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What Are Language Disorders?

Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

LightFieldStudios / Getty Images

Children come to the world almost pre-programmed to learn the language of their environment. But while it appears automatic for a child to learn to read, speak, and understand communication around them—the pace at which these skills are learned vary among children. In some cases, children may not meet certain developmental milestones .

A language disorder occurs when a child is unable to compose their thoughts , ideas, and messages using language. This is known as an expressive language disorder. When a child faces difficulty in understanding what is communicated via language, this is called a receptive language disorder.

Sometimes, a child may live with a mix of expressive and receptive language disorders. A lack of understanding or poor expression of language does not always indicate a language disorder, however. This could simply be the result of a speech delay.

Read on to learn about the types, characteristics, causes, and trusted treatment methods to manage language disorders in children .

Types of Language Disorders in Children 

With language , there are specific achievements expected when children mark a certain age. At 15 months, it is likely that a child can recognize between five to ten people when they are named by parents or caregivers. At 18 months, it is expected that a child can respond to simple directives like ‘let’s go outside’ without challenges. This is an already receptive child.

If at 18 months, a child is unable to pronounce ‘mama’ and ‘dada’, or if at 24 months, this child does not have at least 25 words in their vocabulary—this could signal an expressive language disorder.

Receptive Language Disorder

When a child struggles to understand the messages communicated to, or around them, this can be explained as a receptive disorder. Children with receptive challenges will usually display these difficulties before the age of four.  

Receptive difficulties may be observed where a child does not properly understand oral communication directed at, or around them.

In such cases, the child struggles to understand the spoken conversations or instructions directed around them. Likewise, written words may be difficult to process. Simple gestures to come, go, or sit still may also prove challenging to comprehend.

Expressive Language Disorders

Expressive language disorders occur when a child is unable to use language to communicate their thoughts or feelings.

In this sense, oral communication is just one of the affected areas. A child may also consider written communications difficult to express.

Children with expressive disorders will find it difficult to name objects, tell stories, or make gestures to communicate a point. This disorder can cause challenges with asking or answering questions, and may lead to improper grammar usage when communicating.

Symptoms of Language Disorders

Language disorders are a common observation in children. Up to 1 out of 20 children exhibit at least one symptom of a language disorder as they grow. The symptoms of receptive disorders include:

• Difficulty understanding words that are spoken
• Challenges with following spoken directions
• Experiencing strain with organizing thoughts

Expressive language disorders are identified through the following traits in children:

• Struggling to piece words into a sentence
• Adopting simple and short words when speaking 
• Arranging spoken words in a skewed manner
• Difficulty finding correct words when speaking
• Resorting to placeholders like ‘er’ when speaking
• Skipping over important words when communicating
• Using tenses improperly 
• Repeating phrases or questions when answering

Causes of Language Disorders

With a language disorder, the child does not develop the normal skills necessary for speech and language. The factors responsible for language disorders are unknown, this explains why they are often termed developmental disorders .  

Disabilities or Brain Injury

Despite the uncertainty around the causes of these disorders, certain factors have strong links to these conditions. In particular, other developmental disorders like autism and hearing loss commonly co-occur with language disorders. Likewise, a child with learning disabilities may also live with language disorders.

Aphasia is another condition linked with language disorders. This condition develops from damage to the portion of the brain responsible for language. Aphasia may be caused by a stroke, blows to the head, and brain infections.  The injury may increase the chances of developing a language disorder.  

Diagnosis of Language Disorders

To determine if a child has a language disorder, the first step is to receive an expert’s assessment of their condition.

A speech-language pathologist or a neuropsychologist may administer standardized tests. These are to review the child’s levels of language reception and expression.

The Link Between Deafness and Language Problems

In making their assessment, the health expert will conduct a hearing test to discover if the child suffers from hearing loss. This is because deafness is one of the most common causes of language problems.  

Treatment of Language Disorders

Language disorders can have far-reaching effects on the life of a child. These disorders can lead to poor social interactions, or a dependence on others as an adult. Challenges with reception and expression can also lead to reading challenges, or problems with learning .

To manage this condition, parents/guardians should exercise patience and care when dealing with children managing language disorders. While it can be challenging, children already experience frustration when dealing with others and expressing themselves. Caregivers can provide a place of comfort for children who have learning challenges.

For expert guidance, a speech-language pathologist can work with children and their guardians to improve communication and expression.

Because language disorders can be emotionally taxing, parents and children with these disorders can try therapy . This will help in navigating the emotional and behavioral issues caused by language impairments.

NCBI. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program .

MedlinePlus. Language Disorders in Children .

Ritvo A, Volkmar F, Lionello-Denolf K et al. Receptive Language Disorders . Encyclopedia of Autism Spectrum Disorders . 2013:2521-2526. doi:10.1007/978-1-4419-1698-3_1695

Reindal L, Nærland T, Weidle B, Lydersen S, Andreassen O, Sund A. Structural and Pragmatic Language Impairments in Children Evaluated for Autism Spectrum Disorder (ASD) .  J Autism Dev Disord . 2021. doi:10.1007/s10803-020-04853-1

National Institute on Deafness and Other Communication Disorders. Aphasia .

Centers for Disease Control and Prevention. Language and Speech Disorders in Children .

By Elizabeth Plumptre Elizabeth is a freelance health and wellness writer. She helps brands craft factual, yet relatable content that resonates with diverse audiences.

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Speech and Language Impairments

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

“(11)  Speech or language impairment  means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance.” [34 CFR §300.8(c)(11]

(Parent Information and Resources Center, 2015)

Table of Contents

What is a Speech and Language Impairment?

Characteristics of speech or language impairments, interventions and strategies, related service provider-slp.

• A Day in the Life of an SLP

Assistive Technology

Speech and language impairment  are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.

A speech impairment is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced.

A language impairment is a specific impairment in understanding and sharing thoughts and ideas, i.e. a disorder that involves the processing of linguistic information. Problems that may be experienced can involve the form of language, including grammar, morphology, syntax; and the functional aspects of language, including semantics and pragmatics.

(Wikipedia, n.d./ Speech and Language Impairment)

*It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool.  With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development.  Distinguishing between the two is most reliably done by a certified speech-language pathologist.  (CPIR, 2015)

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an  articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly

Fluency  refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.”

Voice  is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use.

Language  has to do with meanings, rather than sounds.  A language disorder refers to an impaired ability to understand and/or use words in context. A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions.

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

(CPIR, 2015)

• Use the (Cash, Wilson, and DeLaCruz, n.d) reading and/or the [ESU 8 Wednesday Webinar] to develop this section of the summary. 

Cash, A, Wilson, R. and De LaCruz, E.(n,d.) Practical Recommendations for Teachers: Language Disorders. https://www.education.udel.edu/wp-content/uploads/2013/01/LanguageDisorders.pdf 

[ESU 8 Wednesday Webinar] Speech Language Strategies for Classroom Teachers.- video below

Video: Speech Language Strategies for Classroom Teachers (15:51 minutes)’

[ESU 8 Wednesday Webinars]. (2015, Nov. 19) . Speech Language Strategies for Classroom Teachers. [Video FIle]. From https://youtu.be/Un2eeM7DVK8

Most, if not all, students with a speech or language impairment will need  speech-language pathology services . This related service is defined by IDEA as follows:

(15)  Speech-language pathology services  include—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

(v) Counseling and guidance of parents, children, and teachers regarding speech and language impairments. [34 CFR §300.34(c)(15)]

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

A Day in the Life of an SLP

Christina is a speech-language pathologist.  She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie.  He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl  in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning. (CPIR, 2015)

Project IDEAL , suggests two major categories of AT computer software packages to develop the child’s speech and language skills and augmentative or alternative communication (AAC).

Augmentative and alternative communication  ( AAC ) encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. Augmentative and alternative communication may used by individuals to compensate for severe speech-language impairments in the expression or comprehension of spoken or written language. AAC can be a permanent addition to a person’s communication or a temporary aid.

(Wikipedia, (n.d. /Augmentative and alternative communication)

Center for Parent Information and Resources (CPIR)  (2015), Speech and Language Impairments, Newark, NJ, Author, Retrieved 4.1.19 from https://www.parentcenterhub.org/speechlanguage/

Wikipedia (n.d.) Augmentative and alternative communication. From https://en.wikipedia.org/wiki/Augmentative_and_alternative_communication 

Wikipedia, (n.d.) Speech and Language Impairment. From  https://en.wikipedia.org/wiki/Speech_and_language_impairment 

Updated 8.8.23

Understanding and Supporting Learners with Disabilities Copyright © 2019 by Paula Lombardi is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Language Disorder

Reviewed by Psychology Today Staff

Language disorder is a communication disorder in which a person has persistent difficulties in learning and using various forms of language such as spoken, written, or signed. They may struggle to understand the words they hear or see. While they do not have trouble physically making sounds, they may not be able to use language effectively to communicate.

Individuals with language disorder have language abilities significantly below those expected for their age, limiting their ability to effectively communicate or participate in many social, academic, or professional activities. However, they are not necessarily less intelligent than other children.

Language learning and use relies on both expressive and receptive abilities. Expressive ability refers to the production of verbal or gestural signals, while receptive ability refers to the process of receiving and understanding language. Individuals with language disorder may have impairments in either ability, or both, and the symptoms first appear early in childhood development.

People with language disorder have difficulty both learning and using written, spoken, or sign language. They also typically have a limited vocabulary, have trouble constructing sentences and using tenses, and may put words in the wrong order. Because they typically have a limited understanding of vocabulary and grammar, they may also have a limited capacity for engaging in conversation.

Children with language disorder are usually delayed in learning or speaking their first words and phrases. When they do speak, their sentences are shorter and less complex than would be expected for their age. Individuals with language disorder typically speak with grammatical errors, have a small vocabulary, and may have trouble finding the right word at times. In conversation, they may not be able to provide adequate information about the events they’re discussing or tell a coherent story. Because children with language disorder may have difficulty understanding what other people say, they may have an unusually hard time following directions.

Not necessarily. Language skills are highly variable in young children, and many children who are late in speaking their first words or phrases do not develop language disorder. Delayed language acquisition is not predictive of language disorder until age 4, when individual differences in language ability become more stable. Language disorder that is diagnosed at age 4 or later is likely to be stable over time and to persist into adulthood.

No. Language disorder is typically present from early childhood, but because the communication demands and expectations for young children are low, the symptoms may not become obvious until later. Also, deficits in comprehension are often underestimated, because people with language disorder may be good at finding strategies to cope with their difficulties, such as using context to infer meaning.

Children with language disorder may appear shy or reserved and so they may struggle to make friends, which can eventually lead to feelings of social anxiety or depression . Because of their communication deficits, they may prefer to speak only with family members or other familiar people. Such shyness is itself not indicative of language disorder, but when hesitancy to communicate is consistent, it is recommended that parents bring their child to a speech-language pathologist for a full language assessment.

As many as 1 in 20 children have a language disorder. In many cases, the cause is unknown. A brain injury, birth defects, or problems in pregnancy may lead to language disorder, but, as with other communication disorders, the condition has a strong genetic component: Individuals with language disorder are more likely to have family members with a history of language impairment.

Yes. Language disorder is strongly associated with other neurodevelopmental disorders, such as specific learning disorder (literacy and numeracy), attention -deficit/hyperactivity disorder, autism spectrum disorder, and developmental coordination disorder.

The treatment for language disorder is often effective (although less so when the condition is caused by brain injury or similar trauma ). Treatment primarily consists of speech and language therapy in order to improve expressive and receptive language skills and with effective treatment, significant improvement can be achieved, although some symptoms may remain in adulthood. Receptive language deficits (difficulty understanding language) is generally more difficult to treat than expressive impairments (difficulty producing speech).

Psychotherapy can be a helpful tool to manage the emotional and behavioral issues that may arise in children with language disorder. For those whose language disorder symptoms lead to social anxiety or depression, cognitive-behavioral therapy can often be helpful.

Treatment for language disorder should begin as early as possible, as research suggests that children whose deficits are addressed early have better prognoses. A speech-language pathologist will typically ask parents to work with their child daily to help promote their comprehension and speech, such as reading aloud to them every day, listening closely and responding when their child talks, encouraging them to ask questions, and pointing out words all around them.

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Language Disorders in Children

What are language disorders in children?

Most infants or toddlers can understand what you’re saying well before they can clearly talk. As they get older and their communication skills develop, most children learn how to put their feelings into words.

But some children have language disorders. They may have:

Receptive language disorder. A child has trouble understanding words that he or she hears and reads.

Expressive language disorder. A child has trouble speaking with others and expressing thoughts and feelings.

A child will often have both disorders at the same time. Such disorders are often diagnosed in children between the ages of 3 and 5.

What causes language disorders in a child?

Language disorders can have many possible causes. A child’s language disorder is often linked to a health problem or disability such as:

A brain disorder such as autism

A brain injury or a brain tumor

Birth defects such as Down syndrome, fragile X syndrome, or cerebral palsy

Problems in pregnancy or birth, such as poor nutrition, fetal alcohol syndrome, early (premature) birth, or low birth weight

Sometimes language disorders have a family history. In many cases, the cause is not known.

It’s important to know that learning more than one language does not cause language disorders in children. But a child with language disorder will have the same problems in all languages.

Which children are at risk for language disorders?

The cause often is not known, but children at risk for a language disorder include those with:

A family history of language disorders

Premature birth

Low birth weight

Hearing loss

Thinking disabilities

Genetic disorders such as Down syndrome

Fetal alcohol spectrum disorder

Brain injury

Cerebral palsy

Poor nutrition

Failure to thrive

What are the symptoms of language disorders in a child?

Children with receptive language disorder have trouble understanding language. They have trouble grasping the meaning of words they hear and see. This includes people talking to them and words they read in books or on signs. It can cause problems with learning. It needs to be treated as early as possible.

A child with receptive language disorder may have trouble:

Understanding what people say

Understanding gestures

Understanding concepts and ideas

Understanding what he or she reads

Learning new words

Answering questions

Following directions

Identifying objects

A child with expressive language disorder has trouble using language. The child may be able to understand what other people say. But he or she has trouble when trying to talk, and often can’t express what he or she is feeling and thinking. The disorder can affect both written and spoken language. And children who use sign language can still have trouble expressing themselves.

A child with expressive language disorder may have trouble:

Using words correctly

Expressing thoughts and ideas

Telling stories

Using gestures

Asking questions

Singing songs or reciting poems

Naming objects

How are language disorders diagnosed in a child?

Your child’s healthcare provider will ask about your child’s language use. He or she will also look at your child’s health history. Your child may have a physical exam and hearing tests. Your child’s healthcare provider will likely refer your child to a speech-language pathologist (SLP). This specialist can help diagnose and treat your child.

An SLP will evaluate your child during play. This may be done in a group setting with other children. Or it may be done one-on-one with your child. The SLP will look at how your child:

Follows directions

Understands the names of things

Repeats phrases or rhymes

Does in other language activities

How are language disorders treated in a child?

To treat your child, the speech-language pathologist (SLP) will help him or her to learn to relax and enjoy communicating through play. The SLP will use different age-appropriate methods to help your child with language and communication. The SLP will talk with your child and may:

Use toys, books, objects, or pictures to help with language development

Have your child do activities, such as craft projects

Have your child practice asking and answering questions

The SLP will explain more about the methods that are best for your child’s condition.

How can I help my child live with a language disorder?

A language disorder can be frustrating for parents and teachers, and also for the child. Without diagnosis and treatment, children with such a disorder may not do well in school. They may also misbehave because of their frustration over not being able to communicate. But language disorders are a common problem in children. And they can be treated.

If you think your child might have a language disorder, talk with your child’s healthcare provider right away. Research has shown that children who start therapy early have the best outcome. Make sure that the SLP you choose is certified by the American Speech-Language-Hearing Association.

The SLP will guide your child’s treatment. But it’s important to know that parents play a critical role. You will likely need to work with your child to help him or her with language use and understanding. The SLP will also talk with caregivers and teachers to help them work with your child.

Ask the SLP what you should be doing at home to help the process. The SLP may advise simple activities such as:

Reading and talking to your child to help him or her learn words

Listening and responding when your child talks

Encouraging your child to ask and answer questions

Pointing out words on signs

When should I call my child’s healthcare provider?

Call your child’s healthcare provider if your child has:

Symptoms that don’t get better, or get worse

New symptoms

Key points about language disorders in children

Children who have a language disorder have trouble understanding language and communicating.

There are 2 kinds of language disorders: receptive and expressive. Children often have both at the same time.

A child with a receptive language disorder has trouble understanding words that they hear and read.

A child with an expressive language disorder has trouble speaking with others and expressing thoughts and feelings.

Language disorders can have many possible causes, such as a brain injury or birth defect.

A speech-language pathologist can help diagnose and treat a language disorder.

Parents can help their child with language use and understanding through simple activities.

Tips to help you get the most from a visit to your child’s healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

Related Links

• Brain and Behavior
• Developmental-Behavioral Pediatrics
• Speech Sound Disorders in Children
• Age-Appropriate Speech and Language Milestones
• Communication Disorders in Children

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Developmental Disorders

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Speech and Language Impairments

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Table of Contents

A Day in the Life of an SLP

Christina is a speech-language pathologist. She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie. He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

  Back to top

There are many kinds of speech and language disorders that can affect children. In this fact sheet, we’ll talk about four major areas in which these impairments occur. These are the areas of:

Articulation | speech impairments where the child produces sounds incorrectly (e.g., lisp, difficulty articulating certain sounds, such as “l” or “r”);

Fluency | speech impairments where a child’s flow of speech is disrupted by sounds, syllables, and words that are repeated, prolonged, or avoided and where there may be silent blocks or inappropriate inhalation, exhalation, or phonation patterns;

Voice | speech impairments where the child’s voice has an abnormal quality to its pitch, resonance, or loudness; and

Language | language impairments where the child has problems expressing needs, ideas, or information, and/or in understanding what others say. ( 1 )

These areas are reflected in how “speech or language impairment” is defined by the nation’s special education law, the Individuals with Disabilities Education Act, given below. IDEA is the law that makes early intervention services available to infants and toddlers with disabilities, and special education available to school-aged children with disabilities.

Definition of “Speech or Language Impairment” under IDEA

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

Development of Speech and Language Skills in Childhood

Speech and language skills develop in childhood according to fairly well-defined milestones (see below). Parents and other caregivers may become concerned if a child’s language seems noticeably behind (or different from) the language of same-aged peers. This may motivate parents to investigate further and, eventually, to have the child evaluated by a professional.

______________________

More on the Milestones of Language Development

What are the milestones of typical speech-language development? What level of communication skill does a typical 8-month-old baby have, or a 18-month-old, or a child who’s just celebrated his or her fourth birthday?

You’ll find these expertly described in How Does Your Child Hear and Talk? , a series of resource pages available online at the American Speech-Language-Hearing Association (ASHA): http://www.asha.org/public/speech/development/chart.htm

Having the child’s hearing checked is a critical first step. The child may not have a speech or language impairment at all but, rather, a hearing impairment that is interfering with his or her development of language.

It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool. ( 2 ) With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development. ( 3 )  Distinguishing between the two is most reliably done by a certified speech-language pathologist such as Christina, the SLP in our opening story.

Characteristics of Speech or Language Impairments

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly. ( 4 ) ( ASHA’s milestone resource pages , mentioned above, are useful here.)

Fluency refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.” ( 5 )

Voice is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. ( 6 )   The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use. ( 7 )

Language has to do with meanings, rather than sounds. ( 8 )  A language disorder refers to an impaired ability to understand and/or use words in context. ( 9 ) A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions. ( 10 )

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

What Causes Speech and Language Disorders?

Some causes of speech and language disorders include hearing loss, neurological disorders, brain injury, intellectual disabilities, drug abuse, physical impairments such as cleft lip or palate, and vocal abuse or misuse. Frequently, however, the cause is unknown.

Of the 6.1 million children with disabilities who received special education under IDEA in public schools in the 2005-2006 school year, more than 1.1 million were served under the category of speech or language impairment. ( 11 ) This estimate does not include children who have speech/language problems secondary to other conditions such as deafness, intellectual disability, autism, or cerebral palsy. Because many disabilities do impact the individual’s ability to communicate, the actual incidence of children with speech-language impairment is undoubtedly much higher.

Finding Help

Because all communication disorders carry the potential to isolate individuals from their social and educational surroundings, it is essential to provide help and support as soon as a problem is identified. While many speech and language patterns can be called “baby talk” and are part of children’s normal development, they can become problems if they are not outgrown as expected.

Therefore, it’s important to take action if you suspect that your child has a speech or language impairment (or other disability or delay). The next two sections in this fact sheet will tell you how to find this help.

Help for Babies and Toddlers 

Since we begin learning communication skills in infancy, it’s not surprising that parents are often the first to notice—and worry about—problems or delays in their child’s ability to communicate or understand. Parents should know that there is a lot of help available to address concerns that their young child may be delayed or impaired in developing communication skills. Of particular note is the the early intervention system that’s available in every state.

Early intervention is a system of services designed to help infants and toddlers with disabilities (until their 3rd birthday) and their families. It’s mandated by the IDEA. Through early intervention, parents can have their young one evaluated free of charge, to identify developmental delays or disabilities, including speech and language impairments.

If a child is found to have a delay or disability, staff work with the child’s family to develop what is known as an Individualized Family Services Plan , or IFSP . The IFSP will describe the child’s unique needs as well as the services he or she will receive to address those needs. The IFSP will also emphasize the unique needs of the family, so that parents and other family members will know how to support their young child’s needs. Early intervention services may be provided on a sliding-fee basis, meaning that the costs to the family will depend upon their income.

To identify the EI program in your neighborhood  | Ask your child’s pediatrician for a referral to early intervention or the Child Find in the state. You can also call the local hospital’s maternity ward or pediatric ward, and ask for the contact information of the local early intervention program.

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Help for School-Aged Children, including Preschoolers

Just as IDEA requires that early intervention be made available to babies and toddlers with disabilities, it requires that special education and related services be made available free of charge to every eligible child with a disability, including preschoolers (ages 3-21). These services are specially designed to address the child’s individual needs associated with the disability—in this case, a speech or language impairment.

Many children are identified as having a speech or language impairment after they enter the public school system. A teacher may notice difficulties in a child’s speech or communication skills and refer the child for evaluation. Parents may ask to have their child evaluated. This evaluation is provided free by the public school system.

If the child is found to have a disability under IDEA—such as a speech-language impairment—school staff will work with his or her parents to develop an Individualized Education Program , or IEP . The IEP is similar to an IFSP. It describes the child’s unique needs and the services that have been designed to meet those needs. Special education and related services are provided at no cost to parents.

There is a lot to know about the special education process, much of which you can learn at the Center for Parent Information and Resources (CPIR). We offer a wide range of publications and resource pages on the topic. Enter our special education information at: http://www.parentcenterhub.org/repository/schoolage/

Educational Considerations

Communication skills are at the heart of the education experience. Eligible students with speech or language impairments will want to take advantage of special education and related services that are available in public schools.

The types of supports and services provided can vary a great deal from student to student, just as speech-language impairments do. Special education and related services are planned and delivered based on each student’s individualized educational and developmental needs.

Most, if not all, students with a speech or language impairment will need speech-language pathology services . This related service is defined by IDEA as follows:

(15) Speech-language pathology services includes—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning.

Tips for Teachers

— Learn as much as you can about the student’s specific disability. Speech-language impairments differ considerably from one another, so it’s important to know the specific impairment and how it affects the student’s communication abilities.

— Recognize that you can make an enormous difference in this student’s life! Find out what the student’s strengths and interests are, and emphasize them. Create opportunities for success.

—If you are not part of the student’s IEP team, a sk for a copy of his or her IEP . The student’s educational goals will be listed there, as well as the services and classroom accommodations he or she is to receive.

— Make sure that needed accommodations are provided for classwork, homework, and testing. These will help the student learn successfully.

— Consult with others (e.g., special educators, the SLP) who can help you identify strategies for teaching and supporting this student, ways to adapt the curriculum, and how to address the student’s IEP goals in your classroom.

— Find out if your state or school district has materials or resources available to help educators address the learning needs of children with speech or language impairments. It’s amazing how many do!

— Communicate with the student’s parents . Regularly share information about how the student is doing at school and at home.

Tips for Parents

— Learn the specifics of your child’s speech or language impairment. The more you know, the more you can help yourself and your child.

— Be patient. Your child, like every child, has a whole lifetime to learn and grow.

— Meet with the school and develop an IEP to address your child’s needs. Be your child’s advocate. You know your son or daughter best, share what you know.

— Be well informed about the speech-language therapy your son or daughter is receiving. Talk with the SLP, find out how to augment and enrich the therapy at home and in other environments. Also find out what not to do!

— Give your child chores. Chores build confidence and ability. Keep your child’s age, attention span, and abilities in mind. Break down jobs into smaller steps. Explain what to do, step by step, until the job is done. Demonstrate. Provide help when it’s needed. Praise a job (or part of a job) well done.

— Listen to your child. Don’t rush to fill gaps or make corrections. Conversely, don’t force your child to speak. Be aware of the other ways in which communication takes place between people.

— Talk to other parents whose children have a similar speech or language impairment. Parents can share practical advice and emotional support. See if there’s a parent nearby by visiting the Parent to Parent USA program and using the interactive map.

— Keep in touch with your child’s teachers. Offer support. Demonstrate any assistive technology your child uses and provide any information teachers will need. Find out how you can augment your child’s school learning at home.

Readings and Articles

We urge you to read the articles identified in the References section. Each provides detailed and expert information on speech or language impairments. You may also be interested in:

Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2491683/

Organizations to Consult

ASHA | American Speech-Language-Hearing Association Information in Spanish | Información en español. 1.800.638.8255 | [email protected] | www.asha.org

NIDCD | National Institute on Deafness and Other Communication Disorders 1.800.241.1044 (Voice) | 1.800.241.1055 (TTY) [email protected] | http://www.nidcd.nih.gov/

American Cleft Palate and Craniofacial Association (ACPA) 1.800.242.5338 | https://acpacares.org/

Childhood Apraxia of Speech Association of North America | CASANA http://www.apraxia-kids.org

National Stuttering Foundation 1.800.937.8888 | [email protected] | http://www.nsastutter.org/

Stuttering Foundation 1.800.992.9392 | [email protected] | http://www.stuttersfa.org/

1 | Minnesota Department of Education. (2010). Speech or language impairments . Online at: http://education.state.mn.us/MDE/EdExc/SpecEdClass/DisabCateg/SpeechLangImpair/index.html

2 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

4 | American Speech-Language-Hearing Association. (n.d.). Speech sound disorders: Articulation and phonological processes . Online at: http://www.asha.org/public/speech/disorders/speechsounddisorders.htm

5 | Cincinnati Children’s Hospital. (n.d.). Speech disorders . Online at:  http://www.cincinnatichildrens.org/health/s/speech-disorder/

6 | National Institute on Deafness and Other Communication Disorders. (2002). What is voice? What is speech? What is language? Online at: http://www.nidcd.nih.gov/health/voice/pages/whatis_vsl.aspx

7 | American Academy of Otolaryngology — Head and Neck Surgery. (n.d.).   About your voice . Online at:  http://www.entnet.org/content/about-your-voice

8 | Boyse, K. (2008). Speech and language delay and disorder . Retrieved from the University of Michigan Health System website: http://www.med.umich.edu/yourchild/topics/speech.htm

9 | Encyclopedia of Nursing & Allied Health. (n.d.). Language disorders . Online at: http://www.enotes.com/nursing-encyclopedia/language-disorders

10 | Ibid .

11 | U.S. Department of Education. (2010, December). Twenty-ninth annual report to Congress on the Implementation of the Individuals with Disabilities Education Act: 2007 . Online at: http://www2.ed.gov/about/reports/annual/osep/2007/parts-b-c/index.html

10 Most Common Speech-Language Disorders & Impediments

As you get to know more about the field of speech-language pathology you’ll increasingly realize why SLPs are required to earn at least a master’s degree . This stuff is serious – and there’s nothing easy about it.

In 2016 the National Institute on Deafness and Other Communication Disorders reported that 7.7% of American children have been diagnosed with a speech or swallowing disorder. That comes out to nearly one in 12 children, and gets even bigger if you factor in adults.

Whether rooted in psycho-speech behavioral issues, muscular disorders, or brain damage, nearly all the diagnoses SLPs make fall within just 10 common categories…

Types of Speech Disorders & Impediments

Apraxia of speech (aos).

Apraxia of Speech (AOS) happens when the neural pathway between the brain and a person’s speech function (speech muscles) is lost or obscured. The person knows what they want to say – they can even write what they want to say on paper – however the brain is unable to send the correct messages so that speech muscles can articulate what they want to say, even though the speech muscles themselves work just fine. Many SLPs specialize in the treatment of Apraxia .

There are different levels of severity of AOS, ranging from mostly functional, to speech that is incoherent. And right now we know for certain it can be caused by brain damage, such as in an adult who has a stroke. This is called Acquired AOS.

However the scientific and medical community has been unable to detect brain damage – or even differences – in children who are born with this disorder, making the causes of Childhood AOS somewhat of a mystery. There is often a correlation present, with close family members suffering from learning or communication disorders, suggesting there may be a genetic link.

Mild cases might be harder to diagnose, especially in children where multiple unknown speech disorders may be present. Symptoms of mild forms of AOS are shared by a range of different speech disorders, and include mispronunciation of words and irregularities in tone, rhythm, or emphasis (prosody).

Stuttering – Stammering

Stuttering, also referred to as stammering, is so common that everyone knows what it sounds like and can easily recognize it. Everyone has probably had moments of stuttering at least once in their life. The National Institute on Deafness and Other Communication Disorders estimates that three million Americans stutter, and reports that of the up-to-10-percent of children who do stutter, three-quarters of them will outgrow it. It should not be confused with cluttering.

Most people don’t know that stuttering can also include non-verbal involuntary or semi-voluntary actions like blinking or abdominal tensing (tics). Speech language pathologists are trained to look for all the symptoms of stuttering , especially the non-verbal ones, and that is why an SLP is qualified to make a stuttering diagnosis.

The earliest this fluency disorder can become apparent is when a child is learning to talk. It may also surface later during childhood. Rarely if ever has it developed in adults, although many adults have kept a stutter from childhood.

Stuttering only becomes a problem when it has an impact on daily activities, or when it causes concern to parents or the child suffering from it. In some people, a stutter is triggered by certain events like talking on the phone. When people start to avoid specific activities so as not to trigger their stutter, this is a sure sign that the stutter has reached the level of a speech disorder.

The causes of stuttering are mostly a mystery. There is a correlation with family history indicating a genetic link. Another theory is that a stutter is a form of involuntary or semi-voluntary tic. Most studies of stuttering agree there are many factors involved.

Dysarthria is a symptom of nerve or muscle damage. It manifests itself as slurred speech, slowed speech, limited tongue, jaw, or lip movement, abnormal rhythm and pitch when speaking, changes in voice quality, difficulty articulating, labored speech, and other related symptoms.

It is caused by muscle damage, or nerve damage to the muscles involved in the process of speaking such as the diaphragm, lips, tongue, and vocal chords.

Because it is a symptom of nerve and/or muscle damage it can be caused by a wide range of phenomena that affect people of all ages. This can start during development in the womb or shortly after birth as a result of conditions like muscular dystrophy and cerebral palsy. In adults some of the most common causes of dysarthria are stroke, tumors, and MS.

A lay term, lisping can be recognized by anyone and is very common.

Speech language pathologists provide an extra level of expertise when treating patients with lisping disorders . They can make sure that a lisp is not being confused with another type of disorder such as apraxia, aphasia, impaired development of expressive language, or a speech impediment caused by hearing loss.

SLPs are also important in distinguishing between the five different types of lisps. Most laypersons can usually pick out the most common type, the interdental/dentalised lisp. This is when a speaker makes a “th” sound when trying to make the “s” sound. It is caused by the tongue reaching past or touching the front teeth.

Because lisps are functional speech disorders, SLPs can play a huge role in correcting these with results often being a complete elimination of the lisp. Treatment is particularly effective when implemented early, although adults can also benefit.

Experts recommend professional SLP intervention if a child has reached the age of four and still has an interdental/dentalised lisp. SLP intervention is recommended as soon as possible for all other types of lisps. Treatment includes pronunciation and annunciation coaching, re-teaching how a sound or word is supposed to be pronounced, practice in front of a mirror, and speech-muscle strengthening that can be as simple as drinking out of a straw.

Spasmodic Dysphonia

Spasmodic Dysphonia (SD) is a chronic long-term disorder that affects the voice. It is characterized by a spasming of the vocal chords when a person attempts to speak and results in a voice that can be described as shaky, hoarse, groaning, tight, or jittery. It can cause the emphasis of speech to vary considerably. Many SLPs specialize in the treatment of Spasmodic Dysphonia .

SLPs will most often encounter this disorder in adults, with the first symptoms usually occurring between the ages of 30 and 50. It can be caused by a range of things mostly related to aging, such as nervous system changes and muscle tone disorders.

It’s difficult to isolate vocal chord spasms as being responsible for a shaky or trembly voice, so diagnosing SD is a team effort for SLPs that also involves an ear, nose, and throat doctor (otolaryngologist) and a neurologist.

Have you ever heard people talking about how they are smart but also nervous in large groups of people, and then self-diagnose themselves as having Asperger’s? You might have heard a similar lay diagnosis for cluttering. This is an indication of how common this disorder is as well as how crucial SLPs are in making a proper cluttering diagnosis .

A fluency disorder, cluttering is characterized by a person’s speech being too rapid, too jerky, or both. To qualify as cluttering, the person’s speech must also have excessive amounts of “well,” “um,” “like,” “hmm,” or “so,” (speech disfluencies), an excessive exclusion or collapsing of syllables, or abnormal syllable stresses or rhythms.

The first symptoms of this disorder appear in childhood. Like other fluency disorders, SLPs can have a huge impact on improving or eliminating cluttering. Intervention is most effective early on in life, however adults can also benefit from working with an SLP.

Muteness – Selective Mutism

There are different kinds of mutism, and here we are talking about selective mutism. This used to be called elective mutism to emphasize its difference from disorders that caused mutism through damage to, or irregularities in, the speech process.

Selective mutism is when a person does not speak in some or most situations, however that person is physically capable of speaking. It most often occurs in children, and is commonly exemplified by a child speaking at home but not at school.

Selective mutism is related to psychology. It appears in children who are very shy, who have an anxiety disorder, or who are going through a period of social withdrawal or isolation. These psychological factors have their own origins and should be dealt with through counseling or another type of psychological intervention.

Diagnosing selective mutism involves a team of professionals including SLPs, pediatricians, psychologists, and psychiatrists. SLPs play an important role in this process because there are speech language disorders that can have the same effect as selective muteness – stuttering, aphasia, apraxia of speech, or dysarthria – and it’s important to eliminate these as possibilities.

And just because selective mutism is primarily a psychological phenomenon, that doesn’t mean SLPs can’t do anything. Quite the contrary.

The National Institute on Neurological Disorders and Stroke estimates that one million Americans have some form of aphasia.

Aphasia is a communication disorder caused by damage to the brain’s language capabilities. Aphasia differs from apraxia of speech and dysarthria in that it solely pertains to the brain’s speech and language center.

As such anyone can suffer from aphasia because brain damage can be caused by a number of factors. However SLPs are most likely to encounter aphasia in adults, especially those who have had a stroke. Other common causes of aphasia are brain tumors, traumatic brain injuries, and degenerative brain diseases.

In addition to neurologists, speech language pathologists have an important role in diagnosing aphasia. As an SLP you’ll assess factors such as a person’s reading and writing, functional communication, auditory comprehension, and verbal expression.

Speech Delay – Alalia

A speech delay, known to professionals as alalia, refers to the phenomenon when a child is not making normal attempts to verbally communicate. There can be a number of factors causing this to happen, and that’s why it’s critical for a speech language pathologist to be involved.

The are many potential reasons why a child would not be using age-appropriate communication. These can range anywhere from the child being a “late bloomer” – the child just takes a bit longer than average to speak – to the child having brain damage. It is the role of an SLP to go through a process of elimination, evaluating each possibility that could cause a speech delay, until an explanation is found.

Approaching a child with a speech delay starts by distinguishing among the two main categories an SLP will evaluate: speech and language.

Speech has a lot to do with the organs of speech – the tongue, mouth, and vocal chords – as well as the muscles and nerves that connect them with the brain. Disorders like apraxia of speech and dysarthria are two examples that affect the nerve connections and organs of speech. Other examples in this category could include a cleft palette or even hearing loss.

The other major category SLPs will evaluate is language. This relates more to the brain and can be affected by brain damage or developmental disorders like autism. There are many different types of brain damage that each manifest themselves differently, as well as developmental disorders, and the SLP will make evaluations for everything.

Issues Related to Autism

While the autism spectrum itself isn’t a speech disorder, it makes this list because the two go hand-in-hand more often than not.

The Centers for Disease Control and Prevention (CDC) reports that one out of every 68 children in our country have an autism spectrum disorder. And by definition, all children who have autism also have social communication problems.

Speech-language pathologists are often a critical voice on a team of professionals – also including pediatricians, occupational therapists, neurologists, developmental specialists, and physical therapists – who make an autism spectrum diagnosis .

In fact, the American Speech-Language Hearing Association reports that problems with communication are the first detectable signs of autism. That is why language disorders – specifically disordered verbal and nonverbal communication – are one of the primary diagnostic criteria for autism.

So what kinds of SLP disorders are you likely to encounter with someone on the autism spectrum?

A big one is apraxia of speech. A study that came out of Penn State in 2015 found that 64 percent of children who were diagnosed with autism also had childhood apraxia of speech.

This basic primer on the most common speech disorders offers little more than an interesting glimpse into the kind of issues that SLPs work with patients to resolve. But even knowing everything there is to know about communication science and speech disorders doesn’t tell the whole story of what this profession is all about. With every client in every therapy session, the goal is always to have the folks that come to you for help leave with a little more confidence than when they walked in the door that day. As a trusted SLP, you will build on those gains with every session, helping clients experience the joy and freedom that comes with the ability to express themselves freely. At the end of the day, this is what being an SLP is all about.

Ready to make a difference in speech pathology? Learn how to become a Speech-Language Pathologist today

• Emerson College - Master's in Speech-Language Pathology online - Prepare to become an SLP in as few as 20 months. No GRE required. Scholarships available.
• NYU Steinhardt - NYU Steinhardt's Master of Science in Communicative Sciences and Disorders online - ASHA-accredited. Bachelor's degree required. Graduate prepared to pursue licensure.
• Arizona State University - Online - Online Bachelor of Science in Speech and Hearing Science - Designed to prepare graduates to work in behavioral health settings or transition to graduate programs in speech-language pathology and audiology.

Because differences are our greatest strength

What’s the Difference Between Speech Disorders and Language-Based Learning Disabilities?

By Ellen Koslo, AuD

Question: What’s the difference between a speech disorder or impairment and a language-based learning disability?

A speech disorder or impairment usually means a child has difficulty producing certain sounds. This makes it difficult for people to understand what he says. Talking involves precise movements of the tongue, lips, jaw and vocal tract. There are a few different kinds of speech impairments:

Articulation disorder is difficulty producing sounds correctly. A child with this type of speech impairment may substitute one speech sound for another, such as saying wabbit instead of rabbit .

Voice disorder is difficulty controlling the volume, pitch and quality of the voice. A child with this type of speech impairment may sound hoarse or breathy or lose his voice.

Fluency disorder is disruption in the flow of speech, often by repeating, prolonging or avoiding certain sounds or words. A child with this type of speech impairment may hesitate or stutter or have blocks of silence when speaking.

Language-based learning disabilities (LBLD) are very different from speech impairments. LBLD refers to a whole spectrum of difficulties associated with young children’s understanding and use of spoken and written language.

LBLD can affect a wide variety of communication and academic skills. These include listening, speaking, reading, writing and doing math calculations. Some children with LBLD can’t learn the alphabet in the correct order or can’t “sound out” a spelling word. They may be able to read through a story but can’t tell you what it was about. Children with LBLD find it hard to express ideas well even though most kids with this diagnosis have average to superior intelligence.

One place where parents are likely to encounter the term LBLD is in their child’s IEP . But school professionals may refer instead to “ dyslexia ” or “ dysgraphia .” These are more specific and easier to describe to parents.

Unlike speech impairments, LBLD are caused by a difference in brain structure. This difference is present at birth and is often hereditary. LBLD can affect some children more severely than others. For example, one student may have difficulty sounding out words for reading or spelling, but no difficulty with oral expression or listening comprehension . Another child may struggle in all of those areas.

LBLD isn’t usually identified until a child reaches school age. Typically it takes a team of professionals—a speech-language pathologist (SLP), psychologist, and a special educator—to find the proper diagnosis for children with LBLD. The team evaluates speaking, listening, reading and written language.

Learning problems should be addressed as early as possible. If left untreated, they can lead to a decrease in confidence, lack of motivation and sometimes even depression. Seeking treatment for your child can help significantly. Most kids with LBLD can succeed with the right services and supports.

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Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood

Patricia a. prelock.

Department of Communication Sciences, University of Vermont, Burlington, Vermont

Tiffany Hutchins

Frances p. glascoe.

Department of Pediatrics, Vanderbilt University, Nashville, Tennessee

Disclosure: Tiffany Hutchins, PhD, has disclosed no relevant financial relationships in addition to her employment.

Disclosure: Frances P. Glascoe, PhD, has disclosed no relevant financial relationships in addition to her employment.

Abstract and Introduction

Speech-language problems are the most common disability of childhood yet they are the least well detected, particularly in primary care settings. The goal of this article is to: (1) define the nature of speech-language problems, their causes, and consequences; (2) facilitate early recognition by healthcare providers via accurate screening and surveillance measures suitable for busy clinics; and (3) describe the referral and intervention process.

Introduction

Speech-language deficits are the most common of childhood disabilities and affect about 1 in 12 children or 5% to 8% of preschool children. [1] The consequences of untreated speech-language problems are significant and lead to behavioral challenges, mental health problems, reading difficulties, [2] and academic failure including in-grade retention and high school dropout. [3] Yet, such problems are ones that are least well detected in primary care, [4] even though intervention is available and plentiful.

Speech-language impairments embrace a wide range of conditions that have, at their core, challenges in effective communication. As the term implies, they include speech disorders which refer to impairment in the articulation of speech sounds, fluency, and voice as well as language disorders which refer to impairments in the use of the spoken (or signed or written) system and may involve the form of language (grammar and phonology), the content of language (semantics), and the function of language (pragmatics). [5] These may also be described more generally as communication disorders which are typically classified by their impact on a child's receptive skills (ie, the ability to understand what is said or to decode, integrate, and organize what is heard) and expressive skills (ie, the ability to articulate sounds, use appropriate rate and rhythm during speech, exhibit appropriate vocal tone and resonance, and use sounds, words, and sentences in meaningful contexts). There are common conditions in infants, toddlers, and preschoolers that are associated with receptive and expressive communication challenges as presented in Table 1 . [6 – 17]

Disorders in Young Children Commonly Associated With Receptive and Expressive Communication Problems

It is important to distinguish speech and language impairment from language delay and language difference. Language delay is characterized by the emergence of language that is relatively late albeit typical in its pattern of development. In contrast to an impairment or a delay, a language difference is associated with systematic variation in vocabulary, grammar, or sound structures. Such variation is “used by a group of individuals [and] reflects and is determined by shared regional, social, or cultural and ethnic factors” and is not considered a disorder. [18]

Unfortunately, non-native speakers of English, speakers of various dialects (whose language also varies within dialect), and bilingual or multilingual speakers are frequently classified as language delayed or disordered when, in fact, they are language different [18 , 19] –although problems of underidentification also occur. This is particularly important in an increasingly pluralistic society such as ours in which 1 of 4 people identify as other than white non-Hispanic, approximately 17% of the population is bilingual (mostly speaking Spanish and English), and where minorities represent more than 50% of the population in several cities and counties. [20]

The overidentification of culturally and linguistically diverse populations commonly occurs when a mismatch is observed and incorrectly interpreted between a language used in a particular community and that of the majority culture. This may be seen most clearly in the improper use of formal tests of speech and language to assess the competencies of speakers who are dissimilar to the sample upon which the test was normed and developed. [21] Similar errors also occur during informal evaluations of language and literacy as when the sound structure of the language influences the spelling or grammatical conventions used in written discourse. [22] With regard to bilingualism, it is commonly assumed that children's acquisition of 1 or both languages is delayed; however, the effects of bilingualism are more complex and differ with the age of the child, the nature of the linguistic input, and the manner and timing of language acquisition. What is clear is that equivalent proficiency in each language should not be expected or assumed as this has the potential to lead to misidentification of a speech and language impairment. (For more information on the effects of bilingualism on language learning, see http://asha.org/public/speech/development/BilingualChildren.htm and http://asha.org/public/speech/development/second.htm ) In the case of culturally and linguistically diverse individuals, decisions to intervene and bring language use in line with that of the majority culture or promote proficiency in the dominant language are not inappropriate; however, such decisions must be seen as separate from the language difference vs disorder question.

In your experience, which of the following is the most important barrier to the effective assessment of speech and language impairment in young children? (Select only 1 answer.)

• ○ Variability in the development of speech and language in young children
• ○ Lack of effective screening tools that discriminate children with and without speech and language impairment
• ○ Lack of accurate parent interview tools that identify clear concerns in speech and language development
• ○ Insufficient time with young children in the clinical setting to observe speech and language skills
• ○ Inadequate understanding of milestones for speech and language development

How confident are you that you are up-to-date in the diagnosis and management of speech and language impairment in young children? (Select only 1 answer.)

• ○ Not at all confident
• ○ Somewhat confident
• ○ Confident
• ○ Very confident

All of the following statements about young children with speech and language impairment are true except :

• ○ Young children tend to produce words with sounds that are consistent with the words they already know
• ○ Young children are able to communicate intent before speaking their first words
• ○ Disfluency is a common occurrence in a young child's early speech
• ○ Children usually begin to put 2 words together at 30 months

Answer: Children usually begin to put 2 words together at 30 months. Children usually begin to put 2 words together at 18 months.

Etiology, Neurobiology, and Prevalence of Speech-Language Impairments

The etiology of most cases of speech-language impairments is unknown but diverse causes are suspected. The range of causes or origins includes anatomical abnormalities, cognitive deficits, faulty learning, genetic differences, hearing impairments, neurologic impairments, or physiologic abnormalities. [6] As noted above, language differences as revealed in the communication output associated with diverse cultural, ethnic, regional or social dialects are not considered disorders. [5] Speech and language impairments may be acquired (ie, result from illness, injury or environmental factors) or congenital (ie, present at birth).

Children with speech and language impairment are an under-representation of the broader occurrence of communication disorders, [23] especially considering the co-occurrence of communication disorders with other disabilities (eg, learning disabilities). Approximately 8% to 12% of preschool populations exhibit language impairments. [6] Among children enrolled in early intervention programs, 46% have communication impairments while 26% have developmental delays in multiple areas, usually including language skills. [24] These findings indicate that the most common presentation of disability in preschoolers involves problems with language.

In a family with a child with a speech and language impairment, which of the following would be clinically appropriate?

• ○ Reassure the parents that the child is just a late talker and will catch up
• ○ Urge the parents to have their child undergo genetic testing
• ○ Discourage the child's parents and sibling(s) from talking for the child as this may be a primary cause of a speech and language impairment
• ○ Advise the parent to have the child's hearing tested

Answer: Advise the parent to have the child's hearing tested. This is appropriate because hearing would be the first condition to rule out as a potential cause of a speech and language delay.

Course and Prognosis

Speech-language impairment sometimes emerges during infancy with challenges in response to sound, atypical birth cries, or limited response to others and progresses through the toddler and preschool age with limited comprehension of spoken language and difficult interactions with peers and others as well as delays in producing first words and word combinations. Speech and language difficulties often persist in school age with difficulties following directions, attending and comprehending oral and written language, and problems producing narratives and using language appropriately in social contexts. Parents are often the first to notice difficulties as they encounter other children with more advanced speech-language skills and thus often wonder if their child is behind. [25] Although many parents raise concerns to primary care providers, many do not. In turn, primary care providers who do not use quality screening tools often dismiss parental concerns with panaceas such as, “He's a boy. Boys talk later.” Or, “Let's give this some time and see if it continues.” Yet, parental concerns about speech and language are associated with developmental disabilities [26] and, thus, careful screening with accurate tools is the requisite response. [27]

The use of a “wait and see” approach underscores the difficulty in distinguishing children who are language delayed from those who have a speech and language impairment. Although most children who have aspeech and language impairment have a history of language delay, only one quarter to one half of late-talkers are eventually diagnosed with a language disorder. [19] In advocating for a more aggressive response for late-talking children, some have argued for careful scrutiny of other risk factors that may guide decisions to refer and intervene. [19] Predictors of a true speech and language impairment that should be considered include poor receptive language skills, [28] limited expressive language skills (eg, small vocabulary, few verbs), and limited development in the sound structure of a language (eg, limited number of consonants, limited variety in babbling structure, vowel errors). [26] Additional predictors include nonspeech (eg, behavioral problems, few gestures, little imitation or symbolic play), environmental (eg, low socioeconomic status, parental use of a directive rather than sensitive and responsive interactional style), and hereditary factors (eg, family history). [26] As a general recommendation, professionals are urged to consider a larger number of risk factors with greater concern. [26]

Often speech-language impairments can be difficult to distinguish from what is considered typical variations in speech and language. For example, disfluencies in speech may be either normal or abnormal. In the nonstuttering child, the most common disfluencies include 1-unit word repetitions (eg, “I… I want that”), interjections (eg, “I saw a… um… picture”), and revisions (eg, “I don't know where… Mommy, help me find my doll”) and, when combined, comprise no more than 10% of words spoken. [29] In the stuttering child, the fluency disorder typically emerges between the ages of 2 and 5 years, is more common among males than females, and is characterized by more than 10% disfluencies in speech, multi-unit syllable (eg, “s-s-s-s-s-September”) and word (eg, “That's my-my-my ball”) repetitions, and may be accompanied by secondary behaviors such as eye-blinking, head-bobbing, or grimacing, as well as feelings of frustration or embarrassment surrounding the stuttering event. [29]

Identification of speech and language impairments is further complicated by the fact that they often masquerade as other diagnostic conditions. For example, children with a diagnosis of attention-deficit/hyperactivity disorder (ADHD) may in fact have an underlying language disorder. Differential diagnosis is challenged by the diagnostic criteria shared between the 2 conditions. Specifically, the diagnostic criteria for ADHD share several characteristics with language disorders including difficulty listening when spoken to, following instructions, talking excessively, blurting out answers, interrupting, and waiting for turns in conversation. [30] Similarly, 50% of preschoolers presenting for psychiatric services were found in several studies to have undiagnosed language impairment. [31 , 32]

The diagnostic criteria for speech-language impairments are defined both by the Diagnostic and Statistical Manual of Mental Disorders , 4th edition (DSM-IV) [33 , 34] and by the Individuals with Disabilities Education Act (IDEA) through the US Department of Education. Table 2 specifies the criteria for communication disorders as described in the DSM-IV. As an example of eligibility criteria for speech-language impairment in response to IDEA guidelines, Vermont indicates that children must demonstrate significant deficits greater than 2 standard deviations below the mean in listening comprehension (eg, measures of auditory (language) processing or comprehension of connected speech including semantics, syntax, phonology, recalling information, following directions and pragmatics) and/or oral expression (eg, measures of oral discourse-syntax, semantics, phonology and pragmatics; voice; fluency; articulation) to qualify as speech or language impaired. [35]

Characteristics of Communication Disorders as Described in the DSM-IV [33 , 34]

Distinguishing children with speech-language deficits from those with other disabilities is often a challenging task as several disabilities share characteristics and have similar diagnostic criteria. For example, an intellectual disability is one in which a child's performance falls at or below 1.5 standard deviations from the mean on a test of intellectual ability with concurrent deficits in adaptive behavior. Children with intellectual disabilities, however, often have significant challenges in receptive and expressive communication as is typical of children with speech and language impairments. Children with learning disabilities have deficits in 1 or more basic skill areas including oral expression and listening comprehension, challenges characteristic of children with speech-language impairments. Children with pervasive developmental disorders/autism exhibit marked impairments in communication and social interaction and restricted and repetitive stereotyped patterns of behavior. Although social impairment is a defining feature of autism, communication impairments are similar to those with a speech-language impairment.

Which of the following is not true of speech-language impairment?

• ○ Early intervention is critical as speech-language impairments place children at risk for later academic difficulties
• ○ Most children with speech-language impairments have intellectual deficits
• ○ Communication disorders may manifest themselves at different stages of life
• ○ Children with learning disabilities are likely to have speech and language impairments

Answer: Most children with speech-language impairments have intellectual deficits. Although many children who have mental retardation have speech-language impairments, most children with specific speech-language impairments have nonverbal intelligence within normal limits.

Screening and Early Assessment of Speech-Language Disorders

The American Academy of Pediatrics recommends ongoing surveillance and periodic use of broad-band screening measures at all well-visits. Table 3 provides information on a number of tools that have high levels of accuracy in detecting speech-language problems and other disabilities. All included measures were standardized on national samples, proven to be reliable, and validated against a range of measures. When used, referral rates to early intervention programs rise to meet prevalence. [36] In the absence of accurate measures, most providers rely on informal milestone checklists. These lack criteria and are probably the leading reason why only about 1 in 4 children with disabilities of any kind are referred for needed assistance.

Accurate Developmental, Mental Health/Behavioral, and Academic Screens Suitable for Primary Care *

© 2007, Glascoe FP. PEDS: Developmental Milestones Professionals Manual. Nashville, Tennessee: Ellsworth & Vandermeer Press, Ltd. Permission is given to reproduce this table.

The first column in Table 3 provides publication information and the cost of purchasing a specimen set. The “Description” column provides information on alternative ways, if available, to administer measures (eg, waiting rooms). The “Accuracy” column shows the percentage of patients with and without problems identified correctly. The “Time Frame/Costs” column shows the costs of materials per visit along with the costs of professional time (using an average salary of $50 per hour) needed to administer and interpret each measure. Time/cost estimates do not include expenses associated with referring. For parent report tools, administration time reflects not only scoring of test results, but also the relationship between each test's reading level and the percentage of parents with less than a high school education (who may or may not be able to complete measures in waiting rooms due to literacy problems and will need interview administrations).

Even when screens are deployed, it is nevertheless helpful to complement these brief measures with clinical observation. The brevity of screens useful for primary care means that some skills may not be captured. For example, at any given age range, a brief screen may not present articulation items, measure ability to repeat a story, describe daily events, ask questions, or engage in conversation, etc. The value in routinely administering validated, accurate screening tools, however, is essential to improving currently problematic and extremely low rates of early detection on the part of primary healthcare providers.

Table 4 describes some major language developmental milestones in the prelinguistic (birth to 1 year) and linguistic period (1 year and beyond). [37 , 38] It is important to note that there are wide variations in the speed (and style) with which typically developing children acquire language skills.

Average Age and Range of Ages for Achievement for Important Language Developmental Milestones * [37 , 38]

Providers are reminded that these indicators are an aid to early detection but do not substitute for quality measurement. See Table 3 for a list of screening measures with proven accuracy.

Screening for Other Potential Contributors to Speech-Language Deficits

Another critical avenue for exploration into possible contributors to speech-language deficits is psychosocial risk. Parents who are depressed and/or have housing or food instability have children more likely to have language problems, perhaps because parents lack the energy and freedom from preoccupations to engage in the kinds of language-mediated social interactions known to support optimal child language development. Some parents are not aware of positive parenting practices that promote development, especially language skills (eg, talking with and reading to their child, creating opportunities for sustained dialogue, responding contingently to a child's initiations). Detecting and intervening when psychosocial risk factors, including abuse and neglect, are present has the potential to prevent language problems from developing. Screens for psychosocial risk factors including depression and parent-child interactions are widely available and include the Family Psychosocial Screen and the Brigance Parent-Child Interactions Scale . Both are included in PEDS: Developmental Milestones [39] as supplementary measures helpful for surveillance and offer evidence-based compliance with recommendations in early detection from the American Academy of Pediatrics. [40] , Many other screens, such as the Ages and Stages Questionnaire , include a background information questionnaire that captures common psychosocial risk factors. [41]

Screening Older Children

With school-age children, obtaining and reviewing group achievement test scores can help reveal undiagnosed language deficits. Such children typically have weaknesses in general information (eg, science, social studies knowledge), problems with reading comprehension, and sometimes also problems with math concepts. Table 3 also includes screens suitable for primary care professionals working with children aged 8 years and older.

For both preschoolers and school-age children, broad-band screens (or review of group achievement test results) should be deployed first and serve as a guide to the selection of narrow-band instruments. For example, attentional deficits can be due to a range of conditions such as language impairment, learning disabilities, and mental health problems such as depression. The optimal approach is to administer a broad developmental or academic screen along with a measure such as the Pediatric Symptom Checklist (which discriminates mental health from attentional difficulties). Only afterward and as suggested by the results of broad-band measures should a narrowly focused tool such as the Vanderbilt ADHD Diagnostic Rating Scale be administered. Making sure that other conditions are treated first or at least concomitantly with ADHD is essential.

Billing and Coding for Screening

Primary care providers can use the – 25 modifier to their preventive service code (to indicate that stand-alone services were offered and then use 96110 times the number of screens administered, eg, 96110 X 2. For insurers not accepting units, the distinct procedural service of each screen is best represented with the – 59 modifier appended to each additional unit of 96110.

In 2005, the Centers for Medicare and Medicaid Services published a total relative value unit (RVU) of 0.36 for 96110, which amounts to a Medicare payment of $13.64. None of this can guarantee that a valid claim will be accepted, so the American Academy of Pediatrics is willing to help with denied claims via their Coding Hotline: 800-433-9016, x4022, or at .gro.paa@eniltohgnidocpaa RVUs do not cover physician time, so making use of office staff and parent-report tools is essential.

Referrals and Other Interventions

Once suspicion exists that a child may have a speech-language impairment, referral to early intervention or to the public schools (depending on age) is the first step. These programs offer intervention by speech-language pathologists. If sufficient quantity is not available, referrals can also be made to private therapy services, which may be covered by the patients' insurance. If there appear to be underlying medical conditions, assessment by other disciplines, such as developmental-behavioral or neurodevelopmental pediatrics, is important.

For families with psychosocial risk factors, developmental promotion is essential as is careful monitoring of progress. If brief advice and information handouts are not effective and particularly if children have delays not sufficiently great as to qualify for services, then parent training, quality day care, Head Start, after-school tutoring, and private speech-language therapy should be recommended. Table 5 shows a list of professional development and referral resources. Table 6 provides a list of resources and information for parents.

Professional Development and Referral Resources

Resources and Information for Parents

Components of a Diagnostic Evaluation of Speech-Language Impairment and the Nature of Interventions

Although screening tools for speech-language often identify those children who have speech-language impairments, a screening is not a diagnostic evaluation and only suggests a child requires a more comprehensive assessment. There are several goals in a diagnostic assessment, including verifying that a speech-language impairment exists, describing the strengths and challenges of the child's speech and language, evaluating the severity of the problem, ascertaining the etiology, determining recommendations for a treatment plan, and providing a prognosis. [6] Assessment requires obtaining a sample of communication skills across settings through a number of procedures. It is critical to collect information not only from standardized, formal tools but also to gather more authentic, real-life information to facilitate meaningful and accurate decisions. Typically, case history information, parent interviews, checklists from other providers, systematic observation, hearing screening, and examination of the speech mechanism is included. [6] Formal norm-referenced tests are used to assess articulation, phonology, grammatical understanding and production, and pragmatic language use. The collection of data from the authentic assessment tools and the formal measures provide a comprehensive picture of the speech-language needs of a young child with a communication impairment.

All of the following are true in the assessment of a young child with speech-language impairments except :

• ○ Obtaining information from multiple sources across settings is necessary to specify communication strengths and challenges
• ○ Speech-language pathologists (SLPs) make diagnoses of specific speech-language impairment, identify probable causes, determine severity, describe the likely prognosis, and provide recommendations
• ○ Clinical judgment is most appropriate for determining the severity of a child's speech-language impairment
• ○ During assessment, speech, language, hearing, and processing abilities should be probed

Answer: Clinical judgment is most appropriate for determining the severity of a child's speech-language impairment. Objective criteria are important to ensure consistency in the assessment of severity.

To determine the prognosis for a young child with a speech-language impairment, which of the following is true?

• ○ A clinician should avoid providing prognostic information, as questions like “Will my son outgrow his speech-language impairment?” cannot be answered
• ○ Trial therapy during an assessment period is an appropriate strategy to inform prognosis
• ○ Families and clinicians have little difficulty making decisions about whether or not a young child with early expressive language delay will benefit from therapy
• ○ Single evaluation measures can be used to determine the severity of a young child's speech-language impairment and the prognosis for successful outcomes

Answer: Trial therapy during an assessment period is an appropriate strategy to inform prognosis. Clinicians often probe a child's response to intervention strategies to determine responsiveness to treatment and to inform the development of the treatment plan.

Intervention Approaches and Outcomes

The complexity of impairments in speech and language requires a variety of intervention approaches that can address deficits in language form (syntax, phonology, morphology), language content (semantics), and language use (pragmatics) as well as speech and voice production. Further, intervention for young children may involve not just the speech-language pathologist but also care providers and peers.

The ultimate goal of intervention is to increase a child's success in using language to communicate his or her intent, respond to the intent of others, and participate in reciprocal interactions. The speech and language targets vary for each child depending on the context and aspects of communication affected. Targets may or may not follow a strict developmental approach. Sometimes a more functional approach is appropriate, supporting communication at the point of frustration and breakdown. [6] Intervention targets should consider the family's desired outcomes for their child's communication. Targets should be developmentally appropriate and meaningful to the child.

Several teaching methods are used to support the speech and language of children. Modeling is a typical intervention strategy that provides focused stimulation on the speech or language targets selected for an individual child. Cueing is another frequently used technique that includes direct and indirect verbal cues (eg, asking a child to imitate a sound, word, or utterance) or nonverbal cues (eg, giving a child a jar with a desired item that can't be opened without help). In addition, responding to a child's communication efforts through reinforcement or corrective feedback (eg, “Remember to say the ending sound /t/ so we know you mean the word ‘boat’”) is frequently used to facilitate effective communication. [6]

Case Studies

Bobby [pseudonym] is a 7-year-old boy whom you have seen in your office for a number of years. He comes to you today for his annual check-up. Bobby is enrolled in the second grade. His mother is concerned because Bobby's teachers have noted difficulties in his ability to learn to read. Specifically, Bobby's teachers say that he has difficulties with word recognition and reading comprehension. Bobby's mother indicates that this is consistent with her own observations that he seems to have trouble with understanding what is being said (eg, directions, questions) and storytelling. Moreover, she suspects that Bobby's vocabulary is less well developed compared with his peers. She also describes frequent errors in how he formulates sentences such as omitting possessives (eg, “Sam dog” instead of “Sam's dog”) and verbs (eg, “He cooking” instead of “He is cooking”) that she fears are atypical. Bobby's nonverbal IQ is in the typical range.

The difficulties described above are most consistent with a possible diagnosis of:

• ○ Autism spectrum disorder
• ○ Intellectual disability
• ○ Specific language impairment
• ○ Language delay

Answer: Specific language impairment.

Darius [pseudonym] is a 5-year-old African American boy whom you are meeting today for the first time. He and his mother have recently moved to your area and she has brought him to you because he seems to be developing a nasty cough. When talking with Darius, you notice that he is extremely difficult to understand. Darius is a speaker of African American English; however, even with young speakers of this dialect, you have never had such difficulty understanding and communicating effectively. You learn that he and his parents have just moved from an impoverished community in South Carolina where he attended an age-appropriate class in a school in which approximately 85% of his classmates were black, to a school district in your area that almost entirely comprises white administrators, staff, and students. His mother further reports that Darius's new teachers have expressed concerns about his language. They say he is hard to understand, has a limited vocabulary, cannot master letter-sound correspondences, and has trouble listening to and understanding others.

Which of the following additional patient characteristics obtained from the mother would increase your suspicion of a diagnosis of speech and language impairment? (Select all that apply.)

• ▪ Darius's mother reports that he has always talked differently compared with his parents, siblings, and peers
• ▪ Darius's scores on a test of articulation of standard English are in the 10th percentile
• ▪ Darius becomes frustrated when you ask him to repeat himself
• ▪ Even though they are consistent with the sound structure of African American English, errors in Darius's spelling are quite common (eg, he writes "nes" instead of “nest”)

Answer: Darius's mother reports that he has always talked differently compared with his parents, siblings, and peers.

Which of the following additional patient or parent characteristics would increase your suspicion that Darius is exhibiting a language difference as opposed to a speech and language impairment? (Select all that apply.)

• ▪ Not only do you find Darius difficult to understand, but his mother is equally difficult to understand; both seem to be using a variation of African American English dialect that, although not commonly heard in your area, is characteristic of their native community
• ▪ Darius's scores on a test of vocabulary standardized on a cross-section of North American native English speakers are in the 35th percentile
• ▪ Darius's mother has no trouble understanding him
• ▪ Darius's mother does not share these concerns and considers him competent in all aspects of his language development

Answer: Not only do you find Darius difficult to understand, but his mother is equally difficult to understand; both seem to be using a variation of African American English dialect that, although not commonly heard in your area, is characteristic of their native community. Darius's mother does not share these concerns and considers him competent in all aspects of his language development.

You have been Sam's [pseudonym] primary care physician since he was born. He is now 18 months old and comes to you for his annual flu shot. During this visit, his mother expresses concerns about his speech and language development. More specifically, she reports he is “not talking like other kids his age” and uses repeated vocalizations (eg, “eh eh eh eh” while pointing) to communicate. Very recently, Sam has begun to use some words which are often paired with a gesture (eg, “Daddy” while pointing or “up” while raising hands to be picked up). You notice during your visit that Sam is a social and attentive child. He looks at other people and follows their eye gaze to distal objects. He also seems to understand the speech that his mother directs to him and he can easily carry out 2-step commands (eg, “Pick up the cup and sit next to me, please”). Sam's mother is aware of no immediate or extended family members who have ever had a speech or language impairment. Sam has no history of ear infection, and a recent hearing screen indicated hearing in the normal range.

• ▪ Limited imitation
• ▪ Limited pretend play
• ▪ Limited facial expressiveness
• ▪ Excessive use of nonverbal communicative gestures (eg, reaching, pointing, looking)

Answer: Limited imitation. Limited pretend play.

What should the mother expect with time if her child does not have a speech and language impairment but is rather a late-talker? (Select all that apply.)

• ▪ The child will begin to engage in unusual repetitive behaviors
• ▪ The child will steadily albeit slowly add new words and begin to combine them into 2-word utterances
• ▪ Any new words that the child utters are likely to be distorted and difficult to understand
• ▪ The child may develop aggressive behaviors to cope with his inability to communicate effectively

Answer: The child will steadily albeit slowly add new words and begin to combine them into 2-word utterances.

Theresa [pseudonym] is a 3-year-old female whom you have seen in your office regularly since her birth. She comes to you today for her annual check-up. During her visit, you observe that Theresa is precocious in her language development. Indeed, her mother reports that she has always been a “great talker” and that she began to speak in well-formed utterances at age 18 months. During this visit, you notice a number of disfluencies in Theresa's speech. At one point, she repeats a word 3 times before getting the rest of the sentence out (ie, “I see… see… see a book with a clown”). Theresa's mother states that these kinds of disfluencies began about 1 month ago and, although she characterizes them as relatively infrequent, she has questions about whether this kind of speech is normal.

Which of the following additional patient characteristics obtained from your observation of Theresa would increase your suspicion of a diagnosis of a fluency disorder? (Select all that apply.)

• ▪ Theresa seems aware of and perturbed by her disfluencies
• ▪ Theresa sometimes jerks her head when hesitating to utter her next word
• ▪ Approximately 20% of Theresa's words appear to constitute disfluencies
• ▪ Theresa produces multi-unit syllable repetitions (eg, “t-t-t-time”)
• ▪ All of the above

Answer: All of the above.

Reader Comments on: Speech-Language Impairment: How to Identify the Most Common and Least Diagnosed Disability of Childhood See reader comments on this article and provide your own.

Readers are encouraged to respond to the author at [email protected] or to George Lundberg, MD, Editor in Chief of The Medscape Journal of Medicine , for the editor's eyes only or for possible publication as an actual Letter in the Medscape Journal via email: ten.epacsdem@grebdnulg

Contributor Information

Patricia A. Prelock, Department of Communication Sciences, University of Vermont, Burlington, Vermont.

Tiffany Hutchins, Department of Communication Sciences, University of Vermont, Burlington, Vermont.

Frances P. Glascoe, Department of Pediatrics, Vanderbilt University, Nashville, Tennessee.

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What is stuttering?

Who stutters, how is speech normally produced, what are the causes and types of stuttering, how is stuttering diagnosed, how is stuttering treated, what research is being conducted on stuttering, where can i find additional information about stuttering.

Stuttering is a speech disorder characterized by repetition of sounds, syllables, or words; prolongation of sounds; and interruptions in speech known as blocks. An individual who stutters exactly knows what he or she would like to say but has trouble producing a normal flow of speech. These speech disruptions may be accompanied by struggle behaviors, such as rapid eye blinks or tremors of the lips. Stuttering can make it difficult to communicate with other people, which often affects a person’s quality of life and interpersonal relationships. Stuttering can also negatively influence job performance and opportunities, and treatment can come at a high financial cost.

Symptoms of stuttering can vary significantly throughout a person’s day. In general, speaking before a group or talking on the telephone may make a person’s stuttering more severe, while singing, reading, or speaking in unison may temporarily reduce stuttering.

Stuttering is sometimes referred to as stammering and by a broader term, disfluent speech .

Roughly 3 million Americans stutter. Stuttering affects people of all ages. It occurs most often in children between the ages of 2 and 6 as they are developing their language skills. Approximately 5 to 10 percent of all children will stutter for some period in their life, lasting from a few weeks to several years. Boys are 2 to 3 times as likely to stutter as girls and as they get older this gender difference increases; the number of boys who continue to stutter is three to four times larger than the number of girls. Most children outgrow stuttering. Approximately 75 percent of children recover from stuttering. For the remaining 25 percent who continue to stutter, stuttering can persist as a lifelong communication disorder.

We make speech sounds through a series of precisely coordinated muscle movements involving breathing, phonation (voice production), and articulation (movement of the throat, palate, tongue, and lips). Muscle movements are controlled by the brain and monitored through our senses of hearing and touch.

The precise mechanisms that cause stuttering are not understood. Stuttering is commonly grouped into two types termed developmental and neurogenic.

Developmental stuttering

Developmental stuttering occurs in young children while they are still learning speech and language skills. It is the most common form of stuttering. Some scientists and clinicians believe that developmental stuttering occurs when children’s speech and language abilities are unable to meet the child’s verbal demands. Most scientists and clinicians believe that developmental stuttering stems from complex interactions of multiple factors. Recent brain imaging studies have shown consistent differences in those who stutter compared to nonstuttering peers. Developmental stuttering may also run in families and research has shown that genetic factors contribute to this type of stuttering. Starting in 2010, researchers at the National Institute on Deafness and Other Communication Disorders (NIDCD) have identified four different genes in which mutations are associated with stuttering. More information on the genetics of stuttering can be found in the research section of this fact sheet.

Neurogenic stuttering

Neurogenic stuttering may occur after a stroke, head trauma, or other type of brain injury. With neurogenic stuttering, the brain has difficulty coordinating the different brain regions involved in speaking, resulting in problems in production of clear, fluent speech.

At one time, all stuttering was believed to be psychogenic, caused by emotional trauma, but today we know that psychogenic stuttering is rare.

Stuttering is usually diagnosed by a speech-language pathologist, a health professional who is trained to test and treat individuals with voice, speech, and language disorders. The speech-language pathologist will consider a variety of factors, including the child’s case history (such as when the stuttering was first noticed and under what circumstances), an analysis of the child’s stuttering behaviors, and an evaluation of the child’s speech and language abilities and the impact of stuttering on his or her life.

When evaluating a young child for stuttering, a speech-language pathologist will try to determine if the child is likely to continue his or her stuttering behavior or outgrow it. To determine this difference, the speech-language pathologist will consider such factors as the family’s history of stuttering, whether the child’s stuttering has lasted 6 months or longer, and whether the child exhibits other speech or language problems.

Although there is currently no cure for stuttering, there are a variety of treatments available. The nature of the treatment will differ, based upon a person’s age, communication goals, and other factors. If you or your child stutters, it is important to work with a speech-language pathologist to determine the best treatment options.

Therapy for children

For very young children, early treatment may prevent developmental stuttering from becoming a lifelong problem. Certain strategies can help children learn to improve their speech fluency while developing positive attitudes toward communication. Health professionals generally recommend that a child be evaluated if he or she has stuttered for 3 to 6 months, exhibits struggle behaviors associated with stuttering, or has a family history of stuttering or related communication disorders. Some researchers recommend that a child be evaluated every 3 months to determine if the stuttering is increasing or decreasing. Treatment often involves teaching parents about ways to support their child’s production of fluent speech. Parents may be encouraged to:

• Provide a relaxed home environment that allows many opportunities for the child to speak. This includes setting aside time to talk to one another, especially when the child is excited and has a lot to say.
• Listen attentively when the child speaks and focus on the content of the message, rather than responding to how it is said or interruptng the child.
• Speak in a slightly slowed and relaxed manner. This can help reduce time pressures the child may be experiencing.
• Listen attentively when the child speaks and wait for him or her to say the intended word. Don't try to complete the child’s sentences. Also, help the child learn that a person can communicate successfully even when stuttering occurs.
• Talk openly and honestly to the child about stuttering if he or she brings up the subject. Let the child know that it is okay for some disruptions to occur.

Stuttering therapy

Many of the current therapies for teens and adults who stutter focus on helping them learn ways to minimize stuttering when they speak, such as by speaking more slowly, regulating their breathing, or gradually progressing from single-syllable responses to longer words and more complex sentences. Most of these therapies also help address the anxiety a person who stutters may feel in certain speaking situations.

Drug therapy

The U.S. Food and Drug Administration has not approved any drug for the treatment of stuttering. However, some drugs that are approved to treat other health problems—such as epilepsy, anxiety, or depression—have been used to treat stuttering. These drugs often have side effects that make them difficult to use over a long period of time.

Electronic devices

Some people who stutter use electronic devices to help control fluency. For example, one type of device fits into the ear canal, much like a hearing aid, and digitally replays a slightly altered version of the wearer’s voice into the ear so that it sounds as if he or she is speaking in unison with another person. In some people, electronic devices may help improve fluency in a relatively short period of time. Additional research is needed to determine how long such effects may last and whether people are able to easily use and benefit from these devices in real-world situations. For these reasons, researchers are continuing to study the long-term effectiveness of these devices.

Self-help groups

Many people find that they achieve their greatest success through a combination of self-study and therapy. Self-help groups provide a way for people who stutter to find resources and support as they face the challenges of stuttering.

Researchers around the world are exploring ways to improve the early identification and treatment of stuttering and to identify its causes. For example, scientists have been working to identify the possible genes responsible for stuttering that tend to run in families. NIDCD scientists have now identified variants in four such genes that account for some cases of stuttering in many populations around the world, including the United States and Europe. All of these genes encode proteins that direct traffic within cells, ensuring that various cell components get to their proper location within the cell. Such deficits in cellular trafficking are a newly recognized cause of many neurological disorders. Researchers are now studying how this defect in cellular trafficking leads to specific deficits in speech fluency.

Researchers are also working to help speech-language pathologists determine which children are most likely to outgrow their stuttering and which children are at risk for continuing to stutter into adulthood. In addition, researchers are examining ways to identify groups of individuals who exhibit similar stuttering patterns and behaviors that may be associated with a common cause.

Scientists are using brain imaging tools such as PET (positron emission tomography) and functional MRI (magnetic resonance imaging) scans to investigate brain activity in people who stutter. NIDCD-funded researchers are also using brain imaging to examine brain structure and functional changes that occur during childhood that differentiate children who continue to stutter from those who recover from stuttering. Brain imaging may be used in the future as a way to help treat people who stutter. Researchers are studying whether volunteer patients who stutter can learn to recognize, with the help of a computer program, specific speech patterns that are linked to stuttering and to avoid using those patterns when speaking.

The NIDCD maintains a directory of organizations that provide information on the normal and disordered processes of hearing, balance, taste, smell, voice, speech, and language.

Use the following keywords to help you find organizations that can answer questions and provide information on stuttering:

• Speech-language pathologists
• Physician/practitioner referrals

For more information, contact us at:

NIDCD Information Clearinghouse 1 Communication Avenue Bethesda, MD 20892-3456 Toll-free voice: (800) 241-1044 Toll-free TTY: (800) 241-1055 Email: [email protected]

NIH Pub. No. 97-4232 February 2016

* Note: PDF files require a viewer such as the free Adobe Reader .

Convention on the Rights of Persons with Disabilities: 5 fast facts

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Imagine daily life without your sight, hearing or a limb or living with the challenges of neurodiversity or paralysis. That’s a reality for some. One in six of us – or 16 per cent – of the global population had a disability in 2023, according to the World Health Organization (WHO), and many depend on the  Convention on the Rights of Persons with Disabilities to help guard their fundamental freedoms and dignity.

The landmark legally binding treaty entered into force on 3 May 2008, marking a major milestone in the effort to promote, protect and ensure the full and equal enjoyment of all human rights for all.

Ahead of the 17th Conference of States Parties (COSP17) that starts on 11 June, here are five fast facts about the Convention and how it continues to impact the lives of 1.3 billion men, women and children living with disabilities around the world:

1. Why the world needs the Convention

People with disabilities face discrimination and the denial of their human rights around the world. Society’s barriers are the problem, not individual impairments.

That’s why the Convention exists.

The Convention is a human rights treaty that sets out how to make a world disability inclusive.

The goal is to create an enabling environment so that people living with disabilities can enjoy real equality in society.

2. Protected rights

The Convention emphasises that people living with disabilities must have their dignity respected and their voices heard and should be involved in making decisions that affect their lives. That includes all rights, from freedom of speech and education to healthcare and employment.

The treaty tells countries to remove obstacles that prevent people with disabilities from fully participating in all fields, from technology to politics.

It addresses those barriers, including discrimination and accessibility, and also calls for equality for women and girls. In addition, the treaty maps out ways countries around the world can remove barriers preventing people with disabilities from fully enjoying all their rights.

3. How the treaty is enforced

There are several ways the Convention is enforced, respected and implemented.

Individuals can bring petitions to the UN  Committee on the Rights of Persons with Disabilities to report breaches of their rights.

“The mere existence of the Convention gives persons with disabilities and their organisations the ability to say to their governments ‘you have accepted these obligations’ and insist that they be met.” said Don MacKay, chair of the committee that drafted the treaty.

The 18-member Geneva-based committee can also undertake inquires of grave or systematic violations of the Convention and monitors whether rights are being properly applied, online and off in times of peace and of war and other crises.

4. A seat at the table

A key to progress is bringing people whose rights are affected to the table.

This year, hundreds of delegates from non-governmental organizations (NGOs) are coming to New York to take part in the latest Conference of State Parties, COSP17, to be held in June 2024, one of the largest global meetings on disability rights.

Since the time the treaty was negotiated, the perspectives and input of people living with disabilities are being heard at meetings at the UN and in countries around the world.

The bigger table at UN Headquarters now accommodates accessibility requirements, including wheelchair access, hearing loops usage, documentation in Braille, large print or sign language usage.

5. In the spotlight

Global celebrities like the singer-songwriter and UN Messenger of Peace Stevie Wonder, who is visually impaired, have also added their voice.

“Someone being sighted doesn’t mean that they should be blind to those things in the world that we need to fix,” Mr. Wonder  said , noting that there are 300 million visually impaired people around the world.

“We really are abled persons with different abilities. We have to have inclusion.”

Watch UN Video’s Stories from the UN Archive on how the music icon challenged assumptions about Braille:  here .

“I think there are certain sort of stereotypes that we hear about autism, and I’ve learned very quickly through meeting people who either were parents of autistic children or meeting people with autism that those sort of stereotypes don’t really exist,” actor Dakota Fanning told UN News  in a conversation about her role as Wendy, who is autistic, in the film Please Stand By .

“So, I felt that I didn’t I want to further the stereotypes and that I wanted to really portray her as I would portray any other young woman,” she said.

“I have lived with discrimination for part of my life,” said Canadian activist, actor and talk show host Nick Herd, who was born with Down syndrome.

“When I was young, and growing up, I was bullied because of my disability, but now I can use that voice, from the child that I was, to be heard, louder and louder. I can shout it on the top of a building or off a mountain, bigger than the UN so that persons with disabilities are included at the table.”

“In war, those with disabilities are often represented as victims, denied equality in humanitarian support and excluded from peace processes,”  said renowned photographer Giles Duley, the first UN Global Advocate for persons with disabilities in conflict and peacebuilding situations.

“It is time for change, and if we work together, we have the strength and opportunity to create that change.”

Who’s on board?

The Convention on the Rights of Persons with Disabilities was opened for signature in 2006. Here’s who is on board:

• As of today, 191 nations and UN observers have ratified the treaty, and 106 have ratified its Optional Protocol
• Since the Convention entered into force in 2008, the UN and its agencies have worked towards amplifying its provisions
• The 2030 Agenda for Sustainable Development aims to leave no one behind in its 17 Sustainable Development Goals (SDGs)
• The Summit of the Future intends to realign international cooperation to be inclusive across the board
• Check out the  UN Disability Inclusion Strategy
• The Convention and its  Optional Protocol established annual meetings of treaty signatories – the “Conference of States Parties” ( COSP ) – to monitor implementation and discuss current themes and trends, with this year’s COSP17 focusing on jobs, tech and humanitarian emergencies at a meeting at UN Headquarters from 11 to 13 June 2024
• Learn about the Committee on the Rights of Persons with Disabilities  here
• Follow past and present annual Conferences of States Parties (COSP)  here
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Adjunct Faculty, Department of Communication Sciences and Disorders, Speech-Language Pathology

Job Details

The University sits on three adjoining campus sites in Union County, New Jersey covering 180 acres, two miles from Newark Liberty International Airport and thirty minutes from New York City, with additional locations in Ocean County, New Jersey -  Kean Ocean  and Jefferson Township, New Jersey - Kean Skylands . Kean University also operates a unique, additional location in Wenzhou, China .

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