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Facts about language impairment in children
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For some children, language impairment resolves over the course of the first school year, but for many children, the problem persists, and some develop reading and writing difficulties.
What is language impairment?
Language impairment is:
- Difficulty understanding speech
- Difficulty expressing oneself verbally
- Difficulty with correct pronunciation and being understood
Language impairment in connection with other diagnoses
Some children have language impairment in connection with developmental problems, such as autism or Down syndrome. Nonetheless, these children may struggle more than their developmental diagnoses alone would indicate.
Landau-Kleffner syndrome is a type of language impairment characterized by abnormal EEG results and in many cases also epileptic seizures.
Other children have no such developmental difficulties that might explain their language impairment.
Different degrees of severity
There are many ways to differentiate various types of language and speech impairment. There is also significant variation in the severity of language impairment. In Norway, we use three main diagnostic categories, in following with the ICD 10 (International Classification of Diseases, 10th edition), published by the World Health Organization (WHO).
- Expressive language impairment: Difficulty speaking and expressing oneself, while verbal comprehension is good. Expressive means to articulate oneself.
- Receptive language impairment: Difficulties understanding speech. In the majority of cases, there is also a weaker ability to communicate verbally. Receptive means to understand.
- Speech impairment: Difficulties speaking clearly.
New categories of language impairment
Research from the past 10 years has shown a strong correlation between the ability to express oneself verbally and the ability to understand speech. Studies have also shown that children can struggle with specific functions within speech, for example grammar or verb conjugation.
Internationally, there has been a change in the way language impairment is divided. Instead of two categories, expressive and receptive speech, it is now common to use the more general term communication difficulties.
Communication difficulties can be divided into several subcategories, and these constitute developmental difficulties connected to speech, pronunciation and communication.
Communication disturbances include the following diagnostic categories:
- Difficulties with sounds of speech
- Stuttering beginning in childhood
- Difficulty with using speech (pragmatic impairment)
- Communication difficulties not covered by the above categories.
The current American diagnostic system (Diagnostic and Statistical Manual of Mental Disorders, 5th edition, DSM-5) was published in 2013, and recommends that communication difficulties be divided into 4 subcategories. The first draft of the ICD-11, which will be used in Norway when it is published, will follow the same 4 category system. The 4 categories are as follows:
1. Language Impairment
Language impairment involves weaker language acquisition and use than expected at a given age. Difficulties can be connected to one or more areas: vocabulary, grammar or communication skills. These difficulties should be severe enough that they affect functional communication, social participation, mastery in school subjects and professional life.
Many children who begin speaking ‘late’ do catch up with peers in language development, but for some children, delayed language is the first sign of developmental impairment. This can be specific language impairment, Autism spectrum disorder (ASD), learning disorders, ADHD, developmental disabilities or other developmental disorders. It is often difficult to predict which children with delayed speech will later develop specific language impairment (Tager-Flusberg og Cooper, 1999).
An important first step is to find out whether the child has hearing problems, as speech difficulties can be associated with impaired hearing or with weak mouth-motor skills. A language impairment diagnosis can also be useful if difficulties with speech are far greater than can be explained by impaired hearing or mouth motor impairment. Difficulties with language learning can also coincide with a general developmental delay. In such cases, speech impairment is given as a diagnosis only if the speech difficulties themselves are far greater than what can be expected given the level of intellectual development.
Loss of language skills in children under 3 years can be an indication of ASD or a specific neurological condition, such as Landau-Kleffner syndrome. It can also be the first sign of an epileptic seizure. It is therefore important to conduct a broad assessment if a child has lost language skills.
2. Speech impairment
Children can have trouble articulating one or more of the sounds (phonemes) that make up spoken language. In order to enunciate speech sounds clearly, a child must have not only adequate knowledge of the sound system (phonology) and the motor coordination and control in the mouth muscles to produce the necessary movements needed for speech (jaw, tongue and lips), but also be able to adjust breath and vocal sound. The diagnosis is quite broad, because there is a wide spectrum of possible mechanisms that cause speech difficulties in children. This diagnosis is only made in the absence of structural or neurological damage as a cause of impairment. In addition, the speech impairment must affect intelligibility of speech, limit effective communication, social participation and/or mastery of school subjects.
Children can have difficulties that include both pronunciation difficulties and language impairment. In both cases, there may be family members who have or have had speech or pronunciation issues. Articulation is affected by different genetic syndromes, such as Down syndrome, 22q deletion, or gene mutation FoxP2.
In some cases, speech is connected to a specific muscular neurological condition, such as cerebral palsy or Worster-Drought syndrome. In that case, the speech difficulty is called dysarthria. Neurological signs, such as specific vocal characteristics, can help differentiate dysarthria from speech impairment.
3. Fluency impairment, beginning in childhood (stuttering)
Fluency impairment that begins in childhood, also known as stuttering, means that a child has difficulty with speaking with normal fluency. This can present in several ways, but a repetition of sounds or syllables, and small blocks or pauses in speech are the most common difficulties. Fluency impairment often leads to anxiety and uncertainty in speaking, which can cause further trouble with fluency. Children can develop marked avoidance strategies to prevent having to speak. Stuttering that begins in adulthood is identified with its own diagnostic code.
Fluency impairment in childhood can also coincide with movements, such as eye-blinking, tics and twitching of the head. Language skills in children with stutter can vary widely and there is little research on why these symptoms coincide.
4. Pragmatic language impairment
Pragmatic language impairment is when a child has difficulty using speech in a social setting. There may be problems holding a conversation in daily life situations, conveying information, or in basic narration of storylines. The difficulty can also be connected with inadequate customization of communication to the child’s context. The child often struggles to formulate information in a new way if the listener has misunderstood, and the child can struggle with both verbal and non-verbal communication to navigate social interactions.
Children with attention disorder or with specific learning disabilities may have pragmatic language impairment, but this does not include children with ASD. (Bishop og Norburt, 2002). The most important difference between ASD and pragmatic language impairment is that children with ASD show limited, stereotypical and/or repetitive activities or interests (at some point in development).
Studies have shown that pragmatic language impairment is not correlated with difficulties in pronunciation, comprehension or grammar. (Tomlin, 2004)
Children with language impairment often have additional problems. This is especially true of children with persistent difficulties. Children with language impairment are more likely to develop behavioral, social, school-related and mental health problems than those with normal language development. (Ottem og Lian, 2008)
Some children with language impairment become shy and introverted, or have trouble speaking up when they become frustrated. (Snowling, 2006).
It is estimated that around 15-30% of preschool children with language difficulties also have behavioral problems. (Beitchman, 2001)
Children with language impairment can face rejection by peers at play, and therefore may not get the same socialization as peers. (Liiva og Cleave, 2005)
One of the most frequent additional difficulties in children with language impairment is motor impairment. (Hill, 2001), for example, clumsiness or poor fine motor skills.
There is no obvious reason that language impairment should lead to motor impairment, and the correlation has therefore often been used to suggest that specific language impairment is not truly so specific, but rather perhaps just part of a larger picture.
Reading and writing difficulties are also common among children who have or have had language difficulties. (Bishop og Snowling, 2004)
When children with language impairment reach adulthood, they have increased risk for mental health issues, such as social angst, aggression and depression. (Beitchman, 2001)
Among children who have additional problems, language impairment is often more difficult to identify because attention is first and foremost directed at the additional problem. Children with additional problems may have different treatment needs than those with only language impairment.
Incidence: affecting about 10% of children
Language impairment is a common developmental problem in young children. (Heim & Benasich, 2006)
One Norwegian study based on parent-reports from questionnaires shows that 10% of children between 6 and 10 years old have language impairment. (Hollung-Møllerhaug, 2010)
The authors of this Norwegian study divided children into subgroups, and when they removed the children who primarily had social communication impairment, they found that 7.5% of children had language impairment connected with speaking and understanding language.
The results from that Norwegian study correspond with international literature that shows:
- 10–20% of 2-3 year olds have delayed or disordered speech development. (Rescorla & Achenbach, 2002)
- 5-10% of all preschool children have a language impairment. (Bishop, Bishop & Leonard, 2000)
More common among boys
Language impairment is more common among boys than among girls. Studies in the US show that boys are 3 times more likely to have delayed language development compared with girls. (Zubrik, 2007) In Norway, twice as many boys have language impairment, compared with girls, based on parent reports (Hollung-Møllerhaug, 2010)
Delayed language development is most likely caused by both environmental and genetic factors that mutually affect each other over time.
The fact that boys are more often affected, along with results from family and twin studies, suggests that heritability is a contributory factor (Heim & Benasich, 2006; Bishop, 2000). One study shows that in families where one parent had had a language difficulty, 40% of children also had such difficulties. In families where both parents had language difficulties, 70% of children had language difficulties (Tallal, 2001)
In monozygotic (identical) twins, if one has language impairment, the other twin has the same impairment in approximately 80-86% of cases. In dizygotic (fraternal) twins, there is only a 40-50% chance that both twins have the same language impairment (Bishop, 1996). These figures vary depending on what type of language impairment one studies.
For any single child, one cannot assume that there is just one underlying cause. Language impairment can be the result of many underlying difficulties connected to different learning hypotheses and environmental relationships (Bishop, 2006)
Causes: risk and protective factors in the environment
The risk of developing language impairment is greater for:
- Children with low birth weight. Children who weigh less than 85% of optimal weight at birth have double the risk of delayed language development compared with children of optimal birthweight. (Zubrick, 2007)
- Children born prematurely
- Twins and triplets (Rutter, 2003; Schjølberg, 2011).
There is no correlation with parental education level, socioeconomic status, mental health, child-rearing methods or family social dynamics. (Dale, 2003; Paul, 1996)
Nonetheless, many studies show that socioeconomic status and parental education affect children’s general language competence, such as vocabulary, narrative ability and language use. (Hart & Risley, 1995) Therefore, environmental factors may play a contributing role in either reducing or increasing the effect of congenital problems with language acquisition. (Sameroff & MacKenzie, 2003).
How is language impairment identified?
In preschool: The majority of preschools can conduct systematic observations to pick up early language impairment, for example, using TRAS, Språk4 or other methods.
At the pediatric clinic: At the 2 and 4 year visits at the pediatric clinic, nurses assess a child’s hearing and language skills. The child will be referred for further assessment, if needed.
In school: The school has assessment materials that teachers can use to identify language impairment.
Measures to reduce language impairment
Early charting, assessment, and implementation of necessary measures increase the chance that a child with language impairment will master the basic demands s/he meets in childhood, adolescence and adulthood.
Measures at an early stage often have critical influence over whether the child is able to achieve positive development, and avoid developing additional problems, which can hinder the child just as much as language impairment itself.
The pediatric clinic can give advice on preventive measures, for example, stimulating children to use language, play with language, reading, singing, rhyming and classifying words in everyday activities.
Preschool or school can conduct systematic observation and assess the child’s language skills. The child can be referred further to Pedagogical Psychological Services (PPT) if needed.
What parents can do: If parents suspect that the child has language difficulties, they should first speak with teachers at preschool or school, or even with a nurse at the pediatric clinic, if the child doesn’t attend preschool.
Parents can also contact PPT directly if they wish.
It is important that parents not wait, and discuss with a professional which difficulties they see in their child and what they are concerned about.
In many cases, language stimulation is all that is needed to support a child’s language development.
Research at the Norwegian Institute of Public Health
Even though language impairment is widespread in children of preschool age, its causes and development are not well understood. The Language and Learning Study (SOL) is a collaborative project between the Norwegian Institute of Public Health and the Norwegian Ministry of Education, begun in 2007.
The SOL study’s goals are to provide the best possible knowledge base for understanding the causes and developmental pathways of language impairment, such that early preventive measures can be implemented.
The study will also increase knowledge about which factors at home, at preschool and in school may contribute to positive language development and to minimizing difficulties for especially vulnerable children. The SOL study recruits from the Norwegian Mother and Child Cohort Study (MoBa).