CHAPTE R

4 Childhood Language
Disorders
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Learning Objectives
When you have finished this
chapter, you should be able to:
4.1 Describe language
development through the
lifespan.
4.2 Characterize language
disorders and associated
disorders.
4.3 Explain the process of
assessment in language
disorder.
4.4 Describe the overall design
of language intervention.

© Robert Kneschke/Shutterstock

Language disorders, as you’ll see, come in I recall being confronted by a 4-year-old sister, arms
may shapes and sizes. I’ve spent much of my akimbo, who challenged, “You’re making my little
professional life working with children and adults who sister work!”
are just beginning to communicate, getting them started “Yes, we are.”
and after much consultation with family and teachers, Her sister, a late starter, went on to use single
mapping out language that will work best for the child. words and then to combine them into short phrases,
Initially, intervention may be getting a child to such as no eat, go up, ride bike, more juice, and the
communicate by any means, crafting situations like. She eventually began to use short sentences,
in which communication works for the child. For such as Daddy go car. At this point, the structure
example, a child who enjoys “floaty” toys in the tub of language became very important. By first grade,
may now be required to point to the storage basket to although still experiencing language difficulties, she
have the toys dumped in. Children who have not been was ready to begin school with some assistance and
required to communicate or have had every need continued language intervention.
anticipated may resist at first. —Robert Owens

Language disorders are a complex group of both disorders and delays with
a wide range of characteristics, levels of severity, and causes. Some chil-
dren may exhibit disorders in which language is inappropriate, inefficient,
or ineffectual; others use language that is seemingly immature. A word of
2023. Pearson.

89
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Farinella; Introduction to Communication Disorders : A Lifespan Evidence-Based Perspective Account:ehost.
 90 Chapter 4 Childhood Language Disorders

CASE STUDY Jayden

Just like other new parents, Jayden’s mom and (SLP) for an evaluation. They were surprised by the
dad awaited their first child with heightened many questions the SLP asked concerning Jayden’s
anticipation. He was born full term, with no early social development. She explained speech and
complications, and seemed healthy. Although language development to them, especially the early
he had some difficulties nursing and seemed acquisition of intent to communicate, which is
uninterested in eating, these problems were expressed initially in gestures.
attributed to his being a generally fussy baby Although the SLP did not diagnose Jayden
who seemed unable to be comforted. as having autism spectrum disorder (ASD), she
As Jayden developed, he met physical recommended that he be enrolled in a social play group
developmental milestones but seemed to lag for late talkers and strongly suggested that they should
slightly in social and cognitive development. have him evaluated at a local hospital by an ASD team,
The pediatrician assured his parents that there if only to rule it out as a cause of his delay and his
is wide variability across infants and that boys increasing acting-out behavior.
often develop more slowly than girls. His mother
As you read the chapter, think about:
described him as irritable and quick to cry. He
often had temper tantrums, especially when it was • Other explanations beyond the ASD label that
time to eat, bathe, or go to bed. Because of these might explain Jayden’s disorder
increasing behavior outbursts, Jayden’s parents • Possible evaluative procedures that could be used
took him from the home less often than they had to measure Jayden’s language
previously. • Possible targets that the intervention team
When Jayden had not spoken by 18 months, his might choose to help Jayden develop and use
parents took him to a speech-language pathologist language

advice before we begin: It might be helpful to review the parts of language, such
as syntax and semantics, mentioned in Chapter 2 because disorders can affect all
aspects of language.
The term language disorders applies to a heterogeneous group of developmental
and/or acquired disorders that principally affect the use of spoken or written lan-
guage for comprehension and/or production and may involve the form, content,
and/or function of language. Consider the following comments about this defini-
tion of language disorders:
• Individuals with language disorders are very different from each other. The
disorder may occur at any time within the lifespan, and individuals vary
in terms of symptoms, manifestations, effects, and severity over time. The
communication context, content of the communication, and learning task
are also contributing factors to language disorders.
• The disorder may be a result of atypical development and/or may be acquired
as a result of accident, injury, or other environmental factors.
• Deficits and/or immaturities may exist in one or more means of com-
munication. For example, preschoolers with language disorders are often
less able to recognize and copy letters. They are also less likely to write and
draw, to pretend to read, and to ask questions during parental reading

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 Childhood Language Disorders 91

(Marvin & Wright, 1997). In short, young children with language dis-
orders are at risk for literacy difficulties when they later attend school
(Nathan et al., 2004).
• One or more aspects of language—form, content, and use—may be affected.
For example, as a group, children with language disorders use shorter,
less elaborate sentences than typical children their age (Greenhalgh &
Strong, 2001).
It is unclear whether most children with language disorders exhibit disorders in
other areas of development as well, but language deficits persist at least through the
primary school years for many children (Tomblin et al., 2003). In the classroom
and even on the playground, children with language disorders, especially boys and
those with severe receptive language deficits, may be reticent to speak and may
lack social maturity and exhibit behavioral problems (Hart et al., 2004; Huaquing
Qi & Kaiser, 2004).
It’s estimated that at the time of school entry, approximately 10% of children
will have severe enough language disorders to hinder academic progress. In a study
of over 12,000 children, it was reported that the prevalence of language disorders
was 9.92% (Frazier Norbury et al., 2016). Even this figure may be low.
According to a recent national report by the U.S. Social Security Adminis-
tration’s Supplemental Security Income Program, children in low-socioeconomic
(SES) families are more likely than the general population to exhibit all types of dis-
abilities (McNeilly, 2016). Although approximately 21% of children live in low-SES
households, 26% of children with speech and language disorders live in these
same households.
Noticeably absent from our definition of language disorders are language dif-
ferences, such as those found in some dialectal speakers and in English learners
(ELs). Differences do not in themselves constitute a disorder and do not require
clinical intervention by an SLP, although elective assistance is possible at the
client’s or family’s request.
You can find easy-to-read guides to language disorders and other communica-
tion disorders at the American Speech-Language-Hearing Association website at
[Link]. Go to the lower portion of the page and select “Public” at the right,
and then select “Speech and Language Disorders and Diseases.”
Box 4.1 presents a conversation between a teacher and a child with a language
disorder. Notice the child’s repetition and confusion. For example, the child misunder-
stands the question about who walks the dog and responds with a reference to a leash.

BOX 4.1 Example of a Conversation with a Child with a Language Disorder

Teacher: Does your family have a pet? Child: Got a pet.

Child: Yeah. Teacher: Yes, and I really want to hear about him.
Teacher: Tell me about this pet. Child: Got with my . . . ah, go with my . . . Dad go
Child: Got a pet. with . . .

Teacher: Um-hm, tell me about the pet. Teacher: Your dad walks the pet.
(continued)

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 92 Chapter 4 Childhood Language Disorders

Child: No, me. Child: Me dog.

Teacher: Oh, you and your dad walk the pet. Teacher: Oh, it’s your dog. Who walks your dog?
Child: No, me. Child: With one of them things, you know.
Teacher: Oh, just you walk the dog. Teacher: What things? Who walks your dog?
Child: No, me. Child: With them things like this.
Teacher: I’m confused. Teacher: Yes, you use a leash.

Theoretically, all To guide you through this complicated topic, this chapter briefly looks at
speakers of a language typical language development followed by a discussion of language disorders. As an
should be able to SLP, you’ll need to know both. Of necessity, this discussion is an overview, with
communicate. Some details left for further study. You’ll have additional courses in both development
differences may be and disorders.
so great as to impair
communication but not
qualify as a disorder.
Language Development Through the Lifespan
Learning Objective 4.1 Describe language development through the lifespan.

As you already know, language is complex; thus, any attempt to describe its
development is also very complicated. In the following sections, we cover only the
highlights of child and adolescent development and relate these to some of
the disorders to be discussed later in the chapter. An outline of language development
is presented in Table 4.1.

TABLE 4.1
Language Development Through the Lifespan

Age Accomplishments

3 months Responds vocally to partner.

8 months Begins gesturing.
12 months First word spoken. Words fill intentions previously signaled by gestures.
18 months Begins combining words on the basis of word-order rules.
2 years Begins adding bound morphemes. Average length or mean length of utterance
(MLU) is 1.6–2.2 morphemes.
3 years More adult-like sentence structure. MLU is 3.0–3.3 morphemes.
4 years Begins to change style of talking to fit conversational partner. MLU is 3.6–4.7
morphemes.
5 years Ninety percent of language form learned.
6 years Begins to learn visual mode of communication with writing and reading.
Adolescence Able to participate competently in conversations and telling of narratives.
Knows multiple meanings of words and figurative language. Uses a gender style,
or genderlect, when talking.
Source: Based on Owens (2020).

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 Language Development Through the Lifespan 93

Pre-Language
Much of your first year of life was spent learn-
ing to communicate. Parents talk to a newborn
as if the child understands what the adults are
saying. Later on, as children begin to compre-
hend language in limited ways, parents and care-
givers modify their style of talking to maximize
comprehension and participation by the child.
Shortly after birth, you became actively
involved in a reciprocal process with your
family. Sensitive mothers vary their rate of
speech based on their infants’ rate of respond-
ing (Hane et al., 2003). To maintain attention,
a parent or caregiver exaggerates their facial Parents talk to their newborn as if the child already
expressions and voice and vocalizes more often. understands what they are saying.
In turn, the infant responds with eye contact or © Pollyana Ventura/E+/Getty Images
sound making, called vocalizing.
As an infant you were a full partner in this interaction, and your behavior was Children become
influenced by the communication behavior of your caregivers. Gradually, your communicators because
babbling became more speechlike and mature, containing syllables rather than even as newborns they
individual sounds. are treated as if they are
During the first 3 months, caregivers’ responses teach children the “signal” communicators.
value of specific behaviors, and infants learn a stimulus–response sequence. If they
signal—by crying, for example—caregivers respond. In addition, they learn that
a relatively constant stimulus or signal, such as a bottle, results in a predictable
response, such as feeding. The bottle “signals” feeding as words will do later.
By 3 to 4 months, rituals and game playing have emerged. Rituals, such as Games and rituals share
feeding and diaper changing, provide children with predictable patterns. As they many characteristics
learn that interactions can unfold in predictable ways, they begin to form expec- with conversations.
tations of events and to participate more. In addition, games such as “Peekaboo”
and “I’m Gonna Get You” have many of the aspects of communication. There
is an exchange of turns, rules for each turn, and particular slots for words
and actions.
At about 8 to 9 months, you developed intentionality in your interactions, Early intentions, such as
primarily through gestures. For the first time, your behavior was meant to influence attracting attention, are
the other person. The intention to communicate is signaled in gestures accompa- established in gestures,
nied by eye contact with a partner, the use of consistent sound and intonational and first words fill these
patterns for specific intentions, and persistent attempts to communicate. These same functions, often
intentional vocalizations or sounds are different from the sounds infants use in with the accompanying
solitary activities like play (Papaliou & Trevarthen, 2006). gesture.
As an infant, you probably said your first meaningful word at around
12 months. Real words are produced by infants with or without accompanying
gestures to accomplish communication purposes, such as requesting, that were
previously filled by gestures.
To develop spoken language, children must be able to store sounds, use this
information for later comparison and identification, and relate these sounds to
meaning. During the first year, an infant learns the sound patterns of the native
language. Better speech perception at 6 months of age is related to better word
understanding, word production, and phrase understanding later (Tsao et al., 2004).

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 94 Chapter 4 Childhood Language Disorders

An infant’s perceptual ability is usually tuned to their native language’s speech

sounds and syllables by 8 to 10 months of age.
Babbling is important in the emergence of first words, although other factors,
such as gestures and maternal education, may be important in later lexical or
vocabulary growth (McGillion et al., 2017). The frequency of various phonemes
in a child’s babbling influences the words that a child first begins to say (Edwards
et al., 2015). This said, young children seem to operate at a holistic or whole-word
level, meaning children do not seem to build a word bit by bit from various pho-
nemes (Vihman, 2017).
The task of learning language and learning to represent and to symbolize is
strongly related to cognitive abilities. Representation is the process of having
one thing stand for another. For example, in play a hand towel might be used as a
blanket for a doll. Symbolization is using an arbitrary symbol, such as a word or
Pearson eTextbook sign, to stand for something.
Video Example 4.1 Even minimal exposure to multiple languages enhances an infant’s com-
This video features a munication skills, including those of children who are effectively monolingual
conversation between a mother
(Liberman et al., 2017). This may be because infants growing up in a multilin-
and her 1-year-old daughter.
Note how the child attempts
gual environment have different social experiences that may affect early com-
sounds and words and the way munication skills. Different social experiences may provide children with the
in which her mother prompts opportunity of taking another person’s linguistic perspective early in the language
her to do so. development process.

Toddler Language
By 18 months you, like many other children, probably could produce approximately
50 single words and were beginning to combine words in predictable ways. Within
a few short months, three- and four-word combinations appeared. Accompanying
the increases in utterance length and vocabulary is a decrease in the use of babbling,
or sound making.

CASE STUDY Jayden (continued)

Recall that Jayden at 18 months of age was not saying any words.

Use
People who are unfamiliar with young children’s language often think that chil-
dren either imitate all first words or use them only to name. In fact, single words
are used to make requests, comments, inquiries, and more.
As mentioned, words are acquired first within the intentions that the child
is able to express in previously acquired gestures. Several early intentions are pre-
sented in Table 4.2. Note all the uses or intentions expressed in the conversation
presented in Box 4.2.

Content and Form

Vocabulary growth is slow for the first few months, but then increases rapidly.
Although the ability to comprehend words develops gradually, it is highly con-
text dependent at first (Striano et al., 2003). Eighteen-month-olds are capable of
learning associations of new words and the things to which they refer in as few as

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 Language Development Through the Lifespan 95

TABLE 4.2
Examples of Early Intentions of Children

Intention Example

Wanting demand Says the name of the desired item with an insistent voice. Often accompanied
by a reaching gesture.
Protesting Says “No” or the name of the item while pushing it away, turning away, and/
or making a frowning face.
Content questioning Asks “What?” or “That?” or “Wassat?” while pointing and/or looking at an item.
Verbal accompaniment Speech accompanies some action, such as “whee-e-e” when swung or “uh-oh”
when something spills.
Greeting/farewell Waves hi or bye with accompanying words.
Note: A fuller list can be found in Owens (2020).

BOX 4.2 Example of Toddler Language

Stacy and her mother are talking while they are Mom: Mommy has crayons. Mommy’s coloring.
coloring. Note that the language concerns the task. What’s mommy making?
Stacy’s mom keeps her utterances short and cues Stacy
Stacy: Doggie.
to respond by asking questions. Stacy participates by
talking about the task, often incorporating part of the Mom: A doggie.
previous utterance into her own:
Stacy: Okay.
Mom: What are you making?
Mom: All right, I’ll make a doggie. Is this the
Stacy: Doggie. doggie’s tail?

Mom: Are you making a doggie? Oh, that’s nice, Stacy: Doggie’s tail. More.
Stacy. Mom: More doggie?
Stacy: Where more doggie? Stacy: Okay.
Mom: Is there another doggie underneath? Mom: Can Stacy color? Hum?
Stacy: Yeah. Stacy: More doggie there. More doggie daddy.
Mom: Where? Can you find the picture? Is that what Mom: More doggie daddy?
you’re looking for, the picture of the doggie? Where’s
a doggie? Stacy: Want a more doggie. More doggie. Put more
doggie there.
Stacy: A doggie. Color a doggie.
Mom: Okay, you color the doggie on this page.
Mom: Okay, you color the doggie. What color’s your doggie?
Stacy: Mommy color crayon. Stacy: Blue. Color this page, mommy.

three exposures (Houston-Price et al., 2005). By age 2, a toddler has an expressive

vocabulary of about 150 to 300 words. Two-year-olds with larger vocabularies also
use a greater range of grammatical structures (McGregor et al., 2005).
Each toddler has their own lexicon, or personal dictionary, containing words
that reflect that child’s environment. In general, toddlers’ definitions are not the
same as those of adults because they are based on each child’s limited experience.

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 96 Chapter 4 Childhood Language Disorders

The frequency of caregiver child-directed speech is an important predictor of lexi-

cal development (Hansen, 2017) but quantity is only part of the picture. More
important is the quality of caregiver speech. For example, among 24-month-old
Black children from low-SES backgrounds, the quality of wh- questions used by
fathers is associated with toddlers’ vocabulary and later verbal reasoning skills
(Rowe et al., 2017).
Adult and toddler Interestingly, expressive language use also affects expressive vocabulary devel-
definitions are very opment (Ribot et al., 2017). In other words, using language increases vocabulary.
different. Toddler Early word combinations follow predictable patterns. Some individual words
definitions are based are joined with other individual words, such as “Throw ball.” Neither word may be
almost exclusively on combined with other words. In contrast, some words are combined with several
experience, whereas others, as in “Eat cookie,” “Eat cracker,” “Eat candy,” and the like. Finally, other
adult definitions words are used flexibly in several different combinations, as in “Mommy drink,”
are based more on “Drink juice,” and “More drink.” A child’s short utterances represent a complex
meanings shared with interaction of syntactic or word order knowledge, cognitive ability, communicative
others.
goals, and the structure of the conversation (Valian & Aubry, 2005).

Preschool Language
Language learning is For preschoolers, most communication occurs within the framework of conversa-
a lengthy process that tions with parents or caregivers. With increased memory, children with typically
involves identifying developing language (TDL) expand their conversational skills to include recounting
patterns, hypothesis the past and remembering short personal stories. This memory and recall are aided
testing, and refinement. by the child’s increased language skills.
A high percentage of preschool children’s utterances differ only slightly from
utterances produced previously. For example, a child might say, “Doggies are
yucky,” “Kitties are yucky,” “Cows are yucky,” and the like, substituting different
words in the same frame (Lieven et al., 2003).
From interaction with others, children with TDL notice patterns and use these to
produce ever more complex language. This process takes time and begins one utter-
ance at a time. Caregivers in each child’s environment provide feedback and models
for further growth (Chouinard & Clark, 2003). For example, in a reformulation,
an adult might respond to “Tommy come ’morrow my birthday” with “Yes, tomor-
row your cousin Tommy is coming to your birthday party with all the other kids.”
Individual children differ. Some children—maybe you—are risk takers who
attempt new structures and make mistakes. Other, more cautious children may
make few errors because they attempt to produce new structures infrequently
(Rispoli, 2005).

Use
In conversations with caregivers, preschool children introduce topics and maintain
them for an average of two to three turns. It is often easier for a preschool child to
introduce a new topic than to continue an old one, as in the following example:
Child: I got a new bike.
Partner: What color is it?
Child: Red.
Partner: Did you ride it on your birthday?
Child: Mommy saw a spider.

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 Language Development Through the Lifespan 97

In conversations, preschool children begin to consider that the listener needs to

know certain information and the amount of information needed and that there is
a need to change conversational style when speaking to younger children. Style of
talking is also reflected in role playing and narration or storytelling. Four-year-old
children can tell simple sequential stories, usually about past events.

Content
Children’s expressive vocabularies grow to approximately 300 words by age 2, then
mushroom to 900 and 1,500 at ages 3 and 4, respectively (see Box 4.3). They may
comprehend two or three times that many words in context.
Words are learned quickly through a process called fast mapping, in which the
child infers the meaning from context and then uses the word in a similar manner.
Fuller definitions evolve over time.
In addition to single words, preschool children acquire words and phrases that Adult-like forms of many
are used to join other words and create longer units of language. These include sentences evolve during
locational terms such as in, on, and under; temporal terms such as first and last; the preschool years.
quantitative terms such as more than; qualitative terms such as bigger than; familial
terms such as brother; and conjunctions such as and, if, so, but, and because.
In part, semantic development reflects cognitive development. For example,
4-year-olds demonstrate categorization skills that seem to indicate more advanced
procedures for storage of learned information than are seen in younger children.

BOX 4.3 Example of Preschool Language

G and B are young 4-year-olds. They are playing with G: Mine will only stand.
firefighter hats, dishes, and dolls. Notice how different
B: Mine sat.
this sample is from the toddler language in Box 4.2.
Each child supports her portion of the conversation. G: All done with supper. What kind of spoon is this?
The syntax seems adult-like, but the content is pure
B: A plastic one, what else? Now it’s time for me to
preschool. The rapid change of topics gives this sample
make my own dinner.
a nonsensical quality. With no adult to maintain a
cohesive topic structure, this is a free-for-all with only G: Time for me too. I have to use this. My baby has to
one or two turns on each topic before it shifts: go to bed now. We have to first change their diapers.
G: And I gonna wear both of these. B: No we don’t.
B: At the same time? No, I’m wearing this one. G: Come here, look.
G: I’m wearing this one. B: There’s a button. I want something to drink.
B: And then I do this. G: Okay, I’ll give you some. Look at this. Watch this.
I’m gonna try and make this stand. Do you think this is
G: You wear this and I’ll wear this.
a girl or a boy?
B: Two colored cups. You drink out of this one. I drink
B: A boy.
out of the big one. I’m putting the box up there.
G: Oh, cause the boy has the pants on and the girl has
G: Okay, I will have this and you have this.
the dress on.
B: Stay up there.
B: Happy birthday to you.
G: She doesn’t look too happy.
G: Grab everythin’ up. I’m grabbing most of the doll
B: Uh-oh. Why did I spill it? stuff.

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 98 Chapter 4 Childhood Language Disorders

As a child’s vocabulary increases, categorization will become increasingly important

for storage and word finding.
Interestingly, among both monolingual English and EL preschoolers, expres-
sive language skills are related to vocabulary growth (Ribot & Burridge, 2018).
The most important factor seems to be a child’s conversational experience with
adults, which impacts cognitive functioning more than other factors such as SES
(Romeo et al., 2018).
When they try using novel words, children are also influenced by the response
behaviors of others and by the interaction involved in building a conversation
together (Tolins et al., 2017). The partner’s level of acceptance, overall demeanor,
and cooperative effort help the child build a lexicon.
Form
Pearson eTextbook
Video Example 4.2 During the preschool years, changes in language form are very dramatic. Beginning
This video features a with two- to four-word sentences when you were age 2, you probably acquired 90%
conversation between a mother of adult syntax by age 5. For English-speaking preschoolers, language becomes more
and her 4-year-old son. Note how complex as it becomes longer. We can describe children’s language development
much his grammar has improved by calculating the average, or mean length of utterance (MLU), in morphemes.
from the level of his 1-year-old
The calculation of MLU is discussed later in this chapter. Some MLU values are
sister. He uses sentences and is
able to construct a story from a
presented in Table 4.1.
familiar book. The simple constructions found in the utterances of 18- to 24-month-olds
form the basis for a more elaborate grammar, and by age 3 most children’s utter-
ances contain both a subject and a verb. This basic structure is elaborated with the
addition of articles, adjectives, auxiliary verbs, prepositions, pronouns, and adverbs.
In addition, adult-like negative, interrogative, and imperative sentence forms
evolve. For example, a toddler negative consisting of No cookie is modified by words
such as no, not, can’t, don’t, and won’t being placed between the subject and verb,
as in Mommy can’t catch me. Other negatives such as wouldn’t, couldn’t, is not, and
isn’t are added later.
Similarly, interrogatives or questions go from single words—such as Doggie?
and What? or Wassat?—to more complex questions that ask what and where; fol-
lowed developmentally by who, which, and whose; and, finally, when, why, and
how, and a more mature form in which the verb or auxiliary verb and the subject
are reversed from the statement “She is happy” to form “Is she happy?” or “Why
is she happy?” Repeatedly hearing caregiver questions can have a beneficial effect
on a preschooler’s development of adult-like questions (Valian & Casey, 2003).
Early sentences consist of only one clause. A clause, like a sentence, has both
a subject and an accompanying verb. By the end of preschool, children with TDL
are joining two or more independent clauses together to form compound sen-
tences. Late preschoolers can also attach dependent clauses to independent clauses
to form complex sentences such as I didn’t like the big dog that barked at grandpa
last night. “That barked at grandpa last night” is a clause but not a sentence and
cannot stand alone, so it’s called a dependent clause and must be attached to an
independent clause, which can stand alone and can be a sentence. These structures
appear infrequently in preschool; they develop slowly and are refined throughout
the school-age years.
Several bound morphemes are added during the preschool years. These include
the progressive verb ending -ing, as in jumping; plural -s, as in cats; possessive ’-s
(or -s’), as in mommy’s; and the past tense verb ending -ed, as in talked. As might
be expected, it takes children some time to acquire the use of these morphemes,

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 Language Development Through the Lifespan 99

and it is not uncommon to hear words such as eated, goed, sheeps, and foots. The
learning of some low-frequency endings is still underway for many children into
ages 5 and 6 (Tomas et al., 2017).

REFLECTION QUESTION 4.1

At what ages would you say children are able to participate in communication,
comprehend language, or hold up their end in a simple conversation? On what
would you base these decisions?

School-Age and Adolescent Language

When children begin to attend school, they start the long process of establishing
their identity independent of their family. Most communication now occurs in
conversations outside the home. In part, the status of adolescents within their own
social grouping is determined by communication skills.
The means of communication change in school as children learn to read and write.
In turn, this skill enables children to use computers, tablets, and cell phones, and it
opens a whole new world of information. This development is discussed in Chapter 6.
Reading and writing development is related to metalinguistic skills, which
enable a child to consider language in the abstract, to make judgments about its
correctness, and to create verbal contexts, such as in writing. Younger children are
unable to make such judgments, especially without a supporting nonlinguistic con-
text. I once asked a 3-year-old if the sentence Daddy painted the fence was correct.
Her reply was laughter and the response, “No, daddy painted my closet.”
Five-year-olds with TDL use very adult-like language form, although many of
the more subtle syntactic structures are missing. In addition, these children have
not acquired some of the pragmatic skills that are needed to be truly effective
communicators.
As children learn language, they form models or constructs that are used for vari-
ous language tasks. Up through early elementary school, children depend on a single
form for various language tasks (Anthony et al., 2014; Bornstein et al., 2014; Language
and Reading Research Consortium, 2017). As language becomes more complex and
develops new uses, such as literacy, this model becomes more multidimensional.
Over the next few years, language development slows and begins to stabilize,
but it will be nonetheless significant. Many complex forms and subtle linguistic
uses are learned in the adolescent period. The preschool emphasis on development
of language form becomes less prominent and semantic and pragmatic develop-
ment blossom.
Conversation continues to be the primary locus of communication, and chil-
dren and adolescents learn to be more effective and efficient communicators. Inter-
actional lessons from the family form a basis for the deepening relationships with
peers (Whitmire, 2000). In contrast, a child such as Jayden in our Case Study may
be at a real disadvantage given his lack of conversational skill.

Use
During the early school-age years, children’s language use changes in two ways:
Conversational skills continue to develop, and conversational narratives expand
and gain all the elements of mature storytelling. Children with TDL learn effective

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 100 Chapter 4 Childhood Language Disorders

Even with the ways to introduce new topics and to continue and to end conversations smoothly
development of writing, and appropriately. While in a conversation, they make relevant comments and
conversation is still the adapt their roles and moods to fit the situation. In addition, school-age children
predominant use for learn to make even more and increasingly subtle assumptions about the level of
language. knowledge of their listeners and to adjust their conversations accordingly.
Within conversation, teens demonstrate more affect or emotion and discuss
topics infrequently mentioned at home. The number of turns on a topic increase
greatly. Although interrupting increases, it evolves into behaviors, such as asking
pertinent questions, that serve to move the topic along.
Narratives, both in conversation and in writing, gain the elements needed in
our culture to be considered satisfying. American English narratives contain an
introductory setting statement and a challenge or challenges that the characters—
often the speaker—overcome. Events are organized both sequentially and by cause
and effect.

Content
Vocabulary continues to grow, but number of words is only the most superficial
measure of semantic change. First-graders with TDL have an expressive vocabulary
of approximately 2,600 words but may understand as many as 8,000 root English
words, such as happy, and possibly 14,000 when various derivations are included,
such as unhappy and happily. Aided in school, this receptive vocabulary expands to
approximately 30,000 words by sixth grade and to 60,000 words by high school. As
a bright young adult, you may have close to 100,000 words in your receptive store.
Definitions become more dictionary-like, which means they become less expe-
riential or less based on individual experience and more shared, more categorical
(as in An apple is a kind of fruit), and more precise. Multiple word meanings are
also acquired. The ability to provide definitions is related to the acquisition of
metalinguistics, mentioned previously (Benelli et al., 2006).
With vocabulary increases, children find new ways to organize their language
Pearson eTextbook
Video Example 4.3 for storage and retrieval. Words with similar meanings (i.e., rich-wealthy), category
This video features a
membership (i.e., pets) or thematic clustering (i.e., associated with birthday party)
conversation between a mother aid memory by minimizing cognitive energy while maximizing navigation between
and her 7-year-old son. As words (Stella et al., 2018). The resultant neural networks consist of several types
with the other children in this of relationships operating simultaneously.
section, he is being raised as School-age children also learn to understand and use figurative language.
a bilingual German-English Unlike literal meanings, figurative language does not always mean what it seems
speaker. Note that the child
to mean. For example, idioms are expressions that often cannot be understood liter-
easily holds up his end of the
conversation, making relevant
ally, such as “hit the road” or “off the wall.” Figurative language enriches com-
and appropriate comments munication, requires higher language functions of interpretation, and correlates
and displaying a range of with adolescent literacy skills (Dean Qualls et al., 2003). Some forms are not
intentions. comprehended until adulthood.

Form
Following the rapid development of language form in preschool, there is a gradual
slowing, although development continues. Many forms continue to develop into
adolescence.
By age 5, children with TDL use most verb tenses with common verbs and
auxiliary or helping verbs, such as would, should, must, and might; possessive pro-
nouns (his, hers, yours); and the conjunctions and, but, if, because, when, and so.

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 Language Disorders 101

They still have some difficulty with multiple auxiliary verbs, as in should have been.
Five-year-old children also have limited use of the comparative -er, as in bigger, and
superlative -est, as in biggest; relative pronouns used in complex sentences (I know
who lives next door); gerunds (We go fishing); and infinitives (I want to eat now).
Many syntactic structures appear slowly, and children may struggle with acqui-
sition well into the school years (Eisenberg et al., 2008). During the school years,
children gradually add passive sentences, such as The cat is chased by the dog, in
which the entity performing the action is placed at the end rather than the begin-
ning of the sentence; reflexive pronouns, such as myself, yourself, himself, and
themselves; conjunctions, such as although and however; and variations of com-
pound and complex sentences. It frequently takes a child several years of practice to
gain complete control of these linguistic structures. And children may use some
forms, such as the conjunctions though and although, correctly in speech before
they fully understand the relationships expressed (Cain et al., 2005).
Morphological development focuses on derivational suffixes—word endings
that change the word class, such as adding -er to a verb to make a noun, as in
paint/painter—and prefixes. Development of prefixes, such as un-, ir-, and dis-, will
continue into adulthood.

Language Disorders
Learning Objective 4.2 Characterize language disorders and associated disorders.

Across children with language disorders, prelinguistic development is a relatively

stable measure and predictor of later language development. In other words,
children who lag behind in early communication development are likely to have
later language disorders (Määttä et al., 2016). Children identified as late-talkers
at 24 to 31 months are likely to have a weakness in language-related skills in late
adolescence (Rescorla, 2009).
Let’s make some general statements about language disorder before we get
more specific. Children with expressive vocabulary delays at 24 months of age are
at increased risk for later speech/language problems and need for SLP services. Late-
talkers have an ongoing weakness in language
that continues through the preschool years and
into early adulthood (Rescorla & Turner, 2015).
Children with TDL and those with language dis-
orders have similar but divergent developmental
paths. Although both groups have more rapid
language growth in preschool, language growth
of those with TDL appears to slow at age 7 while
those with language disorders do so at age 5
(Schmitt et al., 2017). These facts do not bode
well for Jayden, a late-talker who may have ASD.
Children with language disorders have
poorer academic attainment (Schoon et al.,
2010), fewer social relationships (Durkin &
Conti-Ramsden, 2007), less independence
(Conti-Ramsden & Durkin, 2008; Howlin Children with TDL and those with language disorders
et al., 2000), peer neglect, and bullying—chronic have similar but divergent developmental paths.
stressors that can lead to social-emotional © Angela Hampton/Angela Hampton Picture Library/Alamy Stock Photo

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 102 Chapter 4 Childhood Language Disorders

problems (Barkley, 2006; Tomblin, 2014) and poorer employment (Clegg et al.,
2005; Howlin et al., 2000) than their peers with TDL. A nationwide longitudinal
study in the United Kingdom found that when compared to peers with TDL, chil-
dren with language disorders had poorer outcomes in literacy and in mental health
as well as in employment, even at 34 years of age (Law et al., 2009).
As we saw, language is extremely complex, so it would seem logical to assume
that language disorders would be also. So many things can go wrong at so many
junctures that each child with a language disorder represents a unique set of
circumstances.
Although language disorders are found across children, some children are more
susceptible. The biggest risk factors for language disorder include (Brignell et al.,
2018; Harrison & McLeod, 2010; McNeilly, 2016; Zambrana et al., 2014):
• Being male
• Having ongoing hearing problems
• Having a more reactive temperament
• Coming from a low SES background
• Exhibiting poor early communicative skills
• Having a family history, suggesting a genetic and/or environmental link in
some cases
• Having a low IQ
The risk of being a late-talker at 24 months is strongly associated with being a
boy, low SES, not being an only child, older maternal age at birth, moderately low
birth weight, low-quality parenting, receipt of no day care or for less than 10 hours
a week, and hearing and attention problems (Harrison & McLeod, 2010; Scheffner
Hammer et al., 2017).
Researchers are also identifying important genetic factors that account for
variance in children’s conversational language skills (DeThorne et al., 2008). For
example, a family history of writing and reading difficulties greatly increases the
odds for late-onset and persistent language disorder (Zambrana et al., 2014).
The effect that any disorder has on communication and on language develop-
ment varies with the severity of the disorder and the age of the child. As individuals
mature, the communicative requirements change. It’s easy to assume from these
data that children with language disorders perform like younger children with
similar language skills. That would be incorrect and would overlook the struggles
of these children.
In this section, we discuss several types of language disorders. Of necessity, we
discuss groups of children under different categories. Although categories are help-
ful for discussion of shared characteristics, they are not the same as individuals.
Each of us and each child with a language disorder is unique.

Broad Groupings
We can roughly divide children with language disorders into two broad groups:
those children with seemingly unexplained language problems and those who have
other co-occurring or comorbid conditions, such as ASD, that affect their language
development and use. Our discussion begins with children who seem to exhibit
only language disorders with no associated disorders. Then we look at language
disorders co-occurring with other disorders.

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 Language Disorders 103

TABLE 4.3
Categories of Language Disorders

Categories Disorders

Language disorders in the Developmental language disorder (DLD)

absence of other disorders Social communication disorder (SCD)
Language disorders Autism spectrum disorder (ASD)
associated with other Intellectual developmental disorder (IDD)
disorders Learning disability
Brain injury
Late language emergence (LLE)
Childhood schizophrenia
Selective mutism (SM)
Otitis media (middle ear infection)
Cochlear implants
Disorders due to exposure to drugs and alcohol in
utero
Disorders due to abuse and neglect

Unfortunately, we are unable to cover all possible language disorders. Table 4.3
presents the language disorders we do discuss.
Some concomitant disorders have been omitted because of the small numbers
of children or the paucity of research data. In others, such as Tourette syndrome,
language difficulties are tangential. In addition, hearing impairment and deafness
have also been excluded because these individuals are more thoroughly discussed
in Chapter 12. Children may also exhibit language disorders as a result of localized
brain injury, which is discussed in Chapter 7.

Language Disorders in the Absence of Other Disorders

According to one study, the prevalence of language disorders with no know ori-
gin nor association with other existing disorders is 7.58% of all children (Frazier
Norbury et al., 2016). These children will be the bulk of those you might see as
a school-based SLP. The two disorders found in this category are developmental
language disorder and social communication disorder. Because there are no co-
occurring disorders, SLPs diagnose children as having these disorders.

Developmental Language Disorder

Developmental language disorder (DLD) is defined by what it is not. There is no
obvious cause and DLD seems not to affect nor be affected by anatomical, physical,
or intellectual problems. The language problems of children with DLD are not the
result of other co-occurring disorders.
These children are underidentified or identified late, if at all, especially if they
are not male, White, or from well-educated high-SES families (Catts et al., 2012;
Frazier Norbury et al., 2016; P. L. Morgan et al., 2016; Wittke & Spaulding, 2018).
A general lack of awareness of DLD results in inadequate service delivery (McGregor
et al., 2020). DLD is replacing an older term, specific language impairment (SLI),
although you may encounter SLI in texts and journals.
Children with DLD seem typical in other ways except language. They
have a seemingly unexplained deficit in language abilities despite appropriate

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 104 Chapter 4 Childhood Language Disorders

environmental stimulation and cognitive abilities and no neurological disorders

(Bishop et al., 2017; Leonard, 2014; National Institute of Deafness and Other
Communication Disorders, 2017). Although intelligence ranges across the scale,
many children with DLD are in the low normal range for nonverbal or nonlan-
guage intelligence (Gallinat & Spaulding, 2014).
An analysis of several studies identified five risk factors, not causes, that are
Pearson eTextbook predictive for the majority of children with DLD, including (Rudolph, 2017):
Video Example 4.4
• Late language emergence
The “DLD and Me” site,
sponsored by Boys Town • Maternal education level
National Research Hospital, • Five-minute Apgar score (a health measure used with newborns)
has a number of videos on DLD.
Go to the website at www
• Birth order
.[Link]/topics/videos/ • Biological sex

Lifespan Issues. A majority of children with DLD is likely to experience the

following:
• High risk for reading disorders (Catts, 2004; Catts et al., 2014)
• Low academic achievement and increased risk for stopping education at the
high school level (Tomblin, 2014)
• Peer relationship difficulties (Durkin & Conti-Ramsden, 2007)
• Heightened risk for peer victimization and bullying (Redmond, 2011)
• Increased risk for being identified as having attention deficit hyperactive
disorder
• Increased social anxiety (Brownlie et al., 2016)
In addition, the majority of children with DLD are perceived more negatively by
both teachers and peers (Segebart DeThorne & Watkins, 2001).
Given that communication is fundamental to the initiation and maintenance
of successful relationships, it’s not surprising that children with DLD often have
peer problems. In addition, these children have increased emotional difficulties
(St. Clair et al., 2019). These challenges may arise from deficits in both language
and social cognition, the ability to process, store, and apply information about
other people and social situations. Thus, forty percent of 7- and 8-year-old children
with DLD report physical bullying in school compared with 10% of children with
TDL (Redmond, 2011). Children who are victimized report higher levels of sadness
and fear. These children withdraw and engage in more individual play and outlier
behaviors (Hart et al., 2004; Liiva & Cleave, 2005). Their reticence is characterized
by staring at other children but not reacting, doing nothing even when there are
many opportunities, and demonstrating fear of approaching other children.
Because language and literacy play an increasingly larger role in adolescent
independent functioning, teens with DLD are less independent than their peers
with TDL (Conti-Ramsden & Durkin, 2008). As these teens transition into adult-
hood, parents and caregivers express concern about several aspects of their behavior
(Conti-Ramsden et al., 2008). Young adults with a history of language disorder
enter adulthood less socially confident than their peers with TDL (Durkin et al.,
2017; Wadman et al., 2008). For many children with DLD, brain imaging indicates
brain symmetry in the left and right hemispheres, unlike the usual asymmetry
of left-side predominance in language processing regions (Ors et al., 2005).

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 Language Disorders 105

Further investigation using magnetic resonance imaging suggests that many chil-
dren with DLD exhibit different patterns of brain activation and coordination,
reflecting less efficient patterns of functioning, including reduced activation in
the brain areas critical for communication processing (Ellis Weismer et al., 2005;
Hugdahl et al., 2004). In general, children with DLD have increased integration
of the parietal lobe and decreased integration of the frontal lobe on encoding and
decreased integration of the parietal lobe on decoding.
Many but not all children with DLD show marked deficits in working memory
abilities (Archibald & Joanisse, 2009) and executive function. Working memory
(WM) is an active process that allows limited information to be held in a tem-
porarily accessible state while cognitive processing occurs (Cowan et al., 2005).
Tasks that are particularly demanding from either a storage and/or a processing
perspective result in fewer resources being available for other aspects of the task.
Children with WM deficits, such as those with DLD, exhibit learning difficulties
(Swanson & Beebe-Frankenberger, 2004). Relative to age-matched TD peers, many
children with DLD show several significant limitations in WM mechanisms and in
processing speed. These deficits can, in turn, have a negative impact on language
learning and functioning.
Executive function, located in the frontal lobe of the brain, is the organiz-
ing and directing function of the brain. These functions will vary depending on
the cognitive task. Preschool children with DLD demonstrate executive function
deficits in both visual and linguistic tasks and in problems with both inhibition
control and cognitive flexibility (Pauls & Archibald, 2016; Yang & Gray, 2017).
Many children with DLD also have difficulty controlling auditory attention in both
quiet and noisy situations (Victorino & Schwartz, 2015).

Language Characteristics. DLD is a persistent language disorder. Therefore,

it’s likely that a child with DLD will become an adult with poor language skills,
especially in language form.
Children with DLD begin to use single words and to combine words later than
children with TDL. Language growth is similar to but less advanced and growth
slows even more in preadolescence (Rice, 2012, 2017).
Among school-age children and adolescents with DLD, there is a deficit in
the ability to detect regularities in language, such as verb endings and sentence
structure. In contrast, children with TDL use these patterns to determine the under-
lying language rules. This problem stems, in part, from reduced auditory WM. If a
child has difficulty mentally holding a sentence to process it, they have little cog-
nitive energy left to notice patterns that represent underlying rules. In addition, to
compensate for reduced WM, children with DLD may shorten their own sentences
by omitting smaller, less essential units, such as morphological endings.
In conversation, where most language is learned, many things are occurring
at once that require both of these abilities in order to focus on language. Children
with DLD have deficits in their ability to recognize to express emotions (Brinton
et al., 2007). Social perception skills, such as understanding the thoughts and
emotions of others, affect children's communication abilities.
Children with DLD often have vocabulary disorders, seen in their smaller
receptive vocabulary (Rice & Hoffman, 2015). Both semantic and phonological
deficits contribute to word-learning difficulties (Gray, 2005). In short, children
with DLD have limited semantic knowledge, which, in turn, contributes to their
frequent word errors (McGregor et al., 2002). In part, these semantic issues may

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 106 Chapter 4 Childhood Language Disorders

reflect a difficulty inhibiting similar-sounding words while processing language

(Mainela-Arnold et al., 2008).
A relationship exists between executive function and word learning. Preschool-
ers with DLD perform more poorly than peers with TDL on measures of both
executive function and novel word learning (Kapa & Erikson, 2020). Compared to
peers with TDL, school-age children with DLD demonstrate more effortful cogni-
tion during language comprehension. This contrasts with the more automatic word
processing of children with TDL (Montgomery et al., 2018).
Language comprehension and processing are active processes based on the
auditory message, contextual information, and stored world and word knowledge.
Not surprisingly, school-age children with DLD exhibit significant deficits in
spoken sentence comprehension. Much of this difference can be explained by
memory-based deficits, but we still need more research (Montgomery et al., 2016).
The comprehension and production of complex syntactic structures is restricted
in the majority of children with DLD (Frizelle & Fletcher, 2014a, 2014b; Riches
et al., 2010). This limitation is related to memory difficulties, especially with
sequence-specific information (Hsu & Bishop, 2014; Marton et al., 2006).
Morphological endings and shorter words, such as pronouns, are especially dif-
ficult. As small units of speech, morphemes receive little stress and may be difficult
for a child to identify. Thus, children with DLD often make errors with verb end-
ings, pronouns, and auxiliary verbs (Goffman & Leonard, 2000; Redmond & Rice,
Pearson eTextbook
Video Example 4.5
2001). These children exhibit an ongoing maturational lag in language form com-
pared to age-matched and language-matched peers with TDL (Rice et al., 2009).
In this video is another
description of DLD that In summary, we can say that children with DLD have difficulty (1) learning
includes children with the language rules, (2) registering different contexts, and (3) constructing word–
disorder. meaning associations. The result is difficulty in morphological and phonological
[Link]/ rule learning and in vocabulary development. Pragmatic problems result from
watch?v=tQ-s02HWLb0 inability to use effective forms to accomplish their intentions.
Social Communication Disorder
With this disorder, you might be asking, “Isn’t all communication social?” The
answer, of course, is yes. We can define social communication as “social interac-
tion, social cognition, pragmatics (verbal and nonverbal), and receptive and expres-
sive language processing” (Adams, 2005, p. 182). That’s a mouthful. In general,
it’s the ability to communicate with a variety of partners in various situations not
only through language but through nonlinguistic means, such as facial expression
and eye contact (Curenton & Justice, 2004; Inglebret et al., 2008).
These behaviors vary by culture and also with situations and partners. For
example, lack of eye contact may signal disinterest in general American culture but
be considered polite in other cultures, such as Korean or Japanese.
Social communication disorder (SCD) is persistent difficulty in the social
use of verbal and nonverbal communication and may include problems in all
those areas. Given that many children with ASD exhibit interactional difficulties,
there might be some confusion. As we’ll see later, one characteristic of ASD is
the presence of restricted and repetitive interests and behaviors (RRIBs). Children
with SCD do not exhibit RRIBs (Cholemkery et al., 2016; Swineford et al., 2014;
Timler, 2018a).
SCD is a relatively newly identified disorder, recognized only in 2013 in the
fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
of the American Psychiatric Association. The presence of SCD can limit effective

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 Language Disorders 107

communication and social participation, negatively affect relationships, and lead

to academic and vocational problems.
The causes of SCD may be many and varied and reflect related disorders. Causes
may be biological or may reflect neurological conditions, mental disorders and/or
overall developmental delays.
Precise estimates of the prevalence of SCD are difficult to determine because
of the somewhat ambiguous definition and the validity of the assessment criteria
(Swineford et al., 2014). Pragmatic language disorders occur in about 7.5% of
kindergarten children (Ketelaars et al., 2009) but many are undiagnosed. The rate
is much higher (23%–33%) among children previously diagnosed with language
disorders (Ketelaars et al., 2009). Pragmatic disorders are 2.6 times as prevalent
in boys as in girls.

Lifespan Issues. A young child with SCD may not respond differentially to the
faces of others or to games or sound-making activities. As infants, these children
may prefer aloneness and not respond to or imitate others. They may not initiate
interactions or gesture to express their intentions.
Given the social nature of language development, a child with SCD may be
slow to develop language. At age 4, when children with TDL are becoming aware
of their own and others’ ability to think and reason, children with SCD may fall
behind in emotional understanding and expression. Because delayed development
may mirror a number of disorders or simply reflect typical individuality, it is dif-
ficult to diagnose SCD in young children. Diagnosis is rare before age 4. Children
with mild SCD may not be diagnosed until adolescence.
As preschool and school-age children, those with SCD may become socially
isolated. The lack of both language and social skills makes them less desirable play
and study partners. Their poor language skills, especially the pragmatics of conver-
sation and storytelling, result in difficulties with literacy. They may be inflexible in
conversation and talk at rather than with their peers. As teenagers, children with
SCD may be bullied by other students because of their lack of social skills.

Language Characteristics. In general, the characteristics of SCD include prob-

lems with communication for social purposes. These include deficits in interac-
tional skills, social cognition, pragmatics, and language. Interactional skills include
adjusting your communication style to your partner. For example, around age 4, we
begin to talk differently with younger children than we do with adults. Children
with SCD may have difficulty adjusting their language to different communication
partners, especially in politeness and role recognition. Cooperative tasks such as
play and conflict resolution may be difficult.
Social cognition includes understanding and regulating our emotions as they
affect others and involves something called theory of mind (ToM). ToM is an
evolving notion in children that others have a mind and emotions that differ from
their own and that these must be considered in communication.
The pragmatic aspect of language includes using language to accomplish our
intentions and clearly signaling our intention to our conversational partner. This is
accomplished through linguistic and nonlinguistic means such as body language.
Children with SCD may experience difficulty interpreting the intentions of oth-
ers and encoding their own intentions. Conversations may be incoherent, with
frequent abrupt topic shifts. Events may be related in a confused manner. As men-
tioned, nonlinguistic behaviors may be inappropriate or odd, sending confusing

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 108 Chapter 4 Childhood Language Disorders

messages that may not match the words spoken. Children with SCD may also have
difficulty interpreting the gestures, facial expressions, and other body language
of others.
Common language characteristics of SCD include (American Speech-
Language-Hearing Association [ASHA], 2019):
• Inappropriate and inadequate greetings
• Lack of flexibility in changing language and communication style for
different settings or partners
• Difficulty producing and comprehending narratives
• Awkward engagement in all aspects of conversation, such as initiating or
entering a conversation, maintaining the topic, and turn taking
• Poor repair of communication breakdowns
• Inadequate, ineffective, or confused verbal and nonverbal signals used to
regulate conversational interactions
• Misinterpretation of the verbal and nonverbal signals of others
• Difficulty understanding ambiguous or figurative language and information
not explicitly stated
Not all communication is explicit. As a participant, you sometimes must infer
a speaker’s meaning. When a partner says, “Do you think it’s warm enough in
here?” they may be subtly asking you to turn up the heat. Children with SCD may
be very literal in their interpretations of such indirect comments.

Language Disorders Associated with Other Disorders

The following discussion begins with children with language disorders co-
occurring with ASD. We then proceed through learning disability, intellectual
developmental disorder, neurocognitive disorders such as traumatic brain injury,
language disorders associated with maltreatment and neglect, and finish with
some less frequent disorders.

Autism Spectrum Disorder

According to DSM-5, for a child or an older individual to be diagnosed as having
autism spectrum disorder (ASD), they must have all of the following:

• Persistent problems in social communication and interaction across

different contexts. Deficits do not result from general developmental
delays, such as those in intellectual disability. Problems are seen in all of
the following:
■ Social-emotional reciprocity
■ Nonverbal communicative and social interaction behaviors
■ Developing and maintaining relationships appropriate for maturity level
• Restricted, repetitive patterns of behavior, interests, or activities character-
ized by two or more of the following:
■ Stereotyped or repetitive motor movements, use of objects, or speech
■ Excessive reliance on routines, ritualized patterns of behavior, or
resistance to change

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 Language Disorders 109

■ Highly fixated and restricted, abnormally intense interests or focus

■ Hyper- or hyposensitivity and reactivity to environmental input or
unusual interest in sensory information

Taken together, these characteristics limit and impair daily functioning. Think of
our friend Jayden at the beginning of the chapter as we discuss ASD.
What the characteristics mean are that many but not all children with ASD
have abnormal social interactions and failure in the give-and-take of conversation;
poorly integrated verbal and nonverbal communication, including eye contact and
body language; difficulty adjusting to different social situations and stereotypical
motor patterns; and echolalia, or repetition of others’ speech, repetitive use of
objects, and repetition of certain expressions. For example, when the teacher says,
“It’s time to clean up,” the child may “echo” or repeat the phrase over and over
again. In general, the more severe the symptoms, the poorer the individual’s lan-
guage and overall development (Pry et al., 2005).
Motor patterns of behavior may include rocking and a fascination with lights
or spinning objects. In addition, a child may insist on certain routines or be pre-
occupied with specific objects, foods, or clothing. Paired with these preferences, a
child with ASD may have an adverse reaction to other sounds or textures. One child
in a camp situation had approximately a half-dozen outfits consisting of exactly
the same articles of clothing. Another would eat only foods of certain colors and
textures. Recall Jayden’s behaviors.
ASD is much more common than previously believed. In the United States,
according to the Centers for Disease Control and Prevention (CDC; 2018c), ASD
affects approximately 1 in every 44 children. These data are similar to that reported
in Asia, Europe, South America, and Canada. ASD is four times as common in males
as in females who tend to have less restricted and repetitive behavior compared to
males of similar age and severity (Knutsen et al., 2019). Although 44% of children
identified with ASD have average to above-average intellectual ability (CDC, 2022),
approximately 25% of children with ASD also exhibit intellectual developmental
disorder (IDD) (Chakrabarti & Fombonne, 2001; Fombonne, 2003).
At present, many researchers are trying to identify the early signs of ASD.
Early identification can lead to early intervention. The Autism Spectrum Disorder
Foundation website ([Link]) provides some possible early warning signs.
Select “About Autism” and then “Identifying the Disorder.”
The primary causal factors in autism are biological. The incidence of ASD is
highest among males and those with a family history of autism. The family pat-
tern suggests a genetic basis for the disorder. For example, at least 15% of children
with ASD have a genetic mutation not inherited from either parent (Sebat et al.,
2007; Zhao et al., 2007). This is even higher for those with more severe forms
of the disorder. In addition, between 2 and 6% of children with ASD also have
fragile X syndrome, a genetic mutation of the X chromosome associated with IDD
(Belmonte & Bourgerone, 2006). In addition, approximately 20% of children with
Down syndrome also have ASD (DiGuiseppi et al., 2010; Oxelgren et al., 2017;
Warner et al., 2014).
The average medical expense for a family of a child with ASD is $4,110–6,200
annually (CDC, 2022). Intensive behavioral intervention for a child may cost an
additional $40,000–60,000 per year (Amendah et al., 2011).
Differences in processing incoming information also suggest a neurologi-
cal basis for ASD. Individuals with ASD experience difficulty in analyzing and

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 110 Chapter 4 Childhood Language Disorders

integrating information, resulting in a tendency to fixate on one aspect of a com-

plex stimulus—often some irrelevant, minor detail. Although more research is still
Pearson eTextbook needed, cross-sectional neuroimaging to date reveals abnormalities in primary sen-
Video Example 4.6
sory areas of the brain (Lainhart, 2015).
What is life like for someone Overall cognitive processing by children with ASD has been characterized as a
with high-functioning ASD? In
gestalt, in which unanalyzed wholes are stored and later reproduced in identical
this video, sponsored by the
New York Times, an adult with fashion. The storage of unanalyzed information may account for the way in which
ASD talks about his life and individuals with ASD become quickly overloaded with sensory information. Storage
experiences. of unanalyzed wholes also might hinder memory. It’s difficult to organize informa-
[Link]/ tion on the basis of relationships between stimuli if those stimuli remain
watch?v=qDXo83OtzgE unanalyzed.

Lifespan Issues. Neural studies suggest that the eye and face detection process-
ing of children with autism may be delayed, explaining in part the early failure to
bond with caregivers (Grice et al., 2005). In addition, infants with autism show
no difference in brain response to familiar and unfamiliar faces, supporting the
notion of a facial processing disorder (Dawson et al., 2002).
At present, children with ASD are identified by the time they are 2 or 3 years
of age. Although early intervention (EI) is critical to maximizing outcomes for
children with ASD, EI is often difficult to obtain because of the late age of most
diagnoses. Although no babbling or gesturing by 12 months is an early sign,
it’s not possible at this time to make a definitive diagnosis prior to 24 months
of age (Woods & Wetherby, 2003). Although symptoms are present in early
childhood, they may not manifest fully until social demands exceed a child’s
limited capacities.
Parental behavior can result in more promising outcomes. Positive emo-
tional behavior or affect by the mother and her use of multimodal initiations
and responses are associated with more positive affect, vocalizations, gaze to face,
and multimodal bids or responses among infants with ASD (Schwichtenberg
et al., 2019). Multimodal behaviors include facial expressions, gestures, and
speech.
School-age children and adolescents with ASD may be included in regular
education classes or be in special classes, depending on the severity of the disorder.
In some children, the severity of ASD lessens with age. For example, a young child
with ASD whose behavior is disruptive may have fewer outbursts as a teenager.
People with milder forms of the disorder may be able to live on their own and
hold competitive employment. Unfortunately, the vast majority of people with
severe ASD require lifelong supervision and care; many have adult life patterns
similar to those of adults with ID.

CASE STUDY Jayden (continued)

Jayden was diagnosed with ASD and enrolled in a special preschool. He received
speech and language services in the classroom daily, and his parents continued
intervention at home under the direction of an SLP. Intervention was primarily in
the form of play. By age 5, Jayden signed approximately 50 single words and spoke
about 10 words with a variety of purposes, primarily to request.

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 Language Disorders 111

Language Characteristics. As a group, children with ASD demonstrate sig-

nificant delays in language and communication, especially in pragmatics (Tager-
Flusberg et al., 2005). A communication problem is often one of the first indicators
of possible ASD. At 18 months, Jayden was not speaking.
Between 25 and 60% of individuals with severe ASD remain nonspeaking
throughout their language life. Some autistic children who use speech and language
demonstrate immediate or delayed echolalia, which is a whole or partial repetition
of previous utterances, often with the same intonation. For example, a child named
Mickey would say little during the day but store things said to him and repeat them
in sequence before he went to sleep at night. In contrast, another child, Adam,
would echo immediately. Without his preschool SLP’s use of sign, Jayden may have
also remained nonverbal or minimally verbal.
For some children, echolalia might either be a language processing strategy or
signal agreement with the previous utterance. Even when echolalia decreases, other
problems, especially those related to pragmatics, persist in the child’s language.
Most children with ASD who learn to talk go through a period of using echolalia
(Prizant et al., 1997).
Even those with high-functioning ASD (HFA) have difficulty with the non-
verbal aspects of communication. I remember a college student with HFA relating
that he couldn’t trust what people said because their body language and gestures
didn’t make sense. Although we find a reliance on gestures by children with other
language disorders, those with ASD exhibit a deficit in both oral language and
nonverbal communication (Perrault et al., 2018).
ASD affects pragmatics and semantics more than language form. Syntactic
errors seem to represent a lack of underlying semantic relationships. Prosodic fea-
tures or suprasegmentals, such as stress, intonation, loudness, pitch, and rate, are
often affected, giving the speech of children with ASD the sometimes-mechanical
quality mentioned. Individuals with ASD often have peculiarities and irregu-
larities in the pragmatics of conversation. The range of intentions is often very
limited and may consist solely of demands and, in severe cases, unintelligible
vocalizations. Recall that most of Jayden’s speech served a requesting function
or purpose.
Some individuals incorporate entire verbal routines, called formuli, into their Pearson eTextbook
communication. For example, a child might repeat part or all of a television Video Example 4.7
commercial to indicate a desire for the item that had been in the advertisement. The Oregon Speech-Language
A formula represents the person’s attempt to overcome the difficulty of matching & Hearing Association has a
the content and form of language to the communicative context. Adults with mild number of videos on working
ASD who have good language skills might still misinterpret some of the subtleties with children with ASD. Go to
the website at [Link]
of conversation.
[Link], scroll
As with any other disorder, ASD offers a challenge to parents. The National down to “Short Film Series,”
Institute of Mental Health website ([Link]) has a helpful parents’ and select “Visit our channel.”
guide to ASD. Select “Autism Spectrum Disorder” at the right, then “Brochures and You can also find one of their
Fact Sheets” at the top. There are several other disorders you can also explore on videos at this link: [Link]
this site. .com/watch?v=4rivpFzwMl8

Intellectual Developmental Disorder

Previously termed mental retardation and commonly called intellectual disability
in educational circles, intellectual developmental disorder is the designation
found in DSM-5. The simpler term intellectual disability can be confusing because

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 112 Chapter 4 Childhood Language Disorders

medically it applies to other cognitive impairments, such as dementia and trau-

matic brain injury. So, for these reasons, we use IDD.
IDD is a neurodevelopmental disorder characterized by intellectual difficulties
as well as difficulties in conceptual, social, and practical areas of living. The disorder
has three aspects (American Psychiatric Association [APA], 2013):
• Deficits in intellectual functioning confirmed by clinical evaluation and
individualized standard IQ testing
• Deficits in adaptive functioning that significantly hinder an individual's
independence and ability to meet their social responsibilities
• Onset during childhood, hence the word developmental
In recognition that IQ is only one factor, the focus is on the types and intensities of
supports needed by an individual to lead a normal and independent life. In general,
a child with IDD is affected in all areas of conceptual or intellectual development
and social and daily living skills. Approximately 2.5% of the population are indi-
viduals with IDD, which in practical terms is intellectual functioning significantly
below the general population or below an IQ of approximately 70. Nonetheless, the
designation of IDD reflects several different components of functioning.
Children with IDD differ in severity and other factors, such as amount of home
support, living environment, education, type of IDD, mode of communication, and
age. Some individuals are nonverbal and need round-the-clock care whereas some
adults function well in society, have employment, and are married. The range of
severities of IDD are presented in Table 3.4. Although these classifications are based
on daily living skills, the criteria are somewhat non-specific and for that reason
older classification based on IQ is included.
As we move from mild to profound IDD, we find an increase in co-occurring dis-
orders. Children with profound IDD often have multiple disorders. The most frequent
co-occurring disorders are cerebral palsy and seizure activity. In addition, children
with severe to profound IDD more often have chromosomal syndromes, such as
Down syndrome and fragile X syndrome, which are discussed later in this section.
Several websites provide more information on IDD. The National Institute
of Child Health and Human Development website ([Link]/health/
topics/idds/conditioninfo) is a good place to begin your research of intellectual
and developmental disabilities.
Causes of IDD are almost as varied as individuals. Two large categories of pos-
sible causal factors are biological and socioenvironmental. These factors may be
complicated by cognitive limitations that can affect the processing of incoming
and outgoing information such as speech and language. Biological factors include
the following:
• Genetic and chromosomal abnormalities
• Maternal infections during pregnancy
• Toxins and chemical agents
• Nutritional and metabolic causes
• Gestational disorders affecting development of the fetus
• Complications from pregnancy
• Complications from delivery
• Brain diseases

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 Language Disorders 113

Socioenvironmental factors include a stimulation-impoverished environment, poor

housing, inadequate diet, poor hygiene, and lack of medical care. The effect of each
of these factors varies with each child.
In the United States, SES is a determinant of health. In general, those with a
low-SES background have poorer health overall, poorer nutrition, and poorer access
to education and health care, and a higher incidence of disabilities (Graham,
2015). The prevalence of mild to moderate IDD among children of color from
low-SES backgrounds is more than twice as high as that among children from
middle- or high-SES backgrounds (Bhasin et al., 2006; Boyle et al., 2011; Van
Naarden Braun et al., 2015). That said, race and ethnicity are not causal factors as
much as factors related to low SES. In addition, these same children are less likely
to receive educational services (Gary et al., 2019). Severe IDD is more random in
relation to race/ethnicity and SES.
IQ is not the entire picture. For some individuals with IDD there may be other Individuals with
cognitive processing differences. Incoming sensory information, such as sounds, intellectual disability
are processed by first attending to a stimulus, then perceiving differences and like- may process incoming
nesses, organizing and storing the information, and finally retrieval from memory. sensory information
When compared to peers with TDL, some individuals with IDD do not rely on differently from those
organizational strategies that link words and concepts to one another. Nor do they without disability.
spontaneously rehearse information for easy retrieval. Information stored poorly
can lead to memory or retrieval problems. To some extent, memory is affected by
the type of input. In general, individuals with IDD have more difficulty with audi-
tory input, especially linguistic, than with visual input.
Incoming language information undergoes several types of decoding. Simulta-
neous synthesis occurs all at once and extracts overall meaning. Successive synthesis
is more linear, occurring one at a time. Although individuals with IDD exhibit some
difficulty with both types, those with Down syndrome have much greater difficulty
with successive processing, possibly reflecting poor auditory working memory.

Lifespan Issues. Some newborns and infants with IDD are identified early
because of obvious physical factors, such as syndromes or anatomical anomalies,
at-risk indicators such as low birth weight or poor physical responses, or delayed
development. Intervention may begin at home or in special EI programs in which
a child is seen by a team of medical and educational specialists. It is best for the
child if intervention begins as soon as possible. EI focuses on sensorimotor skills
such as eye–hand coordination, physical development, and social and communica-
tive abilities. An individualized family service plan specifying services is written in
collaboration with caregivers.
Some children with IDD are not identified until age 2 or 3. These youngsters,
along with those previously identified, will likely attend a special preschool. They
may receive intervention services, such as physical therapy, special education, or
speech-language therapy, in either the home or school.
Depending on the severity of a school-age child’s IDD, they may either attend
a regular education class and receive special services or receive education in a
self-contained, special classroom. Education and training will focus on academic
skills, daily living and self-help activities, and vocational needs, depending on the
abilities of the child.
Only children with the most profound IDD accompanied by other disabilities
reside in developmental centers. Generally, children who cannot reside at home live in
community residences with 8 to 10 other children their age and with house parents.

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 114 Chapter 4 Childhood Language Disorders

Mike, a man with profound IDD and cerebral palsy, lived at home with his
older parents as an infant and preschooler. As he matured and his parents aged,
Very few individuals with Mike was placed in a community residence with other young adults with IDD.
intellectual disability He received daily care at this center and was able to continue his education at the
live in large institutions. same school. Most of his training involved daily living skills and use of assistive
Since the 1970s, a communication.
All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law.

philosophy called In adulthood, living and working arrangements vary widely. People with milder
deinstitutionalization has IDD often live in the community and work competitively in minimally skilled jobs.
been responsible for the More severely involved individuals may live with family members or in community
movement of individuals residences containing a small group of similar adults. They may work in a special
with IDD into small workshop or be enrolled in a day treatment program in which education and train-
community residences.
ing continue to be the focus.

Language Characteristics. Children with IDD vary greatly in their commu-

nication abilities. For example, children with Down syndrome (DS) and fragile
X syndrome (FXS) have moderate to severe delays in communication develop-
ment in all areas of language (Roberts et al., 2001). In phonology, boys with
FXS make errors similar to those of younger, typically developing youth, whereas
those with DS have more significant phonological differences than might be
expected by delayed development alone (Roberts et al., 2005). In contrast,
boys with FXS produce longer, more complex utterances than do boys with DS
(Price et al., 2008).
Boys with FXS perform differently in conversation than boys with Down
syndrome. Although both groups make more off-topic responses than boys with
TDL, those with FXS use more repetitive speech (Roberts et al., 2007). Boys with
ASD and boys and girls with FXS co-occurring with ASD have more off-topic
language and more repetitions than those with TDL and FXS without ASD (Martin
et al., 2018).
Late school-age children and adolescents with FXS are less likely to signal non-
comprehension than younger, cognitively matched children with TDL (Thurman
et al., 2017). Likewise, although capable of requesting clarification when com-
munication breaks down, children with IDD are less likely to do so within
conversations.
Boys who have FXS with and without ASD and boys with DS produce shorter,
less complex utterances than do boys with TDL (Price et al., 2008), although the
utterances of boys with FXS are more complex than those of boys with DS. In
general, children with FXS show significant syntactic growth during the preschool
years but seem to plateau or, in some cases, to decline during early school age
(Komesidou et al., 2017). Longitudinal studies indicate that language challenges
persist for both boys and girls with FXS (Brady et al., 2020).
For many individuals with IDD, language is the single most important
limitation. For approximately half of the population with IDD, language compre-
hension and/or production is below the level of cognition. This might be indicative
of cognitive processing problems that accompany IDD. For example, those with DS
exhibit auditory working memory deficits (Seung & Chapman, 2000).
In initial language development, individuals with ID follow a similar but
slower developmental path than that of typically developing children. Even so,
these children often produce shorter, more immature language forms (Boudreau
& Chapman, 2000). In later development, the paths begin to differ more from
2023. Pearson.

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Farinella; Introduction to Communication Disorders : A Lifespan Evidence-Based Perspective Account:ehost.
 Language Disorders 115

typical development. All areas of language exhibit some delay and disorder in chil-
dren with IDD.

Learning Disabilities
Learning disability (LD) is an educational term defined in the Individuals with
Disabilities Education Act (IDEA; 2004), a U.S. federal education law. DSM-5 uses
the medical term specific learning disorder (SLD), and there is considerable overlap
(Cortiella & Horowitz, 2014). Given the wording in IDEA and the common usage
in education, we use the more general term learning disability or LD.
IDEA defines learning disability as:
• Involving one or more of the basic psychological processes
• Affecting the understanding or use of spoken and/or written language
• Manifested in the imperfect ability to listen, think, speak, read, write, spell,
or do mathematical calculations
• Not primarily the result of visual, hearing, motor disabilities, intellectual
disability, or emotional disturbance or of environmental, cultural, or eco-
nomic disadvantage.
Schools often use terms such as dyslexia to describe specific learning problems. Children with learning
Dyslexia refers to difficulties with accurate or fluent word recognition, poor spell- disabilities have difficulty
ing, and deficits in coding abilities (International Dyslexia Association, 2015). learning and using
Approximately 5–15% of school-age children have LD. It’s estimated that about symbols for speaking,
80% of these children also have a reading disorder (APA, 2018). LD is a neurode- listening, reading, and
velopmental disorder that becomes evident during the school-age years and will writing.
most likely persist into adulthood. Learning disabilities affect males four times as
frequently as they do females.
A good place to begin your online exploration of LD is the Learning Disabilities Pearson eTextbook
Association website at [Link]. If you select “For Teachers” or “For Video Example 4.8
Professionals,” you will find a wealth of information on intervention. The site also You can find an introduction
offers links to several other sites. Simply select “Resources.” to and overview of LD and
how these disabilities affect
The characteristics of LD fall into six categories: motor, attention, percep-
language in this video from
tion, symbol, memory, and emotion. Few children exhibit all the characteristics the Learning Disabilities
described. Motor difficulties may include either hyperactivity or hypoactivity. Association of Toronto District
Hyperactivity, or overactivity, is more prevalent, especially among boys. This (LDATD).
results in difficulty attending and concentrating for more than very short [Link]/
periods. Children with hypoactivity may be deficient in their sense of body move- watch?v=GoM5HcfQBwE
ment, definition of handedness, eye–hand coordination, and space and time
conceptualization.
For example, one of the authors has a slight learning disability that is charac-
terized by poor coordination and language issues such as word recall and percep-
tion: “I was once told it was so funny how I mispronounced words on purpose. It
was not being done on purpose.”
Attentional difficulties include a short attention span, inattentiveness, and
distractibility. Irrelevant stimuli may capture the child’s attention, and overstimu-
lation easily occurs. Some children become fixed on a single task or behavior and
repeat it compulsively, a process called perseveration.
Perceptual difficulties of children with LD involve interpretation of incom-
ing stimuli, although this is not a sensory disorder like deafness and blindness.

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 116 Chapter 4 Childhood Language Disorders

Children with perceptual disabilities often confuse similar sounds, similar-sounding

words, and similar-looking printed letters and words. In addition, children with
LD may have difficulty both in determining where to focus their attention and in
integrating sensory information from different sources, such as vision and hearing.
As the above-mentioned author notes, “If a restaurant has a TV in the bar area,
I ask to sit with it at my back or it will capture my attention to the detriment of
any conversation.”
Some children with LD have particular difficulty in comprehending printed
symbols and producing written symbols. It’s estimated that as many as 80% of
children with LD have some form of reading problem and that the incidence of
these problems in the overall population may range from 5 to 17% (Sawyer, 2006).
Memory difficulties affect short-term retrieval, as in remembering directions,
and long-term retrieval, as in recalling names, event sequences, and words. Some
children exhibit word-finding problems that result in blocks and the use of fillers
(“Ah, ah, you know . . . ”) or circumlocutions.
LDs are not caused by Emotional problems are usually a factor that accompanies LD, and not a causal
emotional disorders; factor. They are a reaction to the frustration that these children feel. Although most
rather, emotional children with LD have normal intelligence, they perform poorly on language-based
problems result from tasks, and their parents or teachers may tell them that they are not trying
misperception and from or that they’re lazy or stupid. Emotional outbursts may result in children
frustration. being described as aggressive, impulsive, unpredictable, withdrawn, and/or
impatient. These youngsters may exhibit poor judgment, unusual fears, and/or poor
adjustment to change.
The fact that LD occurs more frequently in families with a history of the
disorder and in children who had a premature or difficult birth suggests possible
biological causal factors. A central nervous system dysfunction may involve a
breakdown along the neural pathways that connect the midbrain with the frontal
cortex, an area that is responsible for attention, regulation, and planning of
cognitive activity.
Although not a causal factor, socioenvironmental factors may account for
at least some of the behaviors seen in children with LD. For example, misper-
ceptions by a child affect interactions, which influence the child’s development,
especially language development. Language difficulties, in turn, affect the child’s
interactions.
Information processing difficulties are characterized by an inability to use cer-
tain strategies or to access certain stored information. In general, children with LD
exhibit poor ability to attend selectively or have difficulty deciding on the relevant
information to which to attend. As we have seen, discrimination is also extremely
difficult. Information that is poorly attended to and poorly perceived will be poorly
organized. The cognitive organization of children with LD reflects this confusion.
In short, the organization is too inefficient for easy retrieval, so memory is less
accurate and retrieval is slower.
Several websites discuss LD. The Learning Disabilities Association of America
website ([Link]) has a brief checklist of symptoms for parents. Simply
go to the site, select “Parents” at the bottom left, and follow “New to LD.” This will
take you to common behaviors seen with LD.
Those who have hyperactivity and attentional difficulties but do not manifest
other characteristics of LD, especially perceptual difficulties, may be labeled as
having attention-deficit/hyperactivity disorder (ADHD). Children with ADHD
have an underlying neurological disorder in executive function that regulates

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 Language Disorders 117

behavior; as a result, they may be impulsive. Although ADHD is not a learning Attentional,
disability, children with ADHD often experience problems in social relations that discriminatory, and
are explained in part by their accompanying pragmatic problems with language use memory deficits, along
(Leonard et al., 2011). Children with ADHD may not be identified on language with both receptive and
testing that ignores pragmatics. expressive symbol use
Possibly because of difficulties attending, children with ADHD are less accurate problems, can result in
in their interpretations of speech (Nilsen et al., 2013). These difficulties could lead many communication
to more miscommunication. breakdowns.

Lifespan Issues. As preschoolers, children with LD may exhibit little interest in

language or even in books. When a child reaches school, the linguistic demands
of the classroom are often well above their language abilities. The result is often
academic underachievement.
Most learning disabilities are not discovered until children go to school,
although some children may be enrolled in special preschool programs or may
receive therapy services because of poor motor coordination, hyperactivity, or fail-
ure to develop language typically. When they reach school, with its accompanying
demand for language skills, many children with LD require the services of special
educators, SLPs, and reading specialists. Some children might not be identified in
early grades. For example, very bright children may “learn” to read by memorizing
word shapes rather than using phonics-based word-attack skills, as discussed
in Chapter 6.
Children with LD often receive special services while being included in regular
classrooms. They can be successful if the teacher makes some adaptation, such as
repeating instructions or allowing for a quiet work space, to accommodate their
needs.
Some children with LD seem to outgrow aspects of their disability. For
example, hyperactivity seems to lessen in some adolescents. Other adolescents
succeed well enough to continue their education and graduate from college.
We know adults with LDs who are chemists, engineers, teachers, and speech-
language pathologists, although some have lingering vestiges of LD that require
lifelong adaptations.
Other adults continue to have difficulty. Matt received special services
throughout his school years and finished high school. His language difficulties
were complicated by a volatile temper and frequent misinterpretations of the com-
municative intentions of others. After being fired from a series of jobs, Matt hit
on the idea of informing his new boss that he was “partially deaf” and needed all
instructions and feedback repeated face to face. He no longer flies off the handle
when given a simple directive by his supervisor and is gainfully employed. Harry,
on the other hand, is in his 50s but has never held a job that required either
reading or writing.

Language Characteristics. All aspects of language, spoken and written, are usu-
ally affected in children with LD. These children experience difficulty with the
Pearson eTextbook
give-and-take of conversation and with the form and content of language. Deducing Video Example 4.9
language rules is particularly difficult, resulting in delays in morphological rule In this TED Talk, a young
acquisition and in the development of syntactic complexity. As a result, overall oral woman with LD presents her
language development may be slow and frequent communicative breakdown is challenges and triumphs.
possible. Word-finding problems may exist, resulting in the child needing more [Link]/watch?
time to respond verbally. v=mwRnPF_NPbk

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 118 Chapter 4 Childhood Language Disorders

REFLECTION QUESTION 4.2

What types of challenges did the woman face?
If you understand the underlying cause for a type of language disorder, you
can often predict the aspects of language that will be difficult. Let’s take two
different disorders with similar outcomes. Children with DLD and those with LD
both tend to omit morphological endings but for different reasons. With limited
capacity, children with DLD tend to not remember endings. Those with LD often
misperceive morphological endings or do not notice them at all.

Brain Injury
Impaired brain functioning, which can happen to any of us, can result from
traumatic brain injury (TBI), cerebrovascular accident or stroke, congenital mal-
formation, convulsive disorders, or encephalopathy, such as infection or tumors.
According to the CDC (2021), in the United States, TBI is the leading cause of
disability and death in children and adolescents. At greatest risk for brain injury
are those age 0–4 and 15–19. Based on emergency department data, an average
of 564,000 children sustain brain injury annually. Of these, 62,000 require hos-
pitalization. Cerebrovascular accidents and a fuller discussion of TBI in adults are
presented in Chapter 7.
Approximately a million children and adolescents in the United States are liv-
ing with TBI-related injury (CDC, 2022). Damage, which may be either localized
or diffuse, is the result of external force, such as a blow to the head from an auto
accident, a fall, or firearms. Individuals with TBI differ greatly from one another
as a result of the site and extent of the injury, the age at onset, and the age of the
injury. In general, the smaller the damaged area, the better the chance of recovery.
Some individuals recover fully; others remain in a vegetative state. People with TBI
exhibit a range of cognitive, physical, behavioral, academic, and linguistic deficits,
any of which may be long term.
Cognitive deficits include difficulties in perception, memory, reasoning, and
problem solving. Deficits vary and may be permanent or temporary and may par-
tially or totally affect functioning ability. Children with TBI tend to be inattentive
and easily distractible. All aspects of cognitive organization—categorizing, sequenc-
ing, abstracting, and generalization—may be affected. Children with TBI have dif-
ficulty perceiving relationships, making inferences, and solving problems. They
struggle to formulate goals, plan, and achieve their ends. Memory is also affected,
although long-term memory before the trauma is often intact.
Psychological maladjustment or “acting-out” behaviors, called social disin-
hibition, may occur, in which a person is incapable of inhibiting or controlling
impulsive behavior. Other characteristics of TBI may include a lack of initiative,
distractibility, inability to adapt quickly, perseveration, low frustration levels,
passive-aggressiveness, anxiety, depression, fear of failure, and misperception.

Lifespan Issues. After a cranial accident, some children with TBI may be unconscious
for a few minutes or much longer. Upon regaining consciousness, a child usually expe-
riences some disorientation and memory loss. Memory loss may involve only the time
of the immediate accident or may be more extensive, including long-term memory
loss. TBI may be accompanied by physical disability and personality changes.

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 Language Disorders 119

Neural recovery over time is often unpredictable and irregular, and the vari-
ables that affect recovery of children with TBI are extremely independent. In gen-
eral, a better recovery is signaled by a shorter, less severe period of unconsciousness
following the injury, a shorter period of amnesia, and better posttraumatic abilities.
The age of the injury can be an inaccurate prognosticator. In general, the older
the injury, the less chance of change, although this can be complicated by the
delayed onset of some deficits, making neural recovery unpredictable and irregular
over time.
When stabilized, a child with TBI begins a long recovery process that can take
years. Within the first few months, they might experience spontaneous recovery
when large gains in ability are made.
Young children often recover quickly but experience difficulties learning new Even individuals who
information and may exhibit severe, long-lasting problems. For example, young have made a seemingly
children with TBI may perform within average limits on standardized language tests full recovery may
but show differences later in more complex language skills, such as reading com- lack subtle cognitive
prehension and pragmatics (Cermak et al., 2019; Haarbauer-Krupa et al., 2018). and social skills. For
Older children and adolescents have more to recover from their memory but less example, although Jane
new information to learn. had been injured in
Although the brains of younger children are more malleable or more adaptable an auto accident but
made a seemingly full
than those of older people, this does not mean that younger children will always
recovery, she began
recover more fully. In addition to recovering the language lost, younger children
to exhibit learning
may still have much language to learn, a task that is possibly made more difficult problems later when she
by the brain injury. attended elementary
school. Unfortunately,
Language Characteristics. Language problems may be evident even after mild her lack of success in
cognitive injuries. Some deficits remain long after the injury, even when general school translated into
improvement is good. For example, individuals with severe TBI and resultant disciplinary problems
deficits in executive function or ability to focus the brain demonstrate problems later on.
with pragmatics (Douglas, 2010). More specifically, these individuals have dif-
ficulty regulating the amount and manner of conversational participation as
well as the relevance of their contributions. A child with TBI may lose the cen-
tral focus or topic in conversation. Utterances are often lengthy, inappropriate,
and off topic and fluency is disturbed, especially if there are accompanying
motor problems.
Language comprehension and higher functions such as figurative language
and dual meanings are also often impaired, although language form is relatively
unaffected. Semantics, especially concrete vocabulary, is also relatively undisturbed,
although word retrieval, naming, and object description difficulties may be present.
Narration, especially maintaining story structure and providing enough informa-
tion, may also pose a problem.

Other Language Disorders

Although we’ve touched on some of the most prevalent language disorders, we have
by no means exhausted the discussion. Other forms of language disorder include
but are not limited to:
• Children who are late-talkers
• Those with childhood schizophrenia, selective mutism, or middle ear
infections (otitis media)

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 120 Chapter 4 Childhood Language Disorders

• Children who have received cochlear implants

• Those who have been exposed to alcohol and drugs in utero
• Those who have experienced abuse and neglect
Although child health is an important factor among late-talkers, most early lan-
guage delay is due to environmental factors such as poverty and/or homelessness.
Another factor may be preterm birth and/or low birth weight.
Childhood schizophrenia, a serious psychiatric illness that causes strange
thinking, odd feelings, and unusual behavior, is uncommon, occurring in approxi-
mately 1 of every 14,000 children younger than 13 years of age. Approximately
55% of children and adolescents with schizophrenia have language abnormali-
ties, including language delay, especially in pragmatics (Mental Health Research
Association, 2007; Nicolson et al., 2000).
Selective mutism (SM) is a relatively rare disorder in which a child does not
speak in specific situations, such as school, although they may speak normally
in others. From 0.2 to 0.7% of all children may have SM at some time, and
girls are nearly twice as likely as boys to be affected (Bergman et al., 2002;
Kristensen, 2000).
Many young children suffer from chronic otitis media. In general, the cumula-
tive effect of recurrent otitis media can be a significant factor in delayed language
development (Feldman et al., 2003).
Those who receive cochlear implants develop language in a manner simi-
lar to typically developing children. Although children implanted later have an
initial advantage of maturity that enhances language growth, those who receive
implants at an earlier age begin to develop spoken language at an ever-increasing
rate that soon eclipses the rate for children receiving implants later in childhood
(Ertmer et al., 2003).
Annually in the United States, approximately 40,000 infants, 1 in every 500
Children with FASD and to 600 live births, are born with fetal alcohol spectrum disorder (FASD). Of these,
drug exposure have as high as 8,000 are born with fetal alcohol syndrome (FAS), the most severe form
many learning problems (American Academy of Pediatrics, 2022). Alcohol interferes with embryonic devel-
similar to those of opment, and infants with FASD often have low birth weight and exhibit central
children with learning nervous system problems. Later, these children demonstrate hyperactivity, motor
disabilities. problems, attention deficits, and cognitive disabilities. The limitations noted at
birth remain with the child for life and can result in poor academic achievement
and antisocial behavior. Children with FASD exhibit language problems character-
ized by delayed development of language, echolalia or inappropriate repetition, and
comprehension problems. Children with FASD and those with fetal drug exposure
are behind their peers in reading and other academic tasks.
Prenatal cocaine exposure (PCE) is a continuing problem in children’s lan-
guage development, even into adolescence (Lewis et al., 2013). As a group, children
with PCE have mild but persistent deficits in syntax and phonological processing,
which in turn adversely affects reading ability. In addition, caregiver variables, such
as low maternal vocabulary, more psychological symptoms, and a poor home envi-
ronment, are also contributing factors.
Finally, each year in the United States 1 in 7 children, approximately 900,000,
are maltreated sufficiently for the neglect and/or abuse to be reported to the author-
ities (U.S. Department of Health and Human Services, 2022). Although neglect
and abuse are rarely the direct cause of communication problems, the context in

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 Language Disorders 121

which they occur directly influences a child’s development. Poor maternal health,
substance abuse, poor or nonexistent pediatric services, and poor nutrition can all
affect brain development and maturation.
In general, maltreated children demonstrated consistently poorer language
skills with respect to receptive vocabulary, expressive language, and receptive lan-
guage (Lum et al., 2015). Maltreated and abused children are less talkative and
have fewer conversational skills than their peers. Their utterances and conversa-
tions are shorter, with less complex language, than are those of nonmaltreated
children (Eigsti & Cicchetti, 2004). Although all aspects of language are affected,
it is in pragmatics that children who have been neglected or abused exhibit the
greatest difficulties.

REFLECTION QUESTION 4.3

Why is pragmatics or language use so frequently the aspect of language disorder
seen in several disorders? Is it related to the nature of pragmatics and how it
differs from other aspects of language?

So many disorders are associated with language disorder that they probably all
have begun to look similar to you. In actual practice, SLPs treat each child as an
individual, not as a member of a category. Of importance is each child’s behavior
and language features, not group characteristics.
Although this section has focused on disorders, it does not address all the fac-
tors that may be related to language disorder. Factors such as SES, nutrition, child
and maternal health, and maternal sensitivity to and stimulation of a child are
also important. For example, most children and mothers who are homeless exhibit
language deficits for a variety of reasons (La Paro et al., 2004; O’Neil-Pirozzi,
2003). Approximately 580,000 people experienced homelessness on an average
night in the United States, an increase of 12,751 people, or 2.2%, from 2019
(U.S. Department of Housing and Urban Development, 2021). Unfortunately,
Black children, children from low-SES households, and children who are ELs are
less likely to receive services when compared to White, middle class, English-
speaking children (Morgan et al., 2016).

Aspects of Language Affected

In addition to the etiological categories we have just described, language disorders
can also be characterized by the language features affected. For example, a child
may have difficulty with word recall and conversational initiation or may pos-
sess a limited vocabulary and seem to talk nonstop. Another child may have poor
syntax and very short sentences or withdraw from conversational give-and-take.
Figure 4.1 presents the most common language features associated with language
disorders. In evaluations, SLPs assess many language features to determine where
to begin intervention.
To understand the range of responsibilities of an SLP in various disorders, check
the ASHA website ([Link]). Enter “scope of practice” in the search field and
then select the communication disorder you want to explore.

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 122 Chapter 4 Childhood Language Disorders

FIGURE 4.1 Most common language characteristics of children with language disorders.

Pragmatics Naming difficulties may reflect less rich and less

elaborate semantic storage or actual retrieval
Difficulty answering questions or requesting
difficulties
clarification
Difficulty initiating and maintaining a conversation Syntax/Morphology
or securing a conversational turn Short, uncomplex utterances
Poor flexibility in language when tailoring the Rule learning difficulties
message to the listener or repairing communication
Run-on, short, or fragmented sentences
breakdowns
Few morphemes, especially verb endings,
Short conversational episodes
auxiliary verbs, pronouns, and function words
Limited range of communication functions (articles, prepositions)
Inappropriate topics and off-topic comments; Overreliance on word order over word relationships
ineffectual, inappropriate comments Difficulty with negative and passive constructions,
Asocial monologues relative clauses, contractions, and adjectival forms

Difficulty with stylistic variations and speaker– Article (a, an, the) confusion
listener roles Phonology
Narrative difficulties Limited syllable structure
Few interactions Fewer consonants in repertoire
Semantics Inconsistent sound production, especially as
complexity increases
Limited expressive vocabulary and slow vocabulary
growth Comprehension
Few or decontextualized utterances, more here-and- Poor discrimination of units of short duration
now; more concrete meanings (bound morphemes)
Limited variety of semantic functions Impaired comprehension, especially in connected
Relational term difficulty (comparative, spatial, discourse such as conversations
temporal) Reliance on context to extract meaning
Figurative language and dual-definition problems Wh- question confusion
Conjunction (and, but, so, because, etc.) confusion Overreliance on nonlinguistic cues for meaning

Assessment
Learning Objective 4.3 Explain the process of assessment in language disorder.

An SLP’s first task in assessment is to distinguish between children who have a

disorder and those who do not. Accurate diagnosis is a prerequisite to ensuring
appropriate intervention and also that scarce financial and personnel resources,
especially in schools, are allocated in the most beneficial way.
Assessment and As with other diagnostics, language assessment is a systematic process of discov-
intervention overlap and ery and information gathering. Good clinical practice requires that the boundary
are parts of the same between assessment and intervention be permeable. A portion of any good assess-
process. ment is attempting to determine possible avenues for intervention. In turn, each
intervention session should contain some assessment of a child’s current skill level.

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 Assessment 123

Assessment should be sufficiently broad and deep and come from a variety
of sources so that all areas of possible concern are identified and described as
accurately as possible. For example, preschool children born preterm perform very
differently when measured on standardized tests and through language sampling
(Imgrund et al., 2019). These findings support the importance of using both meth-
ods of assessment in the evaluation of young children’s language skills.
Ideally, the language assessment would occur within a team that might
include a psychologist, special educator, you as SLP, audiologist, and medical
personnel. Standardized testing is no substitute for assessing language in real-life
contexts. For example, observing WM in communication tasks can offer valu-
able insight into cognitive functioning beyond measures of WM out of context
(Gray et al., 2019).

Assessment of English Learners and Nonmainstream

Dialectal Speakers
Children who are ELs accounted for approximately 10.2% of the students enrolled
in U.S. public schools, rising to 15–22% in Texas, Nevada, and California (National
Clearinghouse for English Language Acquisition, 2018). In preschool Head Start
programs, the percentage of children who use a language other than English is
approximately 30% (Office of Head Start, 2016). These percentages are predicted
to rise nationwide (Silverman & Doyle, 2013).
In addition, many children speak nonmainstream American English (NMAE)
dialects that differ from the mainstream American English dialects that teachers
use for instruction. For example, Black children make up approximately 17% of
the children enrolled in public schools (Fry, 2007). The language of NMAE speak-
ers and those with language disorders are qualitatively different. In general, lan-
guage disorder results in a more restricted range of language on than does dialect
(Oetting, 2019).
Any assessment of children with culturally and linguistically diverse back-
grounds must recognize the possible risk for language disorder. For example, chil-
dren from low-SES backgrounds with poorer maternal education have an increased
incidence of language disorder (Schuele, 2001). The task of an SLP is to differenti-
ate language disorder from language difference.
ELs and children with dialectal differences are more likely to be identified as
needing special education services (de Valenzuela et al., 2006). This is most likely
related to performance on standardized tests, many of which may not be appropri-
ate for these children. Clearly, there is a critical need to develop language assess-
ment measures and/or procedures that are appropriate.
Assessment of ELs poses a challenge for SLPs, especially when the SLP is a
monolingual English speaker. Deciding whether a child has a language disorder or
a language difference can be difficult. We do not have tests in most languages, few
SLPs speak languages that infrequently occur in the United States, and tests normed
on bilingual children are almost nonexistent. ELs with language disorders have
significantly poorer performance than typically developing ELs on most measures
of language except vocabulary (Paradis et al., 2013).
Diagnostic methods for children from culturally and linguistically diverse back-
grounds vary widely, and no single measure or procedure is adequate (Dollaghan
& Horner, 2011). Although grammatical ability of EL preschoolers seems to be
related to lexical vocabulary in that language, there does not seem to be a relation

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 124 Chapter 4 Childhood Language Disorders

between vocabulary and grammar skills across languages (Simon-Cereijido &

Méndez, 2018). These data would lend support to testing in both languages.
A comprehensive assessment can reduce potential misdiagnosis of language dis-
orders in children who are ELs (Dragoo, 2017; Peña & Halle, 2011; U.S. Department
of Education, 2016). Thus, there is a critical need for development and use of
measures to assess all aspects of language (Wright Karem et al., 2019).
Diagnosis should include published tests in both languages, if possible; sponta-
neous and elicited language samples in various settings with differing partners; and
dynamic assessment procedures that are more open-ended and include descriptions
of a child’s use of both English and the child’s first language. In dynamic assess-
ment, an SLP modifies procedures to explore the optimal strategies to enhance a
child’s performance. Dynamic assessment can provide a systematic way to measure
learning processes and learning outcomes (Peña et al., 2014).
For children speaking NMAE, the challenge is to differentiate dialectal dif-
ferences from language disorders. Although some tests have separate norms for
speakers of some dialects, the sample group may be too small to truly represent the
language experience of any given child. The Diagnostic Evaluation of Language
Variation (DELV; Seymour et al., 2018) has been developed for and normed on
NMAE speakers. For other measures, an alternative procedure is dialectal scoring
(Oetting et al., 2019), which accounts for language variations. Dialectal scor-
ing potentially decreases the number of dialectal speakers who may be misdi-
agnosed as having a language disorder (Cleveland & Oetting, 2013; Oetting &
Garrity, 2006).

Referral and Screening

For any individual, referral for a communication evaluation may occur at any point
in their lifespan. Children, such as those with identifiable syndromes or those who
are at risk for developing language disorder, might be referred at birth or in early
infancy; those with LD might go undetected until they begin school; and those with
TBI may be referred at the age when injury occurs. Although parents can be effec-
tive referral sources for children with more severe language problems, they are less
reliable in identifying mild disorder (Conti-Ramsden et al., 2006). Instead, referral
may come from a teacher or health care professional, such as the family physician.
In a public school, an SLP may decide to test a child on the basis of results of
screening testing or teacher referral. Screening tests, used to determine the presence
or absence of language problems, are routinely administered to all kindergarten
and first-grade students. Screening tests must be chosen and administered very
carefully. Even though a test is generally considered nonbiased, some items should
be interpreted with caution because they may be problematic for children with
Information from differing cultural or linguistic backgrounds (Qi et al., 2003).
referrals, questionnaires, Children who are late-talkers but appear to have recovered by age 4 are at mod-
and interviews provides est risk for continuing difficulties in elementary school. This risk is no greater than
needed background that for other 4-year-olds who have similar language performance at age 4. This
from which to begin indicates that the language of all children in the low normal range at age 4 should
investigating for possible be monitored in an ongoing way, including periodic screening (Dale et al., 2014).
language disorder and Surveys and parental questionnaires are also effective diagnostic tools. They
determining what that compare favorably with other language measures and are part of a thorough, well-
disorder entails.
rounded assessment (Patterson, 2000; Rescorla & Alley, 2001; Thal et al., 2000).
In some settings, an interdisciplinary team of child specialists may handle
referral and subsequent evaluation. The nature of many of the disorders mentioned

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 Assessment 125

previously may necessitate input from a pediatrician, a neurologist, an occupa-

tional therapist, a physical therapist, a developmental psychologist, a special edu-
cation teacher, an audiologist, and/or an SLP. An interdisciplinary assessment that
includes families as active participants and collaborators has been shown to be
effective with young children with ASD (Prelock et al., 2003).

Case History and Interview

Administering a case history questionnaire and conducting a parent or teacher
interview are the first steps in a formal information-gathering process. In addi-
tion to asking questions about birth and development, an SLP asks more specific
questions relevant to language disorder. Questions relate to language development,
the language environment of the home, and possible causes for language disorder.
Possible questions are presented in Figure 4.2.

Observation
Language is heavily influenced by the context in which it occurs. It is helpful,
therefore, to observe a child using language in as many contexts as possible. For
example, a school-based SLP might observe in the classroom while a clinic-based

FIGURE 4.2 Possible questions for questionnaires/interviews when a language disorder is suspected.

Language Use Respond when asked to clarify?

How does your child . . . Demonstrate frustration when not understood?
Ask for information? Relay sequential information or stories?
Describe things in the environment? Respond when you say something?
Discuss things in the past, future, or outside of Express emotions?
the immediate context? Are your child’s responses meaningful, mismatched,
Express emotions or discuss feelings? off-topic, or irrelevant?
Request desired items?
Form and Content
Request attention?
Does your child . . .
Direct your attention?
Know the names of common events, objects, and
Conversational Skills people in the environment?
How does your child . . . Seem to rely on gestures, sounds, or immediate
Initiate conversations or interactions with others? environment to be understood?
What are the child’s frequent topics? Speak in single words, phrases, or sentences?
Join in when others initiate? How long is a typical utterance? Does the child
leave out words?
Get your attention before saying something?
Use words such as tomorrow, yesterday, or last
Take turns easily while talking? Are there long night?
gaps between your utterances and the child’s
responses? Follow simple directions?
Demonstrate an expectation that you will How does your child . . .
respond when they speak? Talk about past, present, and future events?
Act if you do not respond? Put several sentences together to form complex
Ask for clarification when confused? descriptions and explanations?

Source: Based on Owens (2014).

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 126 Chapter 4 Childhood Language Disorders

FIGURE 4.3 Possible behaviors to observe during an assessment of language disorder.

With whom the child communicates

Purposes for the child’s communication
Effectiveness of the child’s communication:
Obvious patterns of breakdown

Maturity of the child’s language:

Utterance length
Verb usage
Complexity

Relative amounts of initiative versus responsive communication

Relative amounts of nonsocial versus social communication
Responsiveness of caregiver
Turn allocation, relative size of child’s and caregiver’s turns

SLP might observe on a home visit, in a waiting room, or during a free-play period
between the mother and child. Subsequent testing and sampling can provide addi-
tional observational periods.
Behaviors that are observed vary with the age of the child and the reported
disorder. In addition to observing a child’s communicative behavior, an SLP is also
concerned with a child’s interests, topics, style, and methods of communicating.
With young children, an SLP will also want to note parental sensitivity to a child’s
communication attempts and parental responding to these attempts. Figure 4.3
presents some behaviors that might be observed during an assessment.
An SLP must remain focused during observation. This requires that they
define very carefully the behaviors and/or language features that are observed
and fully describe the events preceding and following them. Hypotheses about
a child’s language disorder are formed during observation. These are either con-
firmed or negated during the remainder of the assessment and further modified
throughout intervention. For example, I observed one adolescent with IDD scream
“Don’t hit me” repeatedly. The teacher determined that the girl was not being
abused. I hypothesized that this occurred when she was asked a question, but the
behavior was inconsistent. It was further hypothesized that the type of question
influenced the response. This hypothesis was confirmed later in the assessment
through careful data collection in which over time the type of question was modi-
fied systematically.

Testing
SLPs should consult test manuals carefully and select tests that are sensitive and
specific to language disorders. Although standardized, norm-referenced tests are
appropriate for determining whether a problem exists, they are less useful in iden-
tifying specific language deficits. More descriptive measures, such as language
sampling, allow an SLP to explore a child’s strengths and weaknesses. In addition,
descriptive results can provide useful information for intervention planning.

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 Assessment 127

After building rapport with a child, an SLP can begin testing. It is best to use
a series of testing tasks to ensure that many features of language are assessed. For
example, one study found that a combination of tasks using children’s books, such
as shared story retelling in which a familiar story element is altered and compre-
hension questions, were effective in identifying 96% of children with language
disorders (Skarakis-Doyle et al., 2008). At the very least, receptive and expres-
sive aspects of language form, content, and use should be tested or sampled in
some way.
Tasks should be varied, based on their potential effect on different children.
Some children can remain on a given task, whereas others are highly distractible.
Others may be reticent to talk or be withdrawn.
Test methodology varies widely. Children may be asked to form syntactically
similar sentences, to make judgments of correctness, to reconfigure scrambled sen-
tences, or to imitate exactly what they hear. They may have to supply definitions,
form sentences, or point to words named. All these tasks require different language
skills. Unfamiliar tasks may unintentionally prejudice the results against the child.
Examples of language test tasks are presented in Figure 4.4. Testing is an atypical
situation for most children. Typical language use is most likely to be displayed in
language sampling.
During testing, an SLP probes a child’s performance to try to identify possible
effective intervention procedures. Of interest are strategies that either increase

FIGURE 4.4 Examples of language test tasks.

Test Procedure Example

Grammatical completion I’m going to say a sentence with one word missing. Listen carefully, then fill in
the missing word. John has a dish and Fred has a dish.
They have two .
Receptive vocabulary Look at the pictures on this page. I’m going to name one, and I want you to
point to it. Touch (Show me) the officer.
Defining words I’m going to say some words. I want you to tell me what each word means or
use it in a sentence in a way that makes sense. For example, if I said “coin,”
you might respond “money made from metal” or “I put my coin in the
vending machine.”
Pragmatic functions I’m going to tell you a story and ask you to imagine what the person in the
story might say. Mary lost her money and she must call home for a ride after band
practice. She decides to borrow a quarter from her best friend, Julie. Before practice
begins, she sits down next to Julie and says .
Sentence imitation I’m going to say some sentences, and I want you to repeat exactly what I say.
Let’s try one. We are going to play ball after school tomorrow.
Parallel sentence production Here are two pictures. I’ll describe the first one, and then you describe the
second one, using the same type of sentence as I use.
For example, for this picture I would say, “The girl is riding her bike,” and for
this one you would say, “The man is driving his car.”
Grammatical correctness I’m going to say a sentence, and I want you to tell me if it is correct or
incorrect. If it is incorrect, you must correct it. For example, if I say, “Thems
is going to the dance,” you would respond, “Incorrect. They are going to
the dance.”

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 128 Chapter 4 Childhood Language Disorders

production or result in more correct production of a certain language feature (Peña

et al., 2001). Sometimes called dynamic assessment, this probing is invaluable in
providing direction for subsequent intervention. Dynamic assessment and tech-
niques that ask children to demonstrate skills that represent realistic learning
demands are especially well suited for children with multicultural or bilingual
backgrounds (Peña et al., 2006; Ukrainetz et al., 2000).
Test scores should be interpreted cautiously. For example, the omission of some
morphological endings by children who are ELs is similar to the error pattern of
children with DLD (Paradis, 2005). This can lead to misdiagnosis. In addition,
children with language disorders aren’t always identified by low scores (Spaulding
et al., 2006).

REFLECTION QUESTION 4. 4
Did you think initially that testing alone would be sufficient for assessing a
language disorder? Can you think of some reasons why testing may not give a
total picture of a child’s communication?

Sampling
Tests do not address all aspects of language. Language is influenced by context. It
follows that the context of test taking influences the language a child produces.
For some children, especially young children, children of color, and those with dis-
abilities, test structure decreases performance (Eisenberg et al., 2001). In addition,
there may be few choices for tests that assess an individual child’s communication.

CASE STUDY Jayden (continued)

Jayden used sign, speech, and an iPad, and his language progressed to two- to three-
word sentences that he used for very limited purposes.

Language sample analysis (LSA) is an additional way to assess a child’s lan-

guage. LSA offers several advantages (Timler, 2018b). Among them is that LSA is
flexible, can be repeated as often as needed, and in some cases, may be the only
way to capture some concerns.
In sampling, an SLP engages a child in conversation or other naturalistic
tasks in an attempt to “stretch” language performance and, in the process, reveal
possible language difficulties. For example, the SLP might attempt to get longer,
more complex language by asking a child to explain how to do something or to
relate a familiar event. When we look at samples from young children with ASD,
we find that the most severe communication impairments are not as common
in naturalistic settings as in standardized assessments such as tests (Bacon et al.,
2018). Although young children engaged in free play produce more utterances
than those telling stories, they produce more complex utterances while telling
stories and in conversation (Southwood & Russell, 2004). A variety of language
tasks, such as conversation, narration, explanation, and interview, can be included
in the sample.

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 Assessment 129

Narratives or stories are especially helpful for exhibiting deficits in school-age

children because of the demands on a speaker. In addition, narratives tend to elicit a
large number and variety of syntactic structures. The personal narratives of children
with language disorders are often so disordered that these stories negatively impact
the social interactions of these children (McCabe & Bliss, 2004–2005). The shorter
personal narratives of children with language disorders often omit key information
and violate chronological sequences of events. With adolescents, posing peer con-
flict resolution problems or asking for explanations of how to accomplish a task is
an effective method for eliciting grammatically complex utterances (Nippold et al.,
2007). Figure 4.5 presents two very different types of language samples.
Whenever possible, it is best to collect at least two samples of the child inter-
acting with different partners, locations, and activities or topics (Owens, 2014).
For example, parent and teacher perceptions of specific social behaviors in children
with ASD do not always agree (Murray et al., 2009). This disparity indicates that
specific social behaviors may be context dependent and would suggest collect-
ing data in different communication contexts. Typical performance may also be
enhanced if parents or teachers interact with a child in familiar settings. An expe-
rienced SLP can also be an excellent conversational or play partner for the child.
The SLP records the language sample(s) and later carefully transcribes the
child’s exact words. MP3 players, cell phones, and tablets can be used effectively
to collect language samples.
The amount of language collected may vary with the child and the aspect of
language that is of concern. For example, most SLPs collect 50 utterances or less,
which takes approximately 7 minutes to collect (Pavelko et al., 2016; Pavelko &
Owens, 2017, 2019). Longer samples of up to 30 minutes have been suggested for
very young children (Hadley et al., 2018).
LSA may consist of several quantitative and qualitative measures. Values such
as mean length of utterance (MLU) in morphemes, the average number of clauses

FIGURE 4.5 Examples of different types of language sampling.

Open-Ended Structured
Clinician: I’ll play with this farm Clinician: Well, here’s the puppy. What should we say to him?
set, and you can too, or you can pick Child: Hi puppy. [GREETING]
another toy.
Clinician: Hi Timmy. I’m hungry. We need to get someone to help
Child: Want farm.
us get those cookies.
Clinician: Oh, you want the farm.
Child: You help. Want cookie. [REQUESTING]
We can share. I wonder what we should
do first. Clinician: I wonder how I can reach it.
Child: Open door. Animals come out. Child: Get chair. [HYPOTHESIZING]
Clinician: Okay. Clinician: Oh, get on the chair. Should I (mumble).
Child: You be horsie and I man. Child: Yeah. [DOES NOT REQUEST CLARIFICATION]
Clinician: Oh, the farmer. Clinician: You want me to (mumble)?
Child: Farmerman chase horsie in barn. Child: What’s that? [REQUESTS CLARIFICATION]
Clinician: Oh, he did. I better run fast. Clinician: Which do you want, the cookie or the chair?
Child: Man go fast in barn. Child: Want cookie. No chair. [CHOICE MAKING]

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 130 Chapter 4 Childhood Language Disorders

per sentence, and the number of different words used within a given period of time
or number of utterances can be compared to the values for typical children of the
same age or developmental level (Johnston, 2001). MLU has been shown to be
both a reliable and valid measure of general language development through age 10
for children with DLD (Pavelko & Owens, 2017; Rice et al., 2006).
LSA might also provide information on the percentage correct for a language
feature, such as past tense -ed. More descriptive measures might be the variety of
intentions expressed by the child, the conversational styles used, and the types of
repair the child uses when the conversation breaks down (Yont et al., 2000). With
some children, the SLP might carefully note the number of different words or lexi-
cal diversity of the sample (Charest et al., 2020).
Being as thorough as possible, an SLP attempts to analyze the sample for all
aspects of form, content, and use appropriate for the particular assessment. For
example, with ELs an SLP might consider code switching (the movement between
two languages), dialect, English proficiency, and contextual effects in addition to
aspects of both languages (Gutierrez-Clellan et al., 2000).
Although LSA may seem very open-ended, it need not be. Methods such as
Systematic Analysis of Language Transcripts (SALT; Miller & Iglesias, 2015), Com-
puterized Language Analysis (CLAN; MacWhinney, 2022), and Sampling Utterances
and Grammatical Analysis Revised (SUGAR; Owens & Pavelko, 2021) are designed
for use with computers. Others, such as Developmental Sentence Scoring (DSS;
Lee, 1974) and Index of Productive Syntax (IPSyn; Scarborough, 1990), have been
adapted to computer analysis. These methods vary in their software but also in the
aspects of language analyzed
For school-age children experiencing literacy difficulties, an SLP may also want
to collect samples of written language. These are discussed in Chapter 6.

Intervention
Learning Objective 4.4 Describe the overall design of language intervention.

As you might guess, the complexity of language necessitates using multiple inter-
vention methods. Different intervention approaches target specific aspects of lan-
guage and employ a variety of procedures. Within limits, we explore these diverse
approaches to remediation of language disorders.
All aspects of language are interrelated. Changes in one area affect others. For
example, learning to use the past tense -ed might increase the quality of personal
narratives because we usually tell of what happened in the past. In intervention,
an SLP should not take such changes for granted and focus solely on one aspect of
language. Intervention goals should focus on stimulating the language acquisition
process beyond the immediate target (Fey et al., 2003).
Similarly, SLPs should use a variety of intervention techniques. For example,
children with ASD can improve social skills better through a combination of peer
training and written cues than by either method alone (Thiemann & Goldstein,
2004). The most effective intervention approach for older school-age children
and adolescents with deficits in syntax is an integrated one in which naturalistic
stimulation approaches are supplemented with deductive teaching procedures. In
a deductive method, children are presented with a rule that guides the use of a
morphological marker, such as past tense -ed, along with models of the inflection
(Finestack & Fey, 2009).

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 Intervention 131

Increasingly, SLPs are including other individuals from a child’s environment

in the training. Recall the SLP working with Jayden worked with him directly and
also worked through the preschool teacher and Jayden’s parents.
Without training, day care providers fail to fine-tune their language for indi-
vidual children’s needs (Girolametto et al., 2000). In early intervention and in
preschool, parents are usually an integral part of their child’s language program.
Working through parents and other caregivers is different than direct intervention
by the SLP with the child, although this is also a program component. Teaching
adults to be language teachers can offer a challenge. Various techniques such as a
Teach-Model-Coach-Review instructional approach have been shown to be effec-
tive (Roberts et al., 2014).
SLPs can help preschool teachers imple-
ment intervention both through activities such
as dramatic play, art, and storybook reading and
through language instruction processes (Pence
et al., 2008). Preschool staff being trained to
respond to children’s initiations, to engage
children, to model simplified language, and
to encourage peer interactions has a signifi-
cant effect on children’s language production
(Girolametto et al., 2003). Even peers can serve
as effective tutors or models for children with
language disorders (McGregor, 2000).
With the aid of an SLP, these and other care
providers, such as parents, may learn how to be
Preschool teachers can learn from SLPs how to
better language partners for children. Despite
implement intervention through activities such as
the many demands on and restrictions faced by dramatic play, art, and storybook reading.
mothers and children who are homeless, it is © Ground Picture/Shutterstock
possible to teach homeless parents, even those
with limited language skills, to use facilitating language strategies during interac-
tions with their preschool children (O’Neil-Pirozzi, 2009).
With school-age children, the SLP can use a variety of intervention models,
including individual and group sessions both within and outside the classroom.
Teachers and aides can also be trained to help children participate. Ideally, the
SLP would also teach the entire class on occasion, being mindful of the needs of
children with language disorders.

Considerations for Children with Culturally and

Linguistically Diverse Backgrounds
According to federal law and American Speech-Language-Hearing Association
guidelines, intervention for language disorders must be responsive to the cultural
and linguistic backgrounds of children and their families (ASHA, 2008, 2017;
IDEA, 2004). Population variability is likely to impact the cultural validity of
language intervention, especially for young children and their families (Cycyk &
Huerta, 2020).
Cultural congruency is the synchrony of intervention strategies and tech-
niques with the cultural values, beliefs and behaviors of a community and is
important in providing appropriate and effective services. In short, language inter-
ventions that match parental, caregiver, and community expectations will have

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 132 Chapter 4 Childhood Language Disorders

more successful outcomes than those that do not (García Coll et al., 2002; Griner
& Smith, 2006; Larson et al., 2020). For example, parents and caregivers may ques-
tion being asked to assist or providing intervention in the home for very young
children. Some intervention techniques, such as the use of play or conversation as
a vehicle for teaching, may not fit cultural norms or expectations. It’s important
to note that what may seem second nature to an SLP may seem very foreign to
some families.
Although SLPs may be focused on English with children who are ELs, maintain-
ing the heritage language is frequently as important for the family and community.
Continued development of the heritage language depends on rich and frequent
exposure and opportunities for practice that usually occur in the home (Pham &
Tipton, 2018). Intervention in both home and school languages and support of
both have been shown to have positive effects (Goodrich et al., 2013; Gorman,
2012; Lim et al., 2019; Restrepo et al., 2013; Riquelme & Rosas, 2014; Rosa-Lugo
et al., 2012). Although optimal, intervention in both English and the heritage
language is not always feasible, especially if the SLP does not speak the heritage
language. In these cases, community resources or the use of translators may help.

Language Target Selection and Sequence of Teaching

The criteria for target The goal of intervention is the maximally effective use of language to accomplish
selection will vary with communication goals within everyday interactions. Although most SLPs would
the child, the affected agree on this overall goal, less unanimity exists on the route to achieving it.
aspects of language, Decisions on target selection and training vary with each child and each SLP.
the child’s disorder, Using the same assessment results, SLPs might differ in the targets they select.
and the needs of the One SLP might use language acquisition knowledge as a general guide. Another
environment. might begin intervention at the point of communication breakdown and frustra-
tion for the child. A more classroom-based approach might suggest training for
language used within the class. Still another approach might be to begin with
language features that are just emerging.
Decisions must also be made about where to begin once the target is selected.
Some SLPs prefer to begin with receptive language training and progress to expres-
sive. Others might start with expressive training.
Expressive training may be bottom-up, in which the SLP begins at the sym-
bol level and works toward conversational goals; top-down, in which training is
placed within a conversational framework; or a combination of the two. Obviously,
the child’s abilities are an important determinant of the method selected. To the
best extent possible, training should be placed within meaningful communicative
contexts.

Evidence-Based Intervention Principles

The needs of children with language disorders suggest several principles that should
guide intervention services. These principles, presented in Figure 4.6, recognize
the need to target a child’s language abilities in their entirety rather than to focus
exclusively on one deficit area. The interrelatedness of all areas of language and
the importance of communication context on the form and content of language
necessitate a more holistic approach.
As a profession, speech-language pathology stresses the importance of evidence-
based practice. This is a combination of scientific evidence, SLP experience and

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 Intervention 133

FIGURE 4.6 Principles of language intervention.

1. The goal of intervention should be greater facility of language use in

conversation, narration, exposition, and other textual genres in hearing,
speaking, reading, and writing.
2. Deficit areas are rarely, if ever, the only areas of language that should be targeted
in an intervention program.
3. Select intermediate goals that stimulate a child’s language acquisition process
rather than goals that focus solely on deficit areas.
4. Select specific goals of intervention based on a child’s readiness and need for the
targeted goals.
5. Manipulate the context to create more opportunities for the language target to
occur.
6. Exploit different genres and modalities to develop appropriate contexts for
intervention targets.
7. Manipulate clinical discourse so targeted areas are more noticeable and
important in various contexts.
8. Systematically contrast a child’s language performance with more mature adult
usage by recasting a child’s utterances.
9. Provide good models of easily comprehended, well-formed phrases and
sentences.
10. Use a variety of verbal and nonverbal strategies to elicit and modify a child’s
language and to give a child practice in using language to accomplish their
communication needs.

client needs and wishes. Although a lack of direct empirical evidence should not
automatically rule out a new teaching method, it should be grounds for suspicion
(Cirrin & Gillam, 2008). Box 4.4 presents recommended practices for language
disorders.

BOX 4.4 Evidence-Based Practice for Childhood Language Disorders

General home is effective. Long-term and standardized

measures have not been applied.
• Intervention is effective for the vast majority of
• Intervention gains in both receptive language and
children.
expressive syntax are best for children receiving
• Benefits accrue from beginning intervention as
both SLP and parent-implemented intervention.
early as possible.
• Multiple measures provide the most accurate
Children with Autism Spectrum Disorder
and valid language assessment.
• Effective interventions are characterized by early
English Learners
intervention and intensive and individualized
• No single measure is adequate for assessment. instruction.
• Maintaining the home language enables parents, • Both structural behavioral approaches and
who may not speak English, to support language naturalistic approaches are effective in replacing
development. challenging behavior with social interactions,
although no method works with all children
Presymbolic Children
with ASD.
• Interactive language intervention in which • Approximately two-thirds of children make
parents are trained to provide intervention at significant measurable gains with intervention.
(continued)

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 134 Chapter 4 Childhood Language Disorders

• The Picture Exchange Communication System • Collaborating with teachers on large-group

(PECS), in which a picture is used to request instruction and slowed presentation rate can
items, demonstrates only small to moderate positively impact vocabulary development.
gains in communication and small to negative • Interactive conversational reading strategies may
gains in speech. Gains may be enhanced if be somewhat helpful for improving receptive
others, such as peers with TDL, are taught to be and expressive vocabulary.
responsive listeners. • There do not seem to be clear differences in
• Although video-modeling is an effective strategy outcome between the various methods used to
for teaching some social interactional behaviors, assist children with word finding.
we still need exploration of the efficacy of other
methods. Language Processing
• Computer intervention using modified speech
Preschool stimuli or speech and language games does not
• Speech and language intervention are most improve performance.
effective for children with phonological or Pragmatics and Discourse
expressive vocabulary difficulties.
• Parent-implemented language interventions • Direct instruction on topic initiation and
have a significant, positive impact on both group entry behaviors can yield moderately
receptive language and expressive syntactic large to large effects for students with social
skills. communication deficits.
• Intervention of more than 8 weeks results in • It is possible to teach social skills to adolescents
better outcomes than shorter intervention. with ASD, although the data are not sufficient to
• Seventy percent of preschool children with identify the most effective method of intervention.
language impairments make significant
Method of Intervention
measurable gains with intervention.
• We can tentatively conclude that preschool
School-Age and Adolescent and early elementary children with LI show
greater improvement with collaborative (teacher
Syntax and Morphology and SLP) teaching, classroom-based language
intervention model than they do in more
• Moderately large to large effects follow use of
traditional pull-out intervention.
imitation, modeling, or modeling plus evoked
• Recast sentences are an effective responsive
production strategies.
method for grammatical intervention. In a recast,
• Computerized input strategies alone have not
the SLP modifies the elements in the child’s
demonstrated extensive benefit as yet.
utterance to make it more correct or mature,
to change the form of the sentence, or to offer
Semantics and Vocabulary
another variation.
• A paucity of research exists and we do not yet • Computer/Internet programs that target
have evidence on the best possible technique for cognitive learning rather than specific skills
effective vocabulary instruction for children in training are effective for working memory and
the early elementary grades. executive function.

Sources: Based on Bedore (2010); Burgess and Turkstra (2006); Cirrin and Gillam (2008); Cleave et al. (2015); Dollaghan and
Horner (2011); Goldstein and Prelock (2008); Johnson and Yeates (2006); Justice and Pence (2007); Law et al. (2004); Peijnenborgh,
Hurks, et al. (2016).

Intervention Procedures
Remember that as an SLP, wherever you may work, you are teaching communicative
skills. SLPs are teachers in the broadest sense. Throwing out questions or cues and
hoping for the right response or providing the answer when the child is incorrect
is not teaching. Teaching is a systematic analysis of what a child is lacking that
results in their failure to succeed.

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 Intervention 135

As an SLP, you need to break any learning task into the sequential steps required
to move from where the child is now to where you want the child to be. Decisions on
sequencing should be determined by the complexity of the task, its cognitive and lin-
guistic requirements, and the learning characteristics of the individual child. The SLP
enhances teaching by anticipating the types of support that a child is likely to need for
success and the types of errors the child is likely to make (Schuele & Boudreau, 2008).
A few basic tenets of good teaching behavior include, but are not limited to,
the following:
• Model the desired behavior for the child. Modeling may include multiple expo-
sures, called focused stimulation or priming, that occur before the child is
required to produce the language feature (Leonard, 2011). This might be
followed by the child imitating the SLP. In a variation called parallel sen-
tence production, an SLP provides a model of the type of utterance desired.
The child is not expected to imitate the model but to provide a similar type
of sentence. For example, you might describe a picture by saying “The girl
is throwing the ball” and then ask the child to describe a second picture
of a boy catching a ball. The need for modeling decreases as the language
feature is learned. Older elementary school children and adolescents may
also benefit from an explanation of the targeted behavior and a rationale
for why its correct use is important.
• Cue the child to respond. Carefully selected cues, such as the use of the word
yesterday to signal a past-tense response, serve as aids for the child in con-
versation. Cues may range from very specific, such as say, imitate, or point
to, to more general conversational cues, such as I wonder what I should say
now to elicit a specific linguistic structure in context or Maybe Carol can help
us if we ask to elicit a question:
■ Cues may be either verbal or nonverbal. Verbal cues attempt to elicit the
language feature by providing a linguistic framework; nonverbal cues use
the context of an event to evoke the feature.
■ The SLP should rate each type of cue or prompt from least to most intru-
sive and supportive (Timler et al., 2007). As intervention proceeds, the
SLP works to minimize prompting whenever possible, so the child can
become more independent.
• Respond to the child in the form of reinforcement and/or corrective feedback. SLPs are teachers of
Reinforcement varies from very direct and obvious forms, such as “Good, language. They must
that was much better,” to more conversational responses, such as “That plan their behaviors well
sounds like fun. Tell me more.” Conversational responses come in many to teach without overly
varieties, including imitating the child, imitating but expanding the child’s relying on less natural
utterance into a more mature version, replying conversationally, and asking strategies, such as drill
for clarification, to name a few. With some children, especially those with and the use of edible
vocabulary deficits, the relationship of the response to the content of the reinforcers.
child’s utterance has more effect on the child’s language than the structural
input of the clinician’s feedback. In other words, respond to the meaning
of what the child said:
■ Natural reinforcers flow from the training target. The most obvious example
is one in which a child obtains a desired object upon responding to
the cue “What do you want?” Conversational responses are natural and
reinforcing.

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 136 Chapter 4 Childhood Language Disorders

■ Corrective feedback may range from a gentle reminder to an instruction.

For example, an SLP might recast a sentence. If the child says, “Boy eat-
ing cookie,” and the target is use of the auxiliary verb be, the SLP might
recast the sentence as “He is eating” or “The boy is eating the cookie.”
Children with DLD and low MLU scores benefit most from responses in
which the child is prompted to attempt the structure prior to the adult’s
recast (Yoder et al., 2011).
■ In general, as a language feature is produced more correctly by a child, an
SLP relies less on these direct forms. When a language feature is correct
most of the time, conversational feedback, such as “What?” or “I don’t
understand,” may be sufficient to cause the child to self-correct the few
errors made.
• Plan for generalization of the learned feature to the everyday use environment
of the child. SLPs can help with generalization by selecting training targets
that are highly likely to occur in the child’s everyday communication and
by including elements of the everyday use environment in the training,
such as familiar locations, people, and objects. Parents are often included
in the training of young children, whereas teachers may be involved in the
intervention of school-age children and adolescents.
Although it may seem counterintuitive, with some intervention targets,
such as verb endings, children with language disorders tend to generalize
rules better if they are presented with a wide variety of verbs rather than a
restricted set that they hear over and over (Plante et al., 2014). In addition,
these children produce more utterances that generalize the learning.
Pearson eTextbook Specific examples of each teaching method are presented in Figure 4.7.
Video Example 4.10 Not all teaching strategies have similar effects. For example, imitation can
In this video is an example of result in rapidly achieving production of grammatical targets (Eisenberg et al.,
a technique called “sentence 2020). The technique is not recommended, however as the sole method of inter-
recasts,” or reformulating the
vention, in part because of poor long-term learning effects and poor generalization.
child’s utterance.
Initially, it might seem that the SLP’s mere presentation of repeated exam-
[Link]/
watch?v=SNOk2nxBOhI
ples of the language target is sufficient for learning to occur. This is an implicit
approach that assumes a child will deduce the underlying language rule. Explicit
instruction tries to make a child consciously aware of the underlying language
pattern. In a study with 5- to 8-year-old children with DLD, Finestack (2018)
demonstrated that children are more likely to acquire, maintain, and generalize
novel grammatical forms when taught with explicit instruction. This methodology
does not preclude using a more conversational approach with periodic reminders
of the rule or why we’re learning a language target.
In short, intervention that includes explicit instruction is more beneficial than
implicit techniques alone (Bangert et al., 2019; Finestack, 2018; Finestack & Fey,
2009; Motsch & Riehemann, 2008). That said, research indicates that combining
implicit and explicit approaches is beneficial when teaching children with signifi-
cant weaknesses in language (Bolderson et al., 2011; Calder et al., 2018; Kulkarni
et al., 2014; Smith-Lock et al., 2013).
Effective language intervention should enhance language and social skills
in real-life interactions (Timler et al., 2007). Success occurs when the newly
taught language feature generalizes to a child’s everyday environment. Children
learn to use language through interactions with many individuals and in varying
situations.

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 Intervention 137

FIGURE 4.7 Examples of teaching methods.

Method Modeling Example

Focused stimulation I’ll pretend to make a cake first. Watch to see if I make a
mistake. I’m putting the eggs in the bowl and taking them
to the table. I’m cracking the eggs. Now I’m beating the eggs.
Next, I’m sifting the flour. I’m adding the flour to the eggs
and mixing them. Now I’m measuring the sugar and pouring
it into the mix . . .
Cuing
Direct Verbal
Imitation Say “I want cookie.”
Cloze This is a .
She should say .
Question What should I say now?
What’s this?
Which one’s this?
Indirect Verbal
Pass it on I wonder if Joan knows the answer. How could we find the
answer? [TARGET IS FORMATION OF QUESTIONS]
Nonverbal Not giving child all the materials needed to complete
a task.
(Inherent in the Not explaining how to accomplish an assigned task.
activity) Playing dumb.
Responding
Direct Reinforcement Good, I like the way you said that. Much better than the
last time.
Indirect Reinforcement
Imitation Child: I go horsie.
Clinician: I go horsie.
Expansion Child: I go horsie.
Clinician: I’m going to go on the horsie.
Extension Child: I go horsie.
Clinician: Yes, cowboys go on horses, too.
Corrective Feedback Remember, when we use a number like two, three, or more,
we say /s/ on the word. Listen. One cat.
Two cats.

Lastly, it’s important to recall that these are children. Children's active
participation is a significant factor in effective language therapy. The level
of a child’s active engagement is directly related to their language gains
(Schmitt, 2020). In addition, more active involvement results in more stable
generalization. Ideally, intervention consists of motivating participatory activi-
ties in various contexts.

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 138 Chapter 4 Childhood Language Disorders

Intervention Through the Lifespan

Targets of intervention vary with the age and language skills of a child. An infant in
an early intervention program would have different training targets than an adoles-
cent with mild LD. In contrast, an infant may be receiving some of the same train-
ing as an adolescent who has profound IDD and is functioning below age 1 year.
Early intervention, especially for children with IDD and ASD, can have a very
positive benefit. Initial training may target presymbolic communicative skills and
cognitive abilities, such as physical imitation, gestures, and understanding of object
uses. Parents may be trained to treat their child’s behaviors as having some com-
municative value or to interpret consistent behaviors as attempts to communicate.
An SLP may attempt to establish an initial communication system by using an
augmentative and alternative communication system (AAC) such as gesturing, a
communication board, or an electronic device. AAC is discussed in more detail in
Chapter 13.
Early symbolic training may focus on receptive understanding, vocabulary
acquisition, semantic categories, word combinations, and an array of early inten-
tions. The beneficial effects of treatment for children with delayed language extend
beyond the trained targets into other areas of linguistic and overall development.
Within a framework of play, shared attention, and naturalistic language teaching,
the use of manual signs along with verbal models appears to facilitate develop-
ment of expressive sign and word communication in some young children with
ID (Wright et al., 2013).

CASE STUDY Jayden (continued)

Jayden’s parents continue to use signs to inform him about routine changes such
as dinnertime. His own use of signs seems to have decreased his frustration and
acting-out behaviors. Jayden prefers to be alone, and even in his preschool class he
rarely interacted with other children, seeming to prefer the company of adults.

Children at the preschool language level usually work on language form in

both conversations and narratives. Longer utterances, bound morphemes, and early
phonological processes may be intervention goals. Vocabulary will continue to be
targeted.
In schools, SLPs provide Intervention with school-age children may focus on pragmatic skills in con-
individual, group, and versations and semantic targets, such as figurative language, multiple meanings,
classroom language abstract terms, and more advanced relational terms, such as conjunctions. Aca-
intervention. demic skills, including summarizing a reading and different types of writing and
note taking, may also be targeted. SLPs may use computerized programs to supple-
ment more face-to-face intervention. Computer use should mesh well with the
SLP’s overall clinical philosophy and the child’s individual needs. Language
enhancement can be infused into the curriculum. SLPs may work with the child
on both spoken and written language. It is also important for children with lan-
guage disorders to learn to navigate the curriculum and understand classroom
expectations.
Language intervention doesn’t end with childhood. Adolescents may continue
to exhibit language disorders and be in need of services. Adults with severe ASD or

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 Epilogue 139

ID will most likely require continued intervention for language and communica-
tion deficits and a range of educational and vocational needs. Individuals with LD
may require additional support in postsecondary education (Downey & Snyder,
2000; Olivier et al., 2000).
With adolescents, an SLP might focus on multiclausal or complex sentences,
variations in the verb, and expository text, which includes persuasive speech
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and writing, explanations of how to do something, and compare and contrast

activities (Scott, 2014). A middle school SLP will need to collaborate with
classroom teachers and reading specialists, have knowledge of the Common Core
State Standards and the language demands of the classroom, and understand later
language development and the reasons for speakers and writers using complex
syntax (Nippold, 2014).

Summary

In this chapter, we discussed several types of language disorders. Although language

disorders are very complex and multifaceted, we have only touched the surface in
this chapter. The number of associated disorders, the language features that are
affected, and the individual differences among children result in each child’s lan-
guage being very individualistic. Recall Jayden. We weren’t as interested in a label
for his disorder as we were with a description of his language and its use. It is very
important to remember that each child is a unique case. Given this fact, assessment
becomes a search to find and describe a child’s individual language abilities. This is
accomplished through referral, collection of a case history, interviews, observation,
testing, and language sampling.
As a result of the assessment process and through repeated assessment probes
during intervention, an SLP attempts to find the most efficient and effective method
for teaching new skills. The SLP identifies targets for intervention and trains these
through a combination of techniques in various settings with the aid of additional
language facilitators.
Obviously, every SLP needs thorough training and extensive experience with
language disorders to serve children with a variety of disabilities. As an SLP, you
want to gain a firm foundation of speech and language development, take several
courses in language disorders in both children and adults, and complete at least
one clinical experience with both populations.

Epilogue Case Study: Jayden

Now age 10, Jayden prefers to use an iPad to communicate even though his speech
has greatly improved. Along with his use of two- to three-word sentences, his
vocabulary has expanded to about 350 words, mostly nouns and verbs. Although
still mostly used for requesting, he will ask the occasional question or make a com-
ment. Jayden is much more social than in preschool and gets along well with his
2023. Pearson.

classmates, although he still seems to prefer being alone.

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Farinella; Introduction to Communication Disorders : A Lifespan Evidence-Based Perspective Account:ehost.
 140 Chapter 4 Childhood Language Disorders

At the moment, Jayden has a keen interest in dinosaurs and beyond his 350
words are another 50 or so that relate to dinosaurs, including tyrannosaurus rex
and paleontology. He will read anything related to dinosaurs but his progress is slow
and labored. In addition, he has demonstrated a real skill at drawing dinosaurs.

Reflections from a Preschool-Based Speech-Language Pathologist

[We] have a district-run preschool for children with extra needs. . . . I’m in
the classrooms every day and I do individual and group intervention there and
in the speech room. I’ve trained the teacher and the aides in how to maximize
communication with children. I also work with parents who are invited to work
with me and/or observe therapy. With some parents I’ve had to explain that when
I play with their child, play is the vehicle for change, not the goal of intervention.
It’s a subtle distinction.
Most of the children I work with have language needs but a few also have
apraxia of speech. Two children are using AAC devices and one has feeding and
swallowing issues. It’s a diverse caseload and was a real education for me. Now,
I feel at ease but each year a new cohort of kiddos poses new challenges for me.
My job is taxing but also fun and enjoyable.
Although I’m sad when the children transition into kindergarten, I do get to
see some in school later. Many are still receiving speech and language services but
a few have transitioned into regular classrooms with no services.
I get my rewards from seeing children grow and change, which they do quickly
at this age. And working closely with parents has its own rewards. Sometimes we
focus on therapy and their child but, when possible, I also just let them talk about
having a child with special needs and their hopes for the future. They’re grateful
for that opportunity and for what I do for their children.

Suggested Readings/Sources

Nelson, N. W. (2010). Language and literacy disorders: Infancy through adolescence.

Pearson.
Owens, R. E. (2018). Early language intervention for infants, toddlers, and preschoolers.
Pearson.
Owens, R. E. (2023). Language disorders: A functional approach to assessment and inter-
vention (6th ed.). Plural.
Reed, V. A. (2018). An introduction to children with language disorders (5th ed.). Pearson.

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