"Incidence" of spoken language disorders refers to the number of new cases identified in a specified time period. No reliable data on the incidence of spoken language disorders in children were located.

"Prevalence" of spoken language disorders refers to the number of people who are living with a spoken language disorder in a given time period. The variability in prevalence estimates below is attributed to differences in how language impairment is defined, the nature of the population studied, and variations in the methodological procedures used (Law, Boyle, Harris, Harkness, & Nye, 2000; Pinborough-Zimmerman et al., 2007).

Language Delay/Disorder

In children 7 years old and younger in the United Kingdom the median prevalence of receptive language delay/disorder ranged from 2.63%-3.59%, expressive language delay/disorder ranged from 2.81%-16%, and combined receptive and expressive language delay/disorder ranged from 2.02%-3.01% (Law et al., 2000).

The prevalence of language impairment in Canadian kindergarten children was 8.04% overall, 8.37% for girls, and 8.17% for boys (Beitchman, Nair, Clegg, & Patel, 1986).

Psychiatric Disorders

Among Canadian children 7 to 14 years old with psychiatric disorders, 40% were found to have a language impairment (Cohen, Barwick, Horodezky, Vallance, & Im, 1998). In the Northeastern region of the United States, about 40%-50% of children and adolescent speakers of Spanish and English who were referred for psychiatric services were found to have a language delay or impairment following testing in both languages (Toppelberg, Medrano, Morgens, & Nieto-Castañon, 2002).

Specific Language Impairment

The prevalence of SLI for kindergartners in the upper Midwestern region of the United States was 7.4% overall, 6% for girls, and 8% for boys (Tomblin et al., 1997). Prevalence of SLI in racial/ethnic groups was highest in Native Americans, with African Americans being the next highest, followed by Hispanics, and then Whites. No students of Asian descent presented with SLI (Tomblin et al., 1997); however, other research does indicate that SLI is present in children of Asian descent (Gray, 2003; Lahey & Edwards, 1999).

Signs and symptoms of spoken language disorders (SLD) vary across individuals, depending on the language domain(s) affected, severity and level of disruption to communication, age of the individual, and stage of linguistic development. Furthermore, signs and symptoms of SLD may become apparent through evaluation of metacognitive/metalinguistic ability; when later-developing language domains, such as reading and writing (i.e., literacy), are developing; when children encounter the unique disciplinary language associated with certain academic subjects (e.g., humanities classes vs. science classes); or through observation of emotional/behavioral difficulty.

Below are common signs and symptoms among monolingual English-speaking children with spoken language difficulties. These signs and symptoms are grouped by domain and in descending order from basic to higher-order skills. Although these domains are listed separately, it is important to note that skills are not discrete, and there is a synergistic relationship across domains. Skills within form (phonology, syntax, and morphology), function (semantics), and use (pragmatics) interact to form a dynamic integrative whole (Berko Gleason, 2005).

Metalinguistic and metacognitive skills (awareness of language and of one's own thinking and behavior), while not listed below, are critical for the development of advanced language skills. Metalinguistic awareness impacts both spoken language and written language abilities to varying degrees. Phonological awareness is one type of metalinguistic skill, which has been shown to be highly correlated with later reading and writing skills (Al Otaiba, Puranik, Zilkowski, & Curran, 2009).

Phonology

Phonological deficits include

• delay in acquisition of phonological skills, including errors similar to those of younger, typically developing children but with greater variability in production at similar stages of phonological development;
• tendency to vocalize less and use less varied/less mature syllable structures than those of same-age, typically developing toddlers;
• problems with early speech sounds affecting intelligibility, generally resolving over time;
• difficulty learning the speech sound system of language, resulting in poor repetition of single and multisyllabic nonwords;
• limited phonological awareness (e.g., rhyming, sound/syllable deleting, segmentation, and blending).

Morphology and Syntax

Morphology and syntax deficits include

• late acquisition of word combinations;
• restricted mean length of utterance (MLU) in morphemes for younger children (although developmental order of morpheme acquisition may be similar to that of typically developing children) and shorter utterances in words for school-age children and adolescents;
• errors occurring most often on verbs (especially verb endings, auxiliary verbs, and past tense marking of regular and irregular forms), function words (e.g., articles and prepositions), and pronouns;
• errors of omission occurring more frequently than errors of misuse, although occurrence of both error types may be inconsistent;
• use of more mature and less mature word forms;
• difficulty comprehending grammatical morphemes, particularly units of short duration (phonetically less salient);
• deficits in morphological awareness (e.g., derivational morphemes, such as prefixes and suffixes, including inflectional morphology, such as plural, present progressive, and past tense markers);
• difficulty judging grammaticality;
• difficulty identifying and correcting grammatical errors;
• difficulty identifying parts of speech;
• problems comprehending and using complex syntactic structures;
• extensive use of simple, non-subordinated utterances in narratives;
• use of subordinating clauses of the earlier developing types, when complex sentences are used;
• difficulty with curriculum-related expository discourse production;
• difficulty decoding (comprehending) morphologically complex words that are common in various academic subjects.

Semantics

Deficits in semantics include

• slower rate of vocabulary development than that of typically developing children (not attributed to second language acquisition);
• late acquisition of first words and word combinations;
• delays in verb acquisition, particularly in languages in which verbs are highly inflected morphologically;
• poor fast-mapping (after a brief or single encounter) of a new word to its referent;
• difficulty understanding new words, particularly action words;
• word-finding difficulties;
• slower confrontation naming that may reflect less rich and less elaborate semantic memory networks;
• use of filler words like "um" to take up time while the child is searching for a word or formulating thoughts;
• difficulty monitoring comprehension;
• difficulty requesting clarification;
• difficulty understanding questions and following directions that are heard;
• difficulty paraphrasing information;
• problems comprehending and using synonyms and antonyms, multiple-meaning words, and figurative language (e.g., idioms, metaphors, proverbs, humor, poetic language);
• poor organization of narratives and expository discourse (impacts ability to convey intended meaning);
• poor comprehension of narrative or expository text, particularly when it is necessary to draw inferences from literal content or when expository text is associated with different academic disciplines.

Pragmatics

Deficits in pragmatics include

• difficulty initiating play with peers, may play alone;
• difficulty understanding others;
• perceived immaturity in relation to same-age peers;
• difficulty expressing ideas, feelings, and personal experiences;
• use of same pragmatic functions as typically developing peers, but may express them differently and less effectively;
• difficulty initiating and sustaining conversations;
• less effective at securing conversational turns than same-age, typically developing peers;
• less flexible language when attempting to tailor a message to the listener or when repairing communication breakdowns;
• limited classroom discourse skills (e.g., language productivity and complexity, self-monitoring; turn-taking), depending on the context (e.g., curriculum-related or non-academic peer interactions);
• difficulty making relevant contributions to classroom discussions;
• uncertainty about what to say and what not to say;
• uncertainty about when to talk and when not to talk;
• difficulty using language to sequence events of a story—narratives lack cohesion;
• tendency to omit some story components.

See social communication disorder for more information about pragmatics.

Behavioral/Emotional/Social Considerations

Children with language disorders may experience social/emotional problems and/or exhibit behaviors secondary to language impairment. These difficulties may impact self-perception and awareness, academic performance, peer relationships, and social interactions. Furthermore, the impact of language disorders can result in misperceptions and misattributions of the child's behavior (Cohen, Davine, Horodesky, Lipsett, & Isaacson, 1993).

Children with spoken language disorders may

• exhibit behavioral difficulties, including hyperactivity and attentional difficulties (Dockrell, Lindsay, Palikara, & Cullen, 2007),
• demonstrate behavioral reticence (withdrawal, wariness, shyness) that can affect initiation of close relationships in adolescence (Fujiki, Spackman, Brinton, & Hall, 2004),
• have difficulty inferring emotional reactions of others (Ford & Miloski, 2003),
• have difficulty judging when it is appropriate to hide emotions/feelings (Brinton, Spackman, Fujiki, & Ricks, 2007),
• have difficulty regulating emotions (e.g., monitoring, evaluating, and modifying emotional reactions; Fujiki, Brinton, & Clarke, 2002),
• have poor social self-esteem (Marton, Abramoff, & Rosenzweig, 2005),
• have difficulty forming and maintaining close social relationships—as adolescents, may be less emotionally engaged in their close relationships (Wadman, Durkin, & Conti-Ramsden, 2011),
• be at risk for bullying and other forms of abuse (Blood, 2014; Brownlie, Jabbar, Beitchman, Vida, & Atkinson, 2007).

A spoken language disorder may be a primary disability (SLI) or may exist in conjunction with other disorders and disabilities (e.g., ASD, ADHD, etc.). When a language disorders occurs in conjunction with other disorders and disabilities, the causes are typically defined in terms of these specific conditions. Links to disorder- and condition-specific Practice Portal pages will be included as those pages are developed.

In the case of SLI, the causes are difficult to determine; however, a number of factors have been proposed, including cognitive processing deficits (e.g., Miller, Kail, Leonard, & Tomblin, 2001; Ellis Weismer & Evans, 2002; Leonard et al., 2007), biological differences (e.g., Ellis Weismer, Plante, Jones, & Tomblin, 2005; Galaburda, 1989; Hugdahl et al., 2004), and genetic variations (e.g., Rice, 2012, 2013). These factors may not be independent of one another. For example, a genetic variation might lead to a difference in brain morphology or function that leads to a difference in cognitive processing (Reed, 2012).

Speech-language pathologists (SLPs) play a critical role in the screening, assessment, diagnosis, and treatment of preschool and school-age children with spoken language disorders (SLD). The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment), prevention and advocacy, and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016).

Appropriate roles for SLPs include:

• providing prevention information to individuals and groups known to be at risk for SLD, as well as to individuals working with those at risk;
• educating other professionals on the needs of persons with SLD and the role of SLPs in diagnosing and managing SLD;
• screening individuals for the presence of language and communication difficulties; determining the need for further assessment and/or referral for other services;
• recognizing that students who have been identified as having SLD have heightened risks for later literacy problems;
• conducting a comprehensive, culturally and linguistically appropriate assessment of language and communication;
• taking into consideration the rules of a spoken dialect or accent, typical dual-language acquisition from birth, and sequential second-language acquisition to distinguish difference from disorder;
• understanding potential situational bias and test-item bias in assessment;
• diagnosing the presence of SLD;
• referring to other professionals to rule out other conditions, determine etiology, and facilitate access to comprehensive services;
• making decisions about the management of SLD;
• developing treatment plans, providing treatment, documenting progress, and determining appropriate dismissal criteria;
• counseling persons with SLD and their families regarding communication-related issues and providing education aimed at preventing further complications relating to SLD;
• consulting and collaborating with other professionals, family members, caregivers, and others to facilitate program development and to provide supervision, evaluation, and/or expert testimony, as appropriate;
• remaining informed of research in the area of SLD and helping advance the knowledge base related to the nature and treatment of SLD;
• advocating for individuals with SLD and their families at the local, state, and national levels;
• serving as an integral member of an interdisciplinary team working with individuals with SLD and their families/caregivers;
• providing quality control and risk management.

As indicated in the Code of Ethics, SLPs who serve this population should be specifically educated and appropriately trained to do so.

Screening

Screening of spoken language skills is conducted if a language disorder is suspected. Screening does not result in a diagnosis, but rather indicates the potential need for further assessment.

Screening typically includes

• gathering information from parents and/or teachers regarding concerns about the child's languages and skills in each language;
• conducting a hearing screening to rule out hearing loss as a possible contributing factor to language difficulties;
• administering formal screening assessments that have normative data and/or cutoff scores and demonstrated evidence of adequate sensitivity and specificity;
• using informal measures, such as those designed by the clinician and tailored to the population being screened (e.g., preschool vs. school age/adolescence);
• screening of articulation if indicated.

Screening may result in recommendations for

• complete audiologic assessment;
• comprehensive language assessment;
• comprehensive speech sound assessment, if the child's speech sound system is not appropriate for his/her age and/or linguistic community.

Comprehensive Assessment

Individuals suspected of having a language impairment based on screening results are referred for a comprehensive, linguistically appropriate assessment by a speech-language pathologist and other professionals as needed. Assessment of language skills should be culturally relevant and functional and involve the collaborative efforts of families/caregivers, classroom teachers, SLPs, special educators, and other professionals as needed. See assessment and evaluation of speech-language disorders in schools.

Assessment typically includes the following, with consideration made for the age and linguistic development of the child:

• relevant case history, including
  • birth and medical history;
  • family history of speech, language, reading, or academic difficulties;
  • family's concerns about the child's language (and speech),
  • languages and/or dialects used in the home, including
    • age of introduction of a second language, as appropriate,
    • circumstances in which each language is used;
  • teachers' concerns regarding the impact of child's language difficulties in the classroom;
• hearing screening, if not available from prior screening;
• oral mechanism examination;
• spoken language testing, including
  • phonology, including phonological awareness,
  • semantics,
  • morphology,
  • syntax,
  • pragmatics, including discourse-level language skills (conversation, narrative, expository).

A literacy assessment (reading and writing) is included in the comprehensive assessment for language disorders because of the well-established connection between spoken and written language. Components of a literacy assessment will vary, depending on the child's age and stage of language development, and can include pre-literacy, early literacy, and advanced literacy skills. See the assessment section of the Written Language Disorders Practice Portal page.

A speech sound assessment may also be included, given that speech sound errors can be a result of a phonological disorder, an articulation disorder, or a combined phonological/articulation disorder. See speech sound disorders: articulation and phonology.

It may also be appropriate to assess the potential benefit of implementing augmentative and alternative communication (AAC) strategies, pending the nature and severity of deficits and the child's developmental history. See ASHA's Practice Portal page on Augmentative and Alternative Communication.

The following procedures and data sources may be utilized in the comprehensive assessment for spoken language disorders (SLD):

Standardized Assessment—an empirically developed evaluation tool with established reliability and validity. Standardized language assessments can be used to identify the broad characteristics of language functioning, but should not be used solely to make the diagnosis of SLD. Given the nuanced and subtle nature of strengths and deficits that many children demonstrate, standardized assessments alone are not sufficient to capture the variety of language details that constitute an individual's profile.

At this time, there are very few standardized assessments for individuals who speak a language other than English or who speak a dialect of English. It is essential to consider the language spoken and/or dialect used by the child before selecting a standardized assessment. Translation of a standardized assessment invalidates the results. Standard scores may not be reported when the assessment has been translated. See cultural responsiveness and bilingual service delivery.

Language Sampling—techniques to elicit spontaneous language in various communication contexts (e.g., free play, conversation/dialogue, narration, expository speech) and derive measures (e.g., Mean Length of Utterance [MLU], Type-Token Ratio [TTR], Developmental Sentence Scoring [DSS], clausal density, use of subordinate clauses) to complement data obtained from standardized language assessments.

Dynamic Assessment—a language assessment method in which an individual is tested, skills are addressed, and then the individual is re-tested to determine treatment outcome (i.e., test-teach and re-test). Dynamic assessment can help distinguish between a language difference and a language disorder and can be used in conjunction with standardized assessment and language sampling.

Systematic Observation/Contextual Analysis—observation in the classroom and in various other contexts to describe communication and identify specific problem areas. Descriptions of language functioning across a variety of settings and tasks are used to identify contextual variables that play a part in the student's communication abilities and to complement findings from other assessment procedures.

Ethnographic Interviewing—a technique for obtaining information from the student and the student's family/caregiver and teachers that avoids the use of leading questions and "why" questions and uses open-ended questions, restatement, and summarizing for clarification. The ethnographic technique is used to obtain information from the perspective of the student and other individuals in the student's environment and to validate other assessment findings.

Parent/Teacher/Child Report Measures—checklists and/or questionnaires completed by the family member(s)/caregiver, teacher, and/or student. These report measures enable the clinician to obtain a comprehensive profile of language skills by comparing findings from multiple sources (e.g., family vs. teacher vs. self-report). For individuals who speak a language other than English in the home, the clinician needs to gather detailed information about use of the primary language and English.

Curriculum-Based Assessment—a technique that uses probes, protocols, and direct assessment to determine the language demands of the curriculum and assess the student's ability to handle those demands.

Assessment may result in

• diagnosis of a spoken language disorder (receptive language disorder only, expressive language disorder only, or expressive-receptive mixed);
• determination of a language delay in the absence of a language disorder (i.e., language delay due to environmental influences);
• description of the characteristics and severity of the disorder or delay;
• determination of performance variability as a function of communicative situations/contexts;
• identification of literacy problems;
• diagnosis of a speech sound disorder;
• identification of possible hearing problems;
• recommendations for intervention and support;
• referral to other professionals as needed.

Special Considerations For Diagnosis of SLD

Early Identification

Not all children with early language delay (late talkers) have significant language problems when they reach school age (Paul, 1989, 1996; Rescorla, 2002), making it difficult to diagnose a language disorder before the age of about 3 years (Leonard, 1998). However, given the risk that language disorders pose for students, children need to be assessed for language difficulties early and monitored periodically at critical educational stages (e.g., in preschool; then in kindergarten, second grade, and third grade; early middle school; and high school) to track language development and identify any problems that might arise.

It is especially important to monitor and assess young children on a regular basis, if multiple risk factors are evident (e.g., family history of language problems, chronic otitis media, cognitive delay, social communication difficulties, and environmental risks; Paradise et al., 2000; Paul, 1996, 2007).

Changing Nature of SLD

Children with SLD demonstrate differing patterns of strengths and weaknesses across listening, speaking, reading, and writing; those patterns of strengths and weaknesses may vary over time. In some cases, the language skills of children with SLD become seemingly similar to those of children without SLD.

However, as the complexity of the language demands increase, difficulty may resurface in one or more language domains. This phenomenon is referred to as illusory recovery (Scarborough & Dobrich, 1990). Although children may acquire new vocabulary or improve their use of grammatical forms following language intervention, they may not actually catch up to their peers. In fact, their rate of language growth may slow or level off when they reach early adolescence, resulting in language levels below those expected for their age groups (Rice, 2013).

For this reason, it is important that practitioners use valid and reliable standardized assessments with normative data, in addition to other data sources (e.g., informal measures, benchmarking, progress reports, etc.), when evaluating the language skills of children with SLD over time.

Cultural and Linguistic Considerations

A communication difference/dialect is a variation of a symbol system—used by a group of individuals—that reflects and is determined by shared regional, social, or cultural/ethnic factors. This variation should not be considered a disorder of speech or language.

In addition, children who demonstrate typical patterns of dual language learning, are learning English as a second language, or speak a non-standard dialect of English should not be considered as having a spoken language disorder, based only on those differences (ASHA, 1993).

Clinicians face unique challenges when identifying SLD in children who speak a dialect of English, are bilingual, or are learning English as a second language. Distinguishing difference from disorder requires familiarity with the rules of the spoken dialect, awareness of typical dual language acquisition from birth, and understanding of the sequential process of second language acquisition. For children who speak a non-standard dialect of English, special consideration is given to the influence of the rules of that dialect on assessment measures, which are typically based on standard American English. Results are not valid, if the norming sample of an assessment is not representative of the child being assessed.

Some linguistic characteristics of dual language learning (simultaneous bilingualism) and second language (L2) acquisition (sequential bilingualism) may be the same as those of monolingual children with language impairment.

There is little research/information regarding bilingualism and the broader scope of spoken language disorders, as defined in this Portal page. However, a number of studies have identified potential areas of overlap between second language learners and monolingual children with SLI—one type of spoken language disorder:

• similar morphosyntactic profiles (Paradis & Crago, 2000, 2004),
• reduced processing efficiency (Windsor & Kohnert, 2004),
• superficial impairment in vocabulary development—when combined vocabularies in both languages are not taken into account (Paradis, Genesee, & Crago, 2011).

Bilingualism is not a cause of language impairment. Typical processes of bilingualism, such as code-mixing, will be seen in bilingual children who have SLI (Gutiérrez-Clellen, Simon-Cereijido, & Leone, 2009). Language dominance may vary across the different domains of language—for example, dominance in L1 in receptive language and dominance in L2 expressively. This also may shift over time relative to environmental linguistic demands. See cultural responsiveness, bilingual service delivery, and phonemic inventories across languages for assistance in distinguishing difference from disorder.

Special Considerations for the School Setting

Disproportionality of Identification

Given the overlap in linguistic characteristics of children during typical bilingual language acquisition and those of monolingual children with language impairment and the reliance on standard measures that are based on rules of standard American English for diagnosis, there is a disproportionate number of linguistically diverse children (e.g., those who speak English as a second language or a dialect of English) who have been (and likely continue to be) identified with speech-language impairment in the school setting. Non-normed (criterion) measures, ethnographic interviewing, and dynamic assessment procedures are fundamental to differentiating a difference from a disorder. Children who have been identified with a difference and not a disorder are not eligible for publicly funded speech-language pathology services.

Cognitive Referencing

In the schools, children and adolescents with SLD should be eligible for speech-language services, due to the pervasive nature of language impairment, regardless of cognitive abilities or performance on standardized testing. As mandated by the Individuals with Disabilities Education Improvement Act (IDEA, 2004), categorically applying a priori criteria (e.g., discrepancies between cognitive abilities and communication functioning, chronological age, or diagnosis) in making decisions on eligibility for services is not consistent with the law and IDEA regulations. Also see National Joint Committee for the Communication Needs of Persons With Severe Disabilities (2002) for information related to a priori criteria.

For more information about eligibility for services in the schools, see eligibility and dismissal in schools, IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services, and 2011 IDEA Part C Final Regulations.

The practice of cognitive referencing, or denying individuals with disabilities access to communication services and supports because their language skills are determined to be commensurate with their cognitive skills, purports that a language delay warrants intervention only when language skill development lags behind cognitive skill development.

Concerns regarding the use of cognitive referencing include

• the relationship between language and cognition is neither straightforward nor static,
• tests purporting to assess cognitive and linguistic performance often measure the same fundamental skills,
• assessments typically used for deriving cognitive/language profiles yield sizable variation in discrepancy determinations,
• children with impaired cognitive and language skills that are commensurate would not receive the diagnosis of language impairment or the associated language services they need.

Common Core State Standards

The Common Core State Standards (CCSS) are internationally benchmarked learning standards being implemented in most states across the country. The standards constitute a framework of knowledge and skills thought necessary to prepare students to enter college and the work force.

Students who have language disorders may require specialized instruction and support to access the CCSS, because language skills are addressed across subject areas and the English Language Arts standards focus on the use of language for communication and academic success. See common core state standards: a resource for SLPs for information and guidance on integrating the CCSS into intervention for students with language disorders.

Spoken language disorders (SLD) are heterogeneous in nature, and the severity of the disorder can vary considerably. Each individual with language difficulties has a unique profile, based on their current level of language functioning, as well as functioning in areas related to language, including hearing, cognitive level, and speech production skills. In addition to having a unique profile of strengths and needs, individuals bring different backgrounds to the treatment setting. For bilingual individuals, it is important that the clinician consider the language or languages used during intervention. See bilingual service delivery.

The goal of language intervention is to stimulate overall language development and to teach language skills in an integrated fashion and in context, so as to enhance everyday communication and ensure access to academic content. Goals are frequently selected with consideration for developmental appropriateness and the potential for improving the effectiveness of communication and academic and social success.

Roth and Worthington (2015) summarize steps in the selection and programming of treatment targets and provide sample case profiles for early intervention through adolescence. They also identify a number of basic principles of effective intervention regardless of client age or disorder. These include:

• to the extent possible, teach strategies for facilitating communication rather than teaching isolated behaviors
• provide intervention that is dynamic in nature and includes ongoing assessment of the child's progress in relation to their goals, modifying them as necessary
• provide intervention that is individualized, based on the nature of a child's deficits and individual learning style
• tailor treatment goals to promote a child's knowledge, one step beyond the current level

Intervention strategies for various age ranges are outlined in the sections below. Older individuals with severely impaired language may be functioning at developing language levels. Rather than being based on developmental sequences, interventions for these individuals may be more functional in nature, focusing on building independence in everyday settings.

Intervention for Preschoolers (Ages 3–5)

In typically developing preschool children, language is developing at a rapid pace; their vocabularies are growing, and they are beginning to master basic sentence structures. For children with language difficulties, this process may be delayed. For children in this population, areas targeted for intervention typically include:

phonology

• improving significantly impaired intelligibility—particularly if it results in frustration in communicating and/or masks problems in semantics and syntax—including
  • increasing consonant repertoire,
  • improving accuracy of sound production,
  • decreasing use of phonological processes;
• enhancing phonological awareness skills, such as
• rhyming;
• blending and segmenting spoken words at the following levels
  • syllable (2 syllables in pancake: pan and cake),
  • onset and rime (2 onsets: p and c; 2 rimes: an and ake),
  • phoneme (6 phonemes: p+a+n+c+a+ke)
• deletion of whole words, syllables, and phonemes in spoken words, phrases, and/or sentences.

semantics

• increasing size of vocabulary, including
  • verbs, pronouns, conjunctions;
  • basic concept vocabulary;
• increasing understanding and use of a wider range of semantic relationships (e.g., agent-action, agent-object, possessor-possession, attribute-entity, recurrence).

morphology and syntax

• facilitating acquisition and use of age-appropriate morphemes—in particular, auxiliary verbs, articles, pronouns;
• increasing sentence length and complexity;
• increasing use of varied sentence types.

pragmatics

• increasing flexibility of language for various contexts;
• using imaginative play activities to practice newly acquired language skills;
• improving conversational skills, including
  • initiating and maintaining communication;
  • turn taking, topic maintenance, and topic shifts;
  • requesting and making conversational repairs;
• developing narrative skills.

See social communication disorder for more information about pragmatics.

literacy

• building emergent literacy skills, including
  • print awareness,
  • book awareness,
  • understanding simple story structure,
  • letter knowledge,
  • matching speech to print.

See the treatment section of the Written Language Disorders Practice Portal page.

Intervention For Elementary School Children (Ages 5–10)

The focus of language intervention for elementary school children with language difficulties is to help the child acquire the language skills needed to learn and succeed in a classroom environment. Interventions are curriculum-based, that is, goals address language needs within the context of the curriculum where these skills are needed.

Interventions may also address literacy skills (e.g., improving decoding, reading comprehension, and narrative and expository writing), as well as metacognitive and metalinguistic skills (e.g., increasing awareness of rules and principles for use of various language forms, improving the ability to self-monitor and self-regulate) that are critical for the development of higher-level language skills. See the treatment section of the Written Language Disorders Practice Portal page.

For children who speak a language other than English in the home, it may be necessary to use the home language as a mechanism for transitioning the child to using the language of the school. Planning and implementing an effective language intervention program is often a coordinated effort involving the SLP, classroom teacher(s), and other school specialists.

Areas targeted for this population typically include

phonology

• enhancing phonological awareness skills,
• eliminating any residual phonological processes.

semantics

• improving knowledge of vocabulary, including knowledge of curriculum-related vocabulary,
• improving depth of vocabulary understanding and use, including
  • subtle differences in meaning,
  • changes in meaning with context,
  • abstract vocabulary,
  • figures of speech;
• understanding figurative language and recognizing ambiguities in language (e.g., words with multiple meanings and ambiguous sentence structures);
• monitoring comprehension, requesting clarification;
• paraphrasing information.

morphology and syntax

• increasing the use of more advanced morphology (e.g., monster/monstrous, medicine/medical, school/scholastic);
• increasing the ability to analyze morphologically complex words (e.g., prefixes, suffixes);
• improving morphosyntactic skills (e.g., use of morphemes in simple and complex clauses, declarative versus questions, tag questions and relative clauses);
• improving the ability to understand and formulate more complex sentence structures (e.g., compound sentences; complex sentences containing dependent clauses);
• judging the correctness of grammar and morphological word forms and being able to correct errors.

pragmatics

• using language in various contexts to convey politeness, persuasiveness, clarification;
• increasing discourse-level knowledge and skills, including
  • academic discourse,
  • social interaction discourse,
  • narrative discourse,
  • expository discourse,
  • use of cohesive devices in discourse;
• improving the ability to make relevant contributions to classroom discussions;
• improving the ability to repair conversational breakdowns;
• learning what to say and what not to say;
• learning when to talk and when not to talk.

Intervention For Adolescent Students (Ages 11 Through High School)

As students enter their adolescent years, curriculum demands increase. Children with language disabilities may have difficulty meeting increased demands of secondary school. Although basic language skills are still taught, it may not be possible to close the gap between skill level and grade level. At this point, interventions tend to focus on teaching ways to compensate for language deficits. Student involvement is important at this age to foster a feeling of collaboration and responsibility for developing and achieving intervention goals and to learn self-advocacy skills for the classroom (e.g., requesting priority seating in front of classroom).

Instructional strategies approaches that focus on teaching rules, techniques, and principles to facilitate acquisition and use of information across a broad range of situations and settings are often used with older students. Enhancing metalinguistic and metacognitive skills is fundamental to learning new strategies. The emphasis is on how to learn, rather than what to learn. Classroom assignments are often used to teach strategies for learning academic content. Some instructional strategies are discipline-specific, and others are generalizable across disciplines (Faggella-Luby & Deshler, 2008). Examples include strategies for using

• context to deduce meaning and infer and identify main ideas;
• deciphering of morphologically complex words associated with different academic course work (e.g., history, literature, chemistry, algebra);
• checklists and graphic organizers to plan assignments (e.g., book reports, presentations, research papers);
• spell check and grammar check to edit written work composed in an electronic format;
• digital technologies (e.g., Internet, collaboration sites) to access and evaluate information, share and collaborate with classmates, produce shared products, etc.

Also see the treatment section of the Written Language Disorders Practice Portal page.

Special Consideration: Transitioning Youth And Post-Secondary Students

Difficulties experienced by children and adolescents with language impairment can continue to impact functioning in post-secondary education and vocational settings. When compared with typically developing peers, fewer individuals with language impairment complete high school or receive an undergraduate degree (Johnson, Beitchman, & Brownlie, 2010). The majority of young adults with specific language impairment who pursue education after high school seek vocational rather than academic qualifications (Conti-Ramsden & Durkin, 2012). In addition, individuals with speech and language impairment tend to be employed in lower-skilled jobs than their typically developing peers (Conti-Ramsden & Durkin, 2012; Johnson, Beitchman, & Brownlie, 2010).

The data on educational and vocational outcomes for individuals with speech and language disorders highlight the need for continued support to facilitate a successful transition to young adulthood. These supports include, but are not limited to, the following:

Transition Planning—the development of a formal transition plan in high school that includes career goals and educational needs; academic counseling (including discussion about requirements for admission to post-secondary schools); career counseling; opportunities for work experience; and community networking

Transition Goals—goals for successful transitioning to post-secondary school or employment that can include preparing a resume; completing a job or college application; effectively presenting skills and limitations during an interview; expressing concerns to authority figures about academic or job performance; stating or restating a position to effectively self-advocate in academic and employment settings

Disability Support Services—individualized support for college-level students that can include accommodations, such as extended time for tests and the use of assistive technology (e.g., to help with reading and writing tasks)

Vocational Support Services—include testing to identify vocational strengths, career counseling, vocational training, job search assistance, and job coaching

Secondary school personnel can assist the student in transition by

• including students and parents in planning,
• being sensitive to culture and values of the student and family,
• educating students about their rights and helping them develop self-advocacy skills,
• helping the student and family in the selection of an appropriate post-secondary school setting and assisting with the application process,
• informing students and families about services in post-secondary settings (e.g., disability support services and academic counseling),
• providing current documentation needed to access services (including academic accommodations) in a post-secondary setting,
• helping students identify the need for supports and any accommodations and assistive technologies.

(National Joint Committee on Learning Disabilities, 1994)

Treatment Modes/Modalities

The treatment modes/modalities described below may be used to implement various treatment options.

Augmentative and Alternative Communication (AAC)—supplementing or replacing natural speech and/or writing with aided (e.g., picture communication symbols (PECS), line drawings, Blissymbols, speech generating devices, and tangible objects) and/or unaided (e.g., manual signs, gestures, and finger spelling) symbols. Whereas aided symbols require some type of transmission device, production of unaided symbols only require body movements. See ASHA's Practice Portal page on Augmentative and Alternative Communication.

Computer Based Instruction—use of computer technology (e.g., iPads) and/or computerized programs for teaching language skills, including vocabulary, social skills, social understanding, and social problem solving.

Video-Based Instruction (also called Video Modeling)—use of video recordings to provide a model of the target behavior or skill. Video recordings of desired behaviors are observed and then imitated by the individual. The learner's self-modeling can be videotaped for later review.

Treatment Options

There are a number of different approaches and strategies for individuals with language disorders. Interventions can vary along a continuum of naturalness (Fey, 1986), ranging from contrived or drill-based activities in a therapy room (clinician directed) to activities that model play or other everyday activities in more natural settings (child centered), to those that use activities and settings that combine both approaches (hybrid).

Below are brief descriptions of general and specific treatments for addressing language disorders. Some attempt has been made to organize treatment options into broader categories, recognizing that intervention approaches do not always fit neatly into one particular category. Several of the approaches listed below are most often associated with treatment for social communication disorder and autism spectrum disorder. These approaches are included here, because they are also used with a broader population of children with language disorders. This list is not exhaustive, and the inclusion of any specific treatment approach does not imply endorsement from ASHA.

SLPs and educators determine which methods and strategies are effective for a particular student by taking into consideration the individual's language profile; the severity of the language disorder; factors related to language functioning (e.g., hearing and cognitive functioning); cultural background and values; learning style; and communication needs.

Behavioral Interventions/Techniques

Behavioral interventions and techniques are designed to reduce problem behaviors and teach functional alternative behaviors using the basic principles of behavior change. These methods are based on behavioral/operant principles of learning; they involve examining the antecedents that elicit a certain behavior, along with the consequences that follow that behavior, and then making adjustments in this chain to increase desired behaviors and/or decrease inappropriate ones. Behavioral interventions range from one-to-one, discrete trial instruction to naturalistic approaches.

Discrete Trial Training (DTT)—one-on-one instructional approach utilizing behavioral methods to teach skills in small, incremental steps in a systematic, controlled fashion. The teaching opportunity is a discrete trial with a clearly identified antecedent and consequence (e.g., reinforcement in the form of praise or tangible rewards) for desired behaviors. DTT is most often used for skills that learners are not initiating on their own; have a clear, correct procedure; and can be taught in a one-to-one setting.

Early Intensive Behavioral Interventions—one-on-one comprehensive treatment programs that teach appropriate behaviors using discrete trial training, natural environment teaching, and analysis of verbal behaviors. Treatment typically begins in the young child's home and expands to include early education settings, the community, and other settings as new skills are acquired.

Functional Communication Training (FCT)—a behavioral intervention program that combines the assessment of the communicative functions of maladaptive behavior with behavioral procedures to teach alternative responses. Problem behaviors can be eliminated through extinction and replaced with alternate, more appropriate forms of communicating needs or wants (Carr & Durand, 1985).

Incidental Teaching—a teaching technique that utilizes behavioral procedures; naturally occurring teaching opportunities are provided, based on the child's interests. Following the child's lead, attempts to communicate are reinforced as these attempts get closer to the desired communication behavior.

Lovaas Therapy—a comprehensive, early intensive behavioral intervention program targeting skills that complement and build on one another (Lovaas, 1987). Treatment is based on principles of applied behavioral analysis. The Lovaas treatment model begins with 10–15 hours per week of therapy, gradually increasing to 35–40 hours per week.

Milieu Therapy—a range of methods (including incidental teaching) that are integrated into a child's natural environment. It includes training in everyday environments and during activities that take place throughout the day, rather than only at "therapy time."

Pivotal Response Treatment (PRT)—a play-based, child-initiated behavioral treatment formerly referred to as the Natural Language Paradigm (NLP). The goals of PRT are to teach language, decrease disruptive behaviors, and increase social, communication, and academic skills. Rather than target specific behaviors, PRT targets pivotal areas of development (response to multiple cues, motivation, self-regulation, and initiation of social interactions) that are central to—and result in improvements across—a wide range of skills (Koegel & Koegel, 2006). PRT emphasizes natural reinforcement (e.g., the child is rewarded with an item when a meaningful attempt is made to request that item).

Language Interventions

Some language intervention programs target specific language skills (e.g., phonology, semantics, syntax, morphology), while others are more holistic in nature, targeting a broader range of language and communication skills (e.g., expressive language interventions and receptive language interventions). Language intervention approaches can include the following.

Clinician-Oriented—the clinician selects the goals and the treatment setting and determines the stimuli to be used and the type and schedule of reinforcement for accurate responses. These approaches utilize operant procedures and are often used to teach language form (e.g., syntax and morphology).

Child-Oriented—the clinician utilizes indirect language stimulation techniques and follows the child's lead in more natural, everyday settings and activities in an effort to stimulate language growth. These approaches are typically used with young children but can be modified for use with older children. Examples include

• expansions—the child's utterance is repeated in response, while the clinician adds grammatical and semantic detail;
• recasts—in this type of expansion, the child's utterance is recast, changing the mode or voice of the original (e.g., declarative to interrogative or active to passive);
• build-ups and breakdowns—the child's utterance is first expanded (built up) and then broken down into grammatical components (break down) and then built up again to its expanded form.

Hybrid—the clinician develops activities that are very natural, but at the same time, allow opportunities for the child's spontaneous use of utterances containing the targeted language forms. Examples include

• focused stimulation—the clinician produces a high density of the child's target forms in meaningful and functional contexts; these contexts are designed to motivate target production by the child, although the child is at no time asked to respond;
• vertical structuring and expansion—the clinician presents a stimulus (e.g., a picture depicting a semantic relationship), asks the child to respond to the stimulus (e.g., What is this? What's happening), and then expands the child's response into a well-formed sentence;
• incidental teaching—the clinician utilizes operant approaches in natural settings to elicit and reinforce target responses; within the setting, the child selects the topic stimulus that initiates the interaction.

Narrative Interventions

Narrative interventions focus on improving a child's story-telling ability, including the ability to provide context for the listener; use narrative structures (story grammars) to organize events; and utilize microstructure (e.g., syntactic complexity, temporal and causal conjunctions, coordinating conjunctions, elaborated phrases, and adverbs) to enhance the clarity of the narrative. Narratives can provide a naturalistic means of targeting specific language difficulties.

Parent-Mediated/Implemented/Involvement

Parent-mediated or implemented interventions consist of parents' using direct, individualized intervention practices with their child to increase positive learning opportunities and acquisition of skills.

Peer-Mediated/Implemented/Involvement

Peer-mediated or implemented treatment approaches incorporate peers as communication partners for children with language disorders in an effort to provide effective role models and boost communication competence. Typically developing peers are taught strategies to facilitate play and social interactions; interventions are commonly carried out in inclusive settings where play with typically developing peers naturally occurs (e.g., preschool setting).

Pragmatics/Social Communication/Discourse

Pragmatics/social communication/discourse approaches are designed to increase social skills and promote socially appropriate behaviors and communication, using social group settings and other platforms to teach peer interaction skills.

Relationship-Based Intervention

Relationship-based practices in early intervention are aimed at supporting parent-child relationships. Greenspan/DIR/Floortime is a relationship-based intervention that promotes development by encouraging children to interact with parents and others through play. The model focuses on following the child's lead; challenges the child to be creative and spontaneous; and involves the child's senses, motor skills, and emotions (Greenspan, Weider, & Simons, 1998).

Sensory-Based Interventions

Sensory-based therapies are used to treat dysfunction in sensory processing or integration. Many of these interventions are based on, or derived from, the principles of sensory integration theory and involve providing enriched or specialized sensory input to the child.

Auditory Integration Therapy(e.g., the Berard method)—involves exercising the middle ear muscles and auditory nervous system to treat distortions/dysfunctions of the auditory system (Berard, 1993).

According to ASHA's position statement titled, Auditory Integration Training, "The 2002 ASHA Work Group on AIT, after reviewing empirical research in the area to date, concludes that AIT has not met scientific standards for efficacy that would justify its practice by audiologists and speech-language pathologists" (ASHA, 2004, para. 1).

Fast ForWord®—a computer-based program designed to strengthen memory, attention, processing rate, and sequencing in children with temporal processing abnormalities. Strengthening these cognitive skills are thought to improve language and reading skills (e.g., phonological awareness, vocabulary, decoding, and comprehension; Tallal, 2004; Institute of Educational Sciences, 2006).

Service Delivery Options

In addition to determining the type of speech and language treatment that is optimal for children with spoken language disorders, SLPs consider other service delivery variables—including format, provider, dosage, and timing—that may impact treatment outcomes.

• Format: whether a person is seen for treatment one-on-one (i.e., individual) or as part of a group
• Provider: the person providing treatment (e.g., SLP, trained volunteer, caregiver)
• Dosage: the frequency, intensity, and duration of service
• Timing: the timing of intervention relative to the diagnosis
• Setting: the location of treatment (e.g., home, community-based, school)

ASHA Resources

• Access to Communication Services and Supports: Concerns Regarding the Application of Restrictive "Eligibility" Policies
• Assessment and Evaluation of Speech-Language Disorders in Schools
• Consumer Information:
  • How Does Your Child Hear and Talk?
  • Let's Talk: For People With Special Communication Needs
  • Your Child's Communication Development: Kindergarten Through Fifth Grade
• Developmental Norms for Speech and Language
• Dynamic Assessment
• Individuals with Disabilities Education Act (IDEA)
• Identify the Signs of Communication Disorders
• Language in Brief
• Operationalizing the National Joint Committee on Learning Disabilities (NJCLD) definition of learning disabilities for ongoing assessment in schools.
• Resources on Cognitive Referencing
• Response to Intervention (RTI)
• Phonemic Inventories Across Languages
• School Setting: Professional and Clinical Resources
• SIG 1, Perspectives on Language Learning and Education
• SIG 16, Perspectives on School-Based Issues
• Social Communication Disorder
• Speech Sound Disorders: Articulation and Phonology

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• NIDCD Speech and Language Developmental Milestones
• Self-Assessment for Cultural Competence
• The Early Childhood Technical Assistance (ECTA) Center
• from the National Joint Committee on Learning Disabilities (NJCLD)
  • Report: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2016)
  • Report Summary: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2017)
  • Infographic: Learning Disabilities and Achieving High Quality Education Standards [PDF] (2017)

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Acknowledgements

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Spoken Language Disorders page.

• Sandra L. Gillam, PhD, CCC-SLP
• Alan G. Kamhi, PhD, CCC-SLP
• Vicki A. Reed, EdD, CCC-SLP
• Mabel L. Rice, PhD, CCC-SLP
• Raul Rojas, PhD, CCC-SLP
• Elaine R. Silliman, PhD, CCC-SLP
• Carol E. Westby, PhD, CCC-SLP
• Kathleen A. Whitmire, PhD, CCC-SLP

Citing Practice Portal Pages 

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Spoken Language Disorders. (Practice Portal). Retrieved month, day, year, from www.Practice-Portal/Clinical-Topics/Spoken-Language-Disorders.