessment of overall level of
tion and less lexical diversity than their age-matched intellectual functioning, in addition to a thorough language

k e r
e s
rs k eers
counterparts. Verbs appear to be the most difficult lexical cat-

rs
egory for them to learn. Syntax is immature but not deviant.
assessment that includes both receptive and expressive lan-
guage components. Other evaluations that may be warranted

o o
o o k o o
o k
Phonology is spared, and speech is intelligible. Repetition is
o
generally better than spontaneous speech. In conversation,
include tests for auditory processing and neuropsychological

oo
assessments for associated problems such as attention deficit

eebb e e
/ b
e b
idiom use is better than spontaneous speech. In one study,
/
fourth graders with LSS evidenced higher disruption rates at
e
disorder.

e /e/ebb
Certain metabolic disorders can present with isolated lan-
e
: / / / .
tm m
phrase boundaries in narratives than did their age-matched
t .
peers, reflecting lexical and syntactic deficits. Pragmatics may
/ / /.tm m
guage delay, so a metabolic screen is appropriate in some
t .
circumstances. Mitochondrial disorders and organic acidemias
:
t p ss
p : /
be impaired, particularly when this syndrome occurs in

t p ss : /
may have language impairment as their primary feature,

p
t
hht t t
hht t
 t t p
t ss:
p t t p
t ss:
p
436
hht
PART VII Neurodevelopmental Disorders
hht
children with SLI have problems with inferencing, linking

k e r
e s
BOX 53-6 Evaluation of a Child With Suspected
rs Language Disorder
k eers
r s directly observed or stated information to likely outcomes.

o o
o o k oooo k They also have limited working memory capacity, and they are

o
more likely to make errors related to inattention. Thus chil-
o
eebb b b
• Complete neurodevelopmental and family history and

/ ee b
neurologic examination (including social interaction and
communicative behaviors)
ee / e e
/ b
dren with SLI are likely to be at a disadvantage in classroom
/ e
situations, particularly for information presented orally and if
e
• Hearing test

: / / t
/ .
t m
. m : / / t t m
the information is complex. The use of pictorial aids may help
. . m
them encode the information. They may also benefit from
/
t p ss : /
• Office developmental screen (e.g., Denver Developmental
Test, MacArthur-Bates Communicative Development
p t ss : /
having information broken into manageable (shorter) units.
p p
t
hht t
Inventory, Children’s Communication Checklist, Preschool
Language Scale, Early Language Milestones) can be helpful
• Psychometric testing to establish general cognitive function
t
hht t When necessary, medications for treatment of attention
deficit hyperactivity disorder (ADHD) should be considered.
Because there is a high incidence of secondary emotional
problems and self-esteem issues associated with SLI, referral
(a nonverbal intelligence test such as the Leiter International
for psychological counseling should be considered as soon as
Performance Scale–Revised or the Test of Non-Verbal
these problems become apparent. Families should be informed
Intelligence–P:4 or I:3 [TONI-P:4; TONI-I:3] is most

k eers
rs
appropriate in a language-impaired child)

k
• Depending on history and examination, other tests to
er
erss
about their child’s condition and be encouraged to provide a
positive and supportive environment. A multidisciplinary

b ooook consider:

b ooook approach, including physician, speech/language pathologist,

o o
teacher, psychologist, and parents, provides the most effective
b
eeb • Sleep electroencephalogram (EEG)
• Overnight video EEG monitoring
ee/ e
/ e b ee/ e
/ e b
means of helping children with SLI.

: / t/.tm
• Magnetic resonance imaging (MRI) of the brain

. m
• Karyotype, fragile X, microarray study, fluorescent in situ
/ : / /t/.
REFERENCES

tm. m
The complete list of references for this chapter is available online at

t p ss
hybridization (FISH) probes

p : /
• Metabolic screen (e.g., urine organic acids, blood amino
tp pss : /
www.expertconsult.com.
acids)
t
hht t t
hht t See inside cover for registration details.

SELECTED REFERENCES
Badcock, N.A., Bishop, D.V., Hardiman, M.J., et al., 2012. Co-
particularly in the first few years of life. Numerous other syn- localisation of abnormal brain structure and function in specific
dromes can present predominantly with language delay. language impairment. Brain Lang. 120 (3), 310–320.

k eer ss
An electroencephalogram (EEG) should be considered in
r keerrss
a child with DLD if there is a history of a language regression
Bates, E., Reilly, J.S., Wulfeck, B., et al., 2001. Differential effects of
unilateral lesions on language production in children and adults.

b ooook b oook
or a suspicion from the history that the child might have sei-
o
zures. Neuroimaging studies are not likely to be helpful unless
Brain Lang. 79, 223–265.

oo
Bishop, D.V.M., Hayiou-Thomas, M.E., 2008. Heritability of specific

b
eeb /e e b
there are abnormal findings on the neurologic examination.
ee / e /e/e
Behav. 7, 365–372.

e b
language impairment depends on diagnostic criteria. Genes Brain

TREATMENT
: / / t
/ m
.t.m : / / t m
Conti-Ramsden, G., Mok, P.L., Pickles, A., et al., 2013. Adolescents

.t.m
with a history of specific language impairment (SLI): strengths and

/
p ss : /
Whether intensive early therapy changes the long-term
t p t ppss : /
difficulties in social, emotional and behavioral functioning. Res.
Dev. Disabil. 34 (11), 4161–4169.

t
hhtt
outcome to an appreciable degree remains to be determined.
Treatment of language-disordered preschool children varies
according to the kind of language impairment and its degree
t
hhtt
Johnson, C.J., Beitchman, J.H., Brownlie, E.B., 2010. Twenty-year
follow-up of children with and without speech-language impair-
ments: Family, educational, occupational, and quality of life
outcomes. Am. J. Speech Lang. Pathol. 19 (1), 51–65.
of severity (Warren and Yoder, 2004). Preschool children with Rapin, I., 1996. Preschool Children With Inadequate Communica-
moderate to severe language impairment may benefit from a tion. Mackeith Press, London.
special education preschool for language-impaired children.

rrss rrss
Snowling, M.J., Bishop, D.V., Stothard, S.E., et al., 2006. Psychosocial
Mildly impaired children may do well in a regular preschool outcomes at 15 years of children with a preschool history of

o k e e k
program combined with individual speech/language therapy.
k o e
k e speech-language impairment. J. Child Psychol. Psychiatry 47 (8),

o
eebb o o b o
b o
Floor time–based language therapy provides a naturalistic and
o
developmentally appropriate way of working on language skill
e
759–765.

e b o
b o
Vernes, C., Newbury, D.F., Abrahams, B.S., et al., 2008. A functional

e / / e
development. Formal language work typically begins at the

m e
phonologic level, involving repetition of sounds and sound ee/ e
genetic link between distinct developmental language disorders.
/
N. Engl. J. Med. 359, 2337–2345.

m
: / /
/ t
/ .t.m
sequences to encourage fluency. Treatment of receptive disor-
: / t
/ .t.m
Warren, S., Yoder, P., 2004. Early intervention for young children with

/
language impairment. In: Verhoeven, L., van Balkom, H. (Eds.),
/
t p
t ss:
ders often necessitates the use of visual modalities, such as

p
signs and gesture. Less severe disorders of comprehension are
t t t p
t ss:
Classification of Developmental Language Disorders. Lawrence

p
Erhbaum, Mahwah, NJ, pp. 367–384.

hht
addressed through practiced structuring of conversations with
the child. Children with severe comprehension deficits rarely
progress as well in treatment as do children with primary
hht Young, A.R., Beitchman, J.H., Johnson, C., et al., 2002. Young adult
academic outcomes in a longitudinal sample of early identified
language impaired and control children. J. Child Psychol. Psychiatry
expressive disorders. 43, 635–645.
Children with significant auditory processing disorders
E-BOOK FIGURES AND TABLES

k e e s
may benefit from a systematic computer-based approach to
r rs k e r
improving the speed of auditory processing, although benefits
e s
rs
o o
o o k
from this type of intervention remain controversial.

o o
oo
Some classroom accommodations may be necessary for thek The following figures and tables are available in the e-book

oo
eebb b b
at www.expertconsult.com. See inside cover for registration

e e
/ b
child with SLI to succeed. Children with SLI may require addi-
/ e
tional help from a resource specialist or tutor. They may
e
details.

ee/e/e b
Box 53-2 Disorders Commonly Associated with Language

/ / / .
tm m
require additional time for giving reports and for taking tests.
t .
Whenever possible, presentation of oral information should
: : / / t. m
. m
Delay/Impairment

/ t
ss : /
be accompanied by visual aids. In support of previous research,

t p p t p ss
p : /
Box 53-5 Differential Diagnosis of Language Delay/Disorder

t
hht t t
hht t