F80.

Communication Disorders

Disorders of communication include deficits in language, speech, and communication. Speech is

the expressive production of sounds and includes an individual’s articulation, fluency, voice, and

resonance quality. Language includes the form, function, and use of a conventional system of

symbols (i.e., spoken words, sign language, written words, pictures) in a

47

rule-governed manner for communication. Communication includes any verbal or nonverbal

behavior (whether intentional or unintentional) that has the potential to influence the behavior,

ideas, or attitudes of another individual. Assessments of speech, language, and communication

abilities must take into account the individual's cultural and language context, particularly for

individuals growing up in bilingual environments. The standardized measures of language

development and of nonverbal intellectual capacity must be relevant for the cultural and

linguistic group (i.e., tests developed and standardized for one group may not provide

appropriate norms for a different group). The diagnostic category of communication disorders

includes the following: language disorder, speech sound disorder, childhood-onset fluency

disorder (stuttering), social (pragmatic) communication disorder, and unspecified communication

disorders Sex differences in the development of early communication may give rise to higher

prevalence rates of communication disorders in boys compared with girls. Given the associated

features of communication disorders and the relationship of communication to other

developmental domains, communication disorders have high rates of comorbidity with other

neurodevelopmental disorders (e.g., autism spectrum disorder, attention-deficit/hyperactivity

disorder (ADHD), specific learning disorder, intellectual developmental disorder [intellectual

disability]), mental disorders (e.g., anxiety disorders), and some medical conditions (e.g., seizure

disorders, specific chromosome abnormalities).

Language Disorder

Diagnostic Criteria

A. Persistent difficulties in the acquisition and use of language across modalities

(i.e., spoken, written, sign language, or other) due to deficits in comprehension

or production that include the following:

1. Reduced vocabulary (word knowledge and use).

form sentences based on the rules of grammar and morphology).

3. Impairments in discourse (ability to use vocabulary and connect sentences to

explain or describe a topic or series of events or have a conversation).

B. Language abilities are substantially and quantifiably below those expected for

age, resulting in functional limitations in effective communication, social

participation, academic achievement, or occupational performance, individually

or in any combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to hearing or other sensory impairment, motor

dysfunction, or another medical or neurological condition and are not better

explained by intellectual developmental disorder (intellectual disability) or global

developmental delay.

Diagnostic Features

The essential features of language disorder are difficulties in the acquisition and use of language

due to deficits in the comprehension or production of vocabulary, grammar, sentence structure,

and discourse. The language deficits are evident in spoken communication, written

communication, or sign language. Language learning and use is dependent on both receptive and

expressive skills. Expressive ability refers to the production of vocal, gestural, or verbal signals,

while receptive ability refers to the process of receiving and comprehending language messages.

Language skills need to be assessed in both expressive and receptive modalities as these may

differ in severity.

Language disorder usually affects vocabulary and grammar, and these effects then limit the

capacity for discourse. The child’s first words and phrases are likely to be delayed

48

in onset; vocabulary size is smaller and less varied than expected; and sentences are shorter

and less complex with grammatical errors, especially in past tense. Deficits in comprehension of

language are frequently underestimated, as children may be good at using context to infer

meaning. There may be word-finding problems, impoverished verbal definitions, or poor

understanding of synonyms, multiple meanings, or word play appropriate for age and culture.

Problems with remembering new words and sentences are manifested by difficulties following
instructions of increasing length, difficulties rehearsing strings of verbal information (e.g.,

remembering a phone number or a shopping list), and difficulties remembering novel sound

sequences, a skill that may be important for learning new words. Difficulties with discourse are

shown by a reduced ability to provide adequate information about the key events and to narrate a

coherent story.

The language difficulty is manifest by abilities substantially and quantifiably below that

expected for age and significantly interfering with academic achievement, occupational

performance, effective communication, or socialization (Criterion B). A diagnosis of language

disorder is made based on the synthesis of the individual’s history, direct clinical observation in

different contexts (i.e., home, school, or work), and scores from standardized tests of language

ability that can be used to guide estimates of severity.

Associated Features

Environmental.

Genetic and physiological.

Normal variations in language.

Individuals, even children, can be adept at accommodating to their limited language. They may

appear to be shy or reticent to talk. Affected individuals may prefer to communicate only with

family members or other familiar individuals. Although these social indicators are not diagnostic

of a language disorder, if they are notable and persistent, they warrant referral for a full language

assessment.

Development and Course

Language acquisition is marked by changes from onset in toddlerhood to the adult level of

competency that appears during adolescence. Changes appear across the dimensions of language

(sounds, words, grammar, narratives/expository texts, and conversational skills) in age-graded

increments and synchronies. Language disorder emerges during the early developmental period;

however, there is considerable variation in early vocabulary acquisition and early word

combinations. Individual differences in early childhood are not, as single indicators, highly

predictive of later outcomes, although a late onset of language at age 24 months in a

sample was the best predictor of outcomes at age 7 years. By age 4 years, individual

differences in language ability are more stable, with better measurement accuracy, and are highly
predictive of later outcomes. Language disorder diagnosed in children age 4 years and older is

likely to be stable over time and typically persists into adulthood, although the particular profile

of language strengths and deficits is likely to change over the course of development.

Language disorders can have social consequences across the lifespan. Children with language

disorders are at risk for peer victimization. For females with childhood language disorders, there

could be almost three times the risk compared with unaffected children for sexual assault in

adulthood.

Risk and Prognostic Factors

Children with receptive language impairments have a poorer prognosis than those with

predominantly expressive impairments. Receptive language impairments are more resistant to

treatment, and difficulties with reading comprehension are frequently seen.

Bilingualism does not cause or worsen a language disorder, but children who are

bilingual may demonstrate delays or differences in language development. A

49

language disorder in bilingual children will affect both languages; therefore, assessment across

both languages is important to consider.

Language disorders are highly heritable, and family members are more

likely to have a history of language impairment. Population-based twin studies consistently

report substantial heritability for language disorder, and molecular studies suggest multiple genes

interacting on causal pathways.

Differential Diagnosis

Language disorder needs to be distinguished from normal

developmental variations, and this distinction may be difficult to make before age 4 years.

Regional, social, or cultural/ethnic variations of language (e.g., dialects) must be considered Hearing
or other sensory impairment.

Intellectual developmental disorder (intellectual disability).

Autism spectrum disorder.

Neurological disorders.

Language regression.

F80.0

when an individual is being assessed for language impairment.

cause of language difficulties. Language deficits may be associated with a hearing impairment,

other sensory deficit, or a speech-motor deficit. When language deficits are in excess of those

usually associated with these problems, a diagnosis of language disorder may be made.

Language impairment is often the

presenting feature of intellectual developmental disorder. However, the definitive diagnosis of

intellectual developmental disorder may not be made until the child is able to complete

standardized assessments. Language disorder can occur with varying degrees of intellectual

ability, and a discrepancy between verbal and nonverbal ability is not necessary for a diagnosis

of language disorder.

Autism spectrum disorder frequently manifests with delayed language

development. However, autism spectrum disorder is often accompanied by behaviors not present

in language disorder, such as lack of social interest or unusual social interactions (e.g., pulling

individuals by the hand without any attempt to look at them), odd play patterns (e.g., carrying

toys around but never playing with them), unusual communication patterns (e.g., knowing the

alphabet but not responding to own name), and rigid adherence to routines and repetitive

behaviors (e.g., flapping, spinning, echolalia).

Language disorder can be acquired in association with neurological

disorders, including epilepsy (e.g., acquired aphasia or Landau-Kleffner syndrome).

Loss of speech and language in a child at any age warrants thorough

assessment to determine if there is a specific neurological condition, such as Landau-Kleffner

syndrome. Language loss may be a symptom of seizures, and a diagnostic assessment is

necessary to exclude the presence of epilepsy (e.g., routine and sleep electroencephalogram).

Declines in critical social and communication behaviors during the first 2 years of life are

evident in most children presenting with autism spectrum disorder and should signal the need for

autism spectrum disorder assessment.

Comorbidity

Language disorder may be associated with other neurodevelopmental disorders in terms of

specific learning disorder (literacy and numeracy), intellectual developmental disorder,

hyperactivity disorder, autism spectrum disorder, and developmental coordination

samples, language disorder may co-occur with speech sound disorder, although data from a large

population-based sample of 6-year-old children in the United States suggest comorbidity might

be rare (1.3%). A positive family history of speech or language disorders is often present.

50

Speech Sound Disorder

Diagnostic Criteria

A. Persistent difficulty with speech sound production that interferes with speech

intelligibility or prevents verbal communication of messages.

B. The disturbance causes limitations in effective communication that interfere with

social participation, academic achievement, or occupational performance,

individually or in any combination.

C. Onset of symptoms is in the early developmental period.

D. The difficulties are not attributable to congenital or acquired conditions, such as

cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain injury, or

other medical or neurological conditions.

Diagnostic Features

Speech sound production describes the clear articulation of the phonemes (i.e., individual

sounds) that in combination make up spoken words. Speech sound production requires both the

phonological knowledge of speech sounds and the ability to coordinate the movements of the

articulators (i.e., the jaw, tongue, and lips,) with breathing and vocalizing for speech. Children

with speech production difficulties may experience difficulty with phonological knowledge of

speech sounds or the ability to coordinate movements for speech in varying degrees. A speech

sound disorder is diagnosed when speech sound production is not what would be expected based

on the child’s age and developmental stage and when the deficits are not the result of a physical,

structural, neurological, or hearing impairment. Among typically developing children at age 3

years, overall speech should be intelligible, whereas at age 2 years, only 50% may be

understandable. Boys are more likely (range of 1.5–1.8 to 1.0) to have a speech sound disorder

than girls.

Associated Features

Language disorder may be found to co-occur with speech sound disorder, although cooccurrences
are rare by age 6 years. A positive family history of speech or language disorders is

often present.

If the ability to rapidly coordinate the articulators is a particular aspect of difficulty, there

may be a history of delay or incoordination in acquiring skills that also utilize the articulators and

related facial musculature; among others, these skills include chewing, maintaining mouth

closure, and blowing the nose. Other areas of motor coordination may be impaired as in

developmental coordination disorder. The terms childhood apraxia of speech and verbal

dyspraxia are used for speech production problems with motor components.

Development and Course

Learning to produce speech sounds clearly and accurately and learning to produce connected

speech fluently are developmental skills. Articulation of speech sounds follows a developmental

pattern, which is reflected in the age norms of standardized tests. It is not unusual for typically

developing children to use developmental processes for shortening words and syllables as they

are learning to talk, but their progression in mastering speech sound production should result in

mostly intelligible speech by age 3 years. Children with speech sound disorder continue to use
Normal variations in speech.

Hearing or other sensory impairment.

Structural deficits.

Dysarthria.

Selective mutism.

immature phonological simplification processes past the age when most children can produce

words clearly.

Most speech sounds should be produced clearly and most words should be pronounced

accurately according to age and community norms by age 5 years. The most

51

frequently misarticulated sounds in English also tend to be learned later, leading them to be

called the “late eight” (l, r, s, z, th, ch, dzh, and zh). Misarticulation of any of these sounds by

itself could be considered within normal limits up to age 8 years; however, when multiple sounds

are involved, it is important to target some of those sounds as part of a plan to improve

intelligibility, rather than waiting until the age at which almost all children can produce them

accurately. Lisping (i.e., misarticulating sibilants) is particularly common and may involve
frontal or lateral patterns of airstream direction. It may be associated with a tongue-thrust

swallowing pattern.

Most children with speech sound disorder respond well to treatment, and speech difficulties

improve over time, and thus the disorder may not be lifelong. However, when a language

disorder is also present, the speech disorder has a poorer prognosis and may be associated with

specific learning disorder.

Differential Diagnosis

Regional, social, or cultural/ethnic variations of speech should be

considered before making the diagnosis. Bilingual children may demonstrate an overall lower

intelligibility rating, make more overall consonant and vowel errors, and produce more

uncommon error patterns than monolingual English-speaking children when assessed only in

English.

Those who are deaf or hard of hearing may have speech

sound production errors. When speech deficits are in excess of those usually associated with

these problems, a diagnosis of speech sound disorder may be made.

Speech impairment may be due to structural deficits (e.g., cleft palate).

Speech impairment may be attributable to a motor disorder, such as cerebral palsy.

Neurological signs, as well as distinctive features of voice, differentiate dysarthria from speech

sound disorder, although in young children (under 3 years) differentiation may be difficult,

particularly when there is no or minimal general body motor involvement (as in, e.g., Worster-

Drought syndrome).

Limited use of speech may be a sign of selective mutism, an anxiety disorder

that is characterized by a lack of speech in one or more contexts or settings. Selective mutism

may develop in children with a speech disorder because of embarrassment about their

impairments, but many children with selective mutism exhibit normal speech in “safe” settings,

such as at home or with close friends.

Comorbidity

Speech may be differentially impaired in certain genetic conditions (e.g., Down syndrome, 22q

deletion, FoxP2 gene mutation). If present, these should also be coded.

F80.81

Childhood-Onset Fluency Disorder (Stuttering)

A. Disturbances in the normal fluency and time patterning of speech that are

inappropriate for the individual’s age and language skills, persist over time, and

are characterized by frequent and marked occurrences of one (or more) of the

following:

1. Sound and syllable repetitions.

2. Sound prolongations of consonants as well as vowels.

52

3. Broken words (e.g., pauses within a word).

4. Audible or silent blocking (filled or unfilled pauses in speech).

5. Circumlocutions (word substitutions to avoid problematic words).

6. Words produced with an excess of physical tension.

7. Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).

B. The disturbance causes anxiety about speaking or limitations in effective

communication, social participation, or academic or occupational performance,

individually or in any combination.

C. The onset of symptoms is in the early developmental period. (Note: Later-onset

cases are diagnosed as F98.5 adult-onset fluency disorder.)

D. The disturbance is not attributable to a speech-motor or sensory deficit,

dysfluency associated with neurological insult (e.g., stroke, tumor, trauma), or

another medical condition and is not better explained by another mental

disorder.

Diagnostic Features

The essential feature of childhood-onset fluency disorder (stuttering) is a disturbance in the

normal fluency and time patterning of speech that is inappropriate for the individual’s age. This

disturbance is characterized by frequent repetitions or prolongations of sounds or syllables and

by other types of speech dysfluencies, including broken words (e.g., pauses within a word),

audible or silent blocking (i.e., filled or unfilled pauses in speech), circumlocutions (i.e., word

substitutions to avoid problematic words), words produced with an excess of physical tension,

and monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”). The disturbance in fluency

may interfere with academic or occupational achievement and with social communication. The
extent of the disturbance varies from situation to situation and often is more severe when there is

special pressure to communicate (e.g., giving a report at school, interviewing for a job).

Dysfluency is often absent during oral reading, singing, or talking to inanimate objects or to pets.

Genetic and physiological.

Associated Features

Fearful anticipation of the problem may develop. The speaker may attempt to avoid dysfluencies

by linguistic mechanisms (e.g., altering the rate of speech, avoiding certain words or sounds) or

by avoiding certain speech situations, such as telephoning or public speaking. In addition to

being features of the condition, stress and anxiety have been shown to exacerbate dysfluency.

Childhood-onset fluency disorder may also be accompanied by motor movements (e.g., eye

blinks, tics, tremors of the lips or face, jerking of the head, breathing movements, fist clenching).

Children with fluency disorder show a range of language abilities, and the relationship between

fluency disorder and language abilities is unclear.

Studies have shown both structural and functional neurological differences in children who

stutter. Males are more likely to stutter than females, with estimates varying depending on the

age and possible cause of stuttering. Causes of stuttering are multifactorial, including certain

genetic and neurophysiological factors.

Development and Course

Childhood-onset fluency disorder, or developmental stuttering, occurs by age 6 for 80%–90% of

affected individuals, with age at onset ranging from 2 to 7 years. The onset can be insidious or

more sudden. Typically, dysfluencies start gradually, with repetition of initial consonants, first

words of a phrase, or long words. The child may not be aware of dysfluencies. As the disorder

progresses, the dysfluencies become more frequent and interfering, occurring on the most

meaningful words or phrases in the utterance. As the child becomes aware of the speech

difficulty, he or she may develop mechanisms for avoiding the

53

dysfluencies and emotional responses, including avoidance of public speaking and use of short

and simple utterances. Longitudinal research shows that 65%–85% of children recover from the

dysfluency, with severity of fluency disorder at age 8 years predicting recovery or persistence

into adolescence and beyond.

Risk and Prognostic Factors

individuals with childhood-onset fluency disorder is more than three times the risk in the general

population. To date, mutations of four genes that underlie some cases of stuttering have been

identified.

Functional Consequences of Childhood-Onset Fluency Disorder

(Stuttering)

In addition to being features of the condition, stress and anxiety can exacerbate dysfluency.

Impairment of social functioning may result from this anxiety. Negative communication attitudes

may be a functional consequence of stuttering starting in the preschool years and increasing with

age.

Differential Diagnosis

Sensory deficits.

Normal speech dysfluencies.

Specific learning disorder, with impairment in reading.

Bilingualism.

Medication side effects.

Adult-onset dysfluencies.

Tourette’s disorder.

F80.82

Dysfluencies of speech may be associated with a hearing impairment or other

sensory deficit or a speech-motor deficit. When the speech dysfluencies are in excess of those

usually associated with these problems, a diagnosis of childhood-onset fluency disorder may be

made.

The disorder must be distinguished from normal dysfluencies that

occur frequently in young children, which include whole-word or phrase repetitions (e.g., “I

want, I want ice cream”), incomplete phrases, interjections, unfilled pauses, and parenthetical

remarks. If these difficulties increase in frequency or complexity as the child grows older, a

diagnosis of childhood-onset fluency disorder may be appropriate.

Children who have dysfluencies when they

read aloud may be diagnosed mistakenly as having a reading disorder. Oral reading fluency

typically is measured by timed assessments. Slower reading rates may not accurately reflect the
actual reading ability of children who stutter.

It is necessary to distinguish between dysfluencies resulting from attempts to learn

a new language and dysfluencies that indicate a fluency disorder, which typically appear in both

languages.

Stuttering may occur as a side effect of medication and may be detected

by a temporal relationship with exposure to the medication.

If onset of dysfluencies is during or after adolescence, it is an “adultonset

dysfluency” rather than a neurodevelopmental disorder. Adult-onset dysfluencies are

associated with specific neurological insults and a variety of medical conditions and mental

disorders and may be specified with them, but they are not a DSM-5 diagnosis.

Vocal tics and repetitive vocalizations of Tourette’s disorder should be

distinguishable from the repetitive sounds of childhood-onset fluency disorder by their nature

and timing.

Comorbidity

Childhood-onset fluency disorder can co-occur with other disorders, such as attentiondeficit/

hyperactivity disorder, autism spectrum disorder, intellectual developmental

54

disorder (intellectual disability), language disorder or specific learning disorder, seizure

disorders, social anxiety disorder, speech sound disorder, and other developmental disorders.

Social (Pragmatic) Communication Disorder

Diagnostic Criteria

A. Persistent difficulties in the social use of verbal and nonverbal communication as

manifested by all of the following:

1. Deficits in using communication for social purposes, such as greeting and

sharing information, in a manner that is appropriate for the social context.

2. Impairment of the ability to change communication to match context or the

needs of the listener, such as speaking differently in a classroom than on a

playground, talking differently to a child than to an adult, and avoiding use of

overly formal language.

3. Difficulties following rules for conversation and storytelling, such as taking

turns in conversation, rephrasing when misunderstood, and knowing how to

4. Difficulties understanding what is not explicitly stated (e.g., making

inferences) and nonliteral or ambiguous meanings of language (e.g., idioms,

humor, metaphors, multiple meanings that depend on the context for

interpretation).

B. The deficits result in functional limitations in effective communication, social

participation, social relationships, academic achievement, or occupational

performance, individually or in combination.

C. The onset of the symptoms is in the early developmental period (but deficits may

not become fully manifest until social communication demands exceed limited

capacities).

D. The symptoms are not attributable to another medical or neurological condition

or to low abilities in the domains of word structure and grammar, and are not

better explained by autism spectrum disorder, intellectual developmental

disorder (intellectual disability), global developmental delay, or another mental

disorder.

Diagnostic Features

Social (pragmatic) communication disorder is characterized by a primary difficulty with

pragmatics (i.e., the social use of language and communication), as manifested by deficits in

understanding and following social rules of both verbal and nonverbal communication in

naturalistic contexts, changing language according to the needs of the listener or situation, and

following rules for conversations and storytelling. The deficits in social communication result in

functional limitations in effective communication, social participation, development of social

relationships, academic achievement, or occupational performance. The deficits are not better

explained by low abilities in the domains of structural language or cognitive ability or by autism

spectrum disorder.

Associated Features

The most common associated feature of social (pragmatic) communication disorder is language

impairment, which is characterized by a history of delay in reaching language milestones, and

historical, if not current, structural language problems (see “Language Disorder” earlier in this

chapter). Individuals with social communication deficits may Genetic and physiological.
Autism spectrum disorder.

Attention-deficit/hyperactivity disorder.

55

avoid social interactions. Attention-deficit/hyperactivity disorder (ADHD), emotional and

behavioral problems, and specific learning disorders are also more common among affected

individuals.

Development and Course

Because social (pragmatic) communication depends on adequate developmental progress in

speech and language, diagnosis of social (pragmatic) communication disorder is rare among

children younger than 4 years. By age 4 or 5 years, most children should possess adequate

speech and language abilities to permit identification of specific deficits in social

communication. Milder forms of the disorder may not become apparent until early adolescence,

when language and social interactions become more complex.

The outcome of social (pragmatic) communication disorder is variable, with some children

improving substantially over time and others continuing to have difficulties persisting into

adulthood. Even among those who have significant improvements, the early deficits in

pragmatics may cause lasting impairments in social relationships and behavior and also low

performance of other related skills, such as written expression, reading comprehension, and oral

reading.

Risk and Prognostic Factors

A family history of autism spectrum disorder, communication

disorders, or specific learning disorder appears to increase the risk for social (pragmatic)

communication disorder; this includes siblings of children with these disorders who may present

with early symptoms of social (pragmatic) communication disorder.

Differential Diagnosis

Autism spectrum disorder is the primary diagnostic consideration for

individuals presenting with social communication deficits. The two disorders can be

differentiated by the presence in autism spectrum disorder of restricted/repetitive patterns of

behavior, interests, or activities and their absence in social (pragmatic) communication disorder.

Individuals with autism spectrum disorder may only display the restricted/repetitive patterns of

behavior, interests, and activities during the early developmental period, so a comprehensive
history should be obtained. Current absence of symptoms would not preclude a diagnosis of

autism spectrum disorder, if the restricted interests and repetitive behaviors were present in the

past. A diagnosis of social (pragmatic) communication disorder should be considered only if the

current symptoms or developmental history fails to reveal evidence of symptoms that meet the

diagnostic criteria for restricted/repetitive patterns of behavior, interests, or activities of autism

spectrum disorder (i.e., Criterion B) causing current impairment. The social communication

symptoms may be milder in social (pragmatic) communication disorder than in autism spectrum

disorder, although qualitatively similar.

Primary deficits of ADHD may cause impairments in social

communication and functional limitations of effective communication, social participation, or

academic achievement.

Social anxiety disorder.

Intellectual developmental disorder (intellectual disability) and global developmental delay.

F84.0

The symptoms of social (pragmatic) communication disorder overlap with

those of social anxiety disorder. The differentiating feature is the timing of the onset of

symptoms. In social (pragmatic) communication disorder, the individual has never had effective

social communication; in social anxiety disorder, the social communication skills developed

appropriately but are not utilized because of anxiety, fear, or distress about social interactions.

56

Social

communication skills may be deficient among individuals with global developmental delay or

intellectual developmental disorder, but a separate diagnosis is not given unless the social

communication deficits are clearly in excess of the intellectual limitations.

Unspecified Communication Disorder

F80.9

This category applies to presentations in which symptoms characteristic of

communication disorder that cause clinically significant distress or impairment in

social, occupational, or other important areas of functioning predominate but do not

meet the full criteria for communication disorder or for any of the disorders in the

neurodevelopmental disorders diagnostic class. The unspecified communication

the reason that the criteria are not met for communication disorder or for a specific

neurodevelopmental disorder, and includes presentations in which there is

insufficient information to make a more specific diagnosis.