Models of child language disorder

Diagnostic issues in Developmental Language Disorder (DLD)

ASHA’S De nition (1993): ASHA has de ned language disorder as an impairment in comprehension and

/OR use of a spoken , written and /or other symbol system.

The disorder may involve: REMINDER:

Form = phonology,
1 . The Form of the language morphology & syntax

2. The Content of the language Content = semantics

3. The Function of the Language Function = pragmatics

Naturalist perspective: impairment is characterized as a deviation from the average level of

ability achieved by a similar group of people

It’s useful because ? It covers a a broad range of of language behaviors across different modalities
It does not help the clinician ? Decide what differences in language behavior constitute an
impairment or at what level of impairment intervention is required
‫ﻣﺎﻛﻮ نﺴﺒﻪ ﺧﺎرج ﻋﻦ اﻻداء اﻟﻄﺒﻴىع ﺗﺤﺪد ﻣ* ﻳﺤﺘﺎج ﺗﺪﺧﻞ‬
Questions to consider:

• Should the decision be based on deviation from chronological age expectations or general level of
cognitive ability?

• How far behind does a child’s language need to be to require intervention?

• Is an isolated impairment in one aspect of language as serious as a more mild

impairment across a range of language skills?

Normative perspective : focuses on real world impact language disorder is diagnosed when it affects
social academic or future success

Key challenge determining how to measure impairment severity, and its effect on daily life

• language disorder exists when the Childs level of language achievement Results in an
unacceptable level of risk for undesirable outcome

According to the normative perceptive language disorder should only be diagnosed when ? it
interferes with the child’s ability to meet social expectations now or in the future this could include
dif culties with social relationships, academic achievement, and future employment prospects

• The de nition is neutral regarding the cause of the language impairment instead of focuses on
those language behaviors that increase risk for unfavorable outcomes

Questions to consider

• The greatest risk of poor outcome?

• How do we measure The impact of impairment on the child’s every day activities?
 DLD likely involves the
Is There a Gene for Language? whole brain and altered connectivity
in regions important for language
learning
FOXP2 Gene (2001)
• Discovered in 2001 in a three-generation family with severe speech and language disorder

it was Initially called ? “language gene” by the media, but genes do not directly encode behavior.

More accurately described as a “chief executive of cer” why ? because it regulates other genes
involved in motor control and speech

Expressed in brain regions crucial for speech and language: Caudate nucleus, putamen, cerebellum,
temporal cortex, inferior frontal gyrus, and motor cortex.

Found in other body tissues (e.g., heart, lungs, gut) and other species (e.g., songbirds, mice).

FOXP2 Does not explain most cases of DLD

DLD (Developmental Language Disorder) is not caused by a single gene.

The pattern of inheritance in most cases of DLD is not consistent with a single-gene disorder.
FOXP2 is not linked to common cases of DLD.

CNTNAP2 gene is Linked to

DLD, autism, intellectual disability, seizures, and even depression.

Suggests that DLD is caused by disrupted neural connectivity, not just one speci c damaged area.

Shows that language impairment is part of a broader spectrum of neurodevelopmental disorders.

DLD involves the whole brain, unlike acquired language disorders, which are due to focal brain lesions.

The severity of CNTNAP2-related impairments varies widely bet ween individuals.

Speech, Language, & Communication

Speech, language, and communication are distinct but interrelated Impairments in one area can
affect the others, but they do not always co-occur.

Speech Sound Disorder (SSD): Produces a restricted range of speech sounds, making speech
unintelligible.
• Language skills may be intact.
• Communication may be affected if listeners do not understand the speaker.
• May use gestures or reformulate speech to aid communication.

Developmental Language Disorder (DLD):Speech sounds may be typical, but language is impaired
(e.g., poor comprehension, limited vocabulary, immature sentences).
• Affects communication due to dif culty understanding and expressing thoughts.

Autism Spectrum Disorder (ASD):Speech and language skills may be intact, with clear articulation
and complex sentences.

• Communication is impaired (e.g., tangential speech, repetitive language, dif culty repairing
conversation breakdowns).

Identifying speech, language, or communication as the primary dif culty helps clinicians target
intervention appropriately.
 SSD = not clear speech + good
language & communication

DLD = language skills are

impaired → affecting
communication

ASD= speech B language are

intact but communication
skills are impaired

Speech , language and communication

Why do we use the separate terms speech, language, and communication when a single word label
might be preferable? Because the three do not always go together but impairments in one area
might in uence development or competencies in another
In other words they are distinct but interrelated

Speech sound disorder (SSD) : the child produces a restricted range of speech sounds rendering
( making) spoken output unintelligible, the child may have normal language skills, understanding
what others say and using grammatically complex sentences.
• the ability to communicate may be affected because conversational partners may not always
understand the intended meaning.
• She may also have a typical drive ( desire ) to communicate, supplementing impaired speech with
gestures and reformulating spoken output in order to be understood.

Development Language Disorder (DLD) : The child not have dif culties producing speech sounds, but his
ability to communicate may be limited by poor understanding of what others say to him
• Language skills are impaired affecting communication
• limited vocabulary, and reliance on simple and immature sentences. However, he may still use
these limited language skills to share his thoughts and experiences with other people.

Autism spectrum disorder (ASD) :children may have perfect articulation, exceptional vocabularies,
and be able to express themselves using long and grammatically-complex sentences; yet their
communication skills are limited
by? odd and tangential speech, repetitive language, and a reduced ability to repair breakdowns in
conversation
• Good speech and language but impaired communication

Extra:
What is odd and tangential speech?
• Odd speech refers to speech that sounds strange or unusual overall. ، ‫اسلوب رسمي او طفولي بزيادة‬
‫مثال تسأله سوال بسيط يرد عليك بجواب فلسفي‬، ‫أسلوب الكالم يكون غريب و غير معتاد‬
• Tangential speech speci cally refers to going off-topic without returning to the original point.
‫ كل شوي يغير املوضوع بدون ال يخلص السالفه‬،‫ما يثبت على موضوع واحد‬

Key distinctions : researchers and practitioners often make a distinction bet ween speech,
language, and communication why ? in order to highlight the child’s most salient ( important)
dif culty.
What’s in a name?

Co-occurring impairments: Speech, language, and communication impairments often occur

alongside developmental disorders like ASD or Down syndrom

Terminology confusion: Dif cult to label language disorders in a way that the public
understands.
• Historical inconsistency in naming:
• Bishop (2010) found 130 different terms used in research from 1994–2010.
• Terms like speci c language impairment (SLI) were dominant but faced challenges
over time.
• Unlike autism or ADHD, language disorders have had unstable terminology.
• Consensus on terminology (Bishop & CATALISE consortium, 2017):
• Language Disorder: Used when impairment signi cantly affects daily life,
regardless of cause.
• Developmental Language Disorder (DLD): Language impairment without a known
biomedical cause.
• Risk factors (e.g., biological or environmental) and co-occurring conditions (e.g.,
ADHD, dyslexia) do not exclude a DLD diagnosis.
• Three key groups of children with language disorders:
1. DLD (Primary Language Disorder): Language dif culties are the main issue without a
known cause.
2. Language-Learning Disorders: DLD coexists with literacy disorders (e.g., dyslexia,
poor reading comprehension).
3. Secondary Language Disorders: Language dif culties occur alongside other
developmental conditions (e.g., ASD, intellectual disabilities).
• Challenges in diagnosing DLD:
• Language development is dynamic, meaning dif culties change with age.
• Language is complex, spanning multiple modalities (spoken, written).
• Determining when a dif culty is severe enough to be considered a disorder is
subjective.
Aspects & Modalities of Language Disorders

Form
• Grammar De cits in DLD:
• Omission of morphosyntactic markers (e.g., past tense “-ed,” third-person
singular “-s,” copula “is”).
• More omissions than substitutions.
• Persistent grammatical errors beyond age 5.
• Dif culty with wh- questions, verb alternations, and obligatory verb
arguments.
• Poor understanding of complex syntax (e.g., passives, embedded clauses,
datives, pronominal reference).
• Inconsistent grammatical knowledge—errors appear as if rules are
“optional.”
• Phonological De cits:
• Dif culty with speech sound discrimination and categorization.
• Issues with speech production and phonemic contrasts.
• Poor memory for novel sound sequences.
• Struggles with manipulating speech sounds.
• Phonological impairments often arise from processing dif culties rather
than physical causes.
• These de cits impact vocabulary and grammatical development.

Content & Use in Developmental Language Disorder (DLD)

Content (Vocabulary & Semantic Dif culties)

• Vocabulary Challenges:
• Persistent impoverished vocabulary.
• Slow to learn, retain, and encode new words.
• Require more exposure to learn novel words.
• Frequently make naming errors (e.g., calling “scissors” a “knife”).
• Semantic Dif culties:
• Struggle with multiple word meanings (e.g., “cold” as temperature vs. illness).
• Dif culty understanding jokes, gurative language, and metaphors due to limited word
associations.
• Verb Learning Dif culties:
• Verbs are particularly hard to acquire.
• This impacts sentence structure and grammatical tense development.

Use (Pragmatic & Social Communication Dif culties)

• Pragmatic Challenges:
• Social communication skills are immature rather than qualitatively abnormal (unlike
ASD).
• Weaker social understanding, though not as severe as in ASD.
• Conversational Dif culties:
• Struggles with initiating and maintaining topics, turn-taking, and requesting/
providing clari cation.
• Dif culty matching communication to social context.
• Understanding Social Cues & Context:
• Problems interpreting others’ thoughts and emotions from nonverbal cues and
situational context.
• Dif culty making inferences, understanding gurative language, and constructing
coherent narratives.

This broad understanding of DLD highlights the importance of identifying different aspects of
language impairment, not just in sentence construction but also in vocabulary and social
communication.
Diagnostic Issues in Developmental Language Disorder (DLD)

Mental Age vs. Chronological Age in DLD Diagnosis

• Mental Age:
• Represents developmental level based on cognitive (nonverbal) tests.
• Previously used to diagnose DLD by comparing language ability to mental age
rather than chronological age.
• Problems with this approach:
• Different tests yield inconsistent results.
• Not psychometrically valid to compare scores from different language and
cognition tests.
• Nonverbal IQ scores uctuate, making them unreliable for diagnosis.
• Chronological Age:
• Now the preferred benchmark for diagnosing DLD.
• Ensures children with lower IQ (70–85) are not unfairly excluded from SLP
ser vices.
• IQ-based exclusion from inter vention is not evidence-based.

The Problem with Using Mental Age for Diagnosis

• Cognitive Referencing Criticism:
• Some children with DLD have uneven language pro les (e.g., severe de cits in
morphology but stronger vocabulary skills).
• IQ-based exclusion limits access to intervention even when children show
signi cant language impairment.
• ASHA (2000) opposes cognitive referencing for ser vice eligibility decisions.

The Role of IQ in Diagnosis & Inter vention

• IQ as a Predictor of Language Development?
• Children with IQ scores bet ween 70–85 have similar language de cits as those
with higher IQ.
• IQ does not predict severity of academic, social, or emotional problems.
• Language de cits are only qualitatively different when intellectual disability or
biomedical disorders are present.
• Intervention Considerations:
• IQ should not determine eligibility but can guide treatment goals.
• Language goals should align with a child’s developmental level rather than just
chronological age.
• More research is needed on how children with lower IQ respond to language
intervention.

This shift toward using chronological age rather than mental age ensures that children with
DLD receive necessary support, regardless of their cognitive abilities.
Challenges in Diagnosing Developmental Language Disorder (DLD)

Standardized Test Cutoffs: How Low is Too Low?

• DLD diagnosis via standardized tests is arbitrary
• A common cutoff is the 10th percentile (−1.25 SD).
• Some researchers use a stricter 3rd percentile (−2 SD), but this excludes many children
with signi cant language dif culties.
• The ideal cutoff is debated because language abilities vary across different domains (e.g.,
vocabulary, grammar, narrative).
• Uneven Language Pro les Complicate Diagnosis
• Children with DLD often perform differently across language subtests.
• Example: A child scoring just above the cutoff on multiple tests might still struggle
signi cantly in real life.
• Strict cutoffs may exclude children who need support.

Problems with Current Diagnostic Criteria

1. High False Positive Rate
• 46% of children diagnosed with DLD at school entry no longer met criteria a year later
(Tomblin et al., 2003).
• This suggests some children experience temporary delays rather than persistent DLD.
2. Many Children with DLD Go Unnoticed
• Only 29% of children meeting research criteria for DLD were identi ed by parents or
teachers.
• Even with a stricter −2 SD cutoff, only 39% of children were referred for ser vices.
• Suggests standardized tests may not capture real-world language dif culties.
3. Overlooked Areas in Standard Assessments
• Phonological de cits (sound processing issues) and pragmatic de cits (social language use)
are often not included in standardized tests.
• Children with phonological de cits are more likely to be identi ed and referred for
services.
• Excluding phonological and pragmatic measures may underestimate the prevalence of DLD.

Key Takeaways
• Standardized test cutoffs for DLD are arbitrary and inconsistent.
• Many children with DLD are either misidenti ed or overlooked.
• Language assessments should include phonological and pragmatic measures for better
real-world accuracy.
• Clinical identi cation differs from research-based identi cation, raising concerns about
access to inter vention
 Impact on Daily Living
• Standardized tests alone are not enough to determine the need for SLP services.
• Tests may lack validity, have measurement errors, or not cover all aspects of language.
• Pragmatic language and social communication are context-dependent and dif cult to
assess in structured settings.
• Functional impact matters—language de cits must affect social and academic success
to warrant intervention.
• Some children may score within the normal range but still struggle with communication
in real-life situations.
• Others may have low test scores but function well in their environment.
• Cultural & linguistic biases exist in testing.
• Standardized tests often favor mainstream cultural backgrounds, disadvantaging
children from diverse linguistic communities.
• Alternative assessments like non-word repetition (NWR) tasks can help distinguish
language disorders from language differences but do not provide a full picture of a child’s language
abilities.
• Language impairments can go unnoticed but still impact learning & social development.
• Subtle comprehension issues may manifest in academic struggles, social dif culties, or
behavioral problems.
• Children with expressive language dif culties are more likely to be referred for
assessment than those with comprehension dif culties.
• Stricter diagnostic criteria identify more at-risk children, but some struggling children
may still be excluded.
• Research shows that children with signi cant language de cits in early school years
often struggle academically.
• DSM-5 & WHO diagnostic frameworks emphasize the importance of evaluating how a
language disorder affects daily well-being.
• Contextual factors (e.g., social attitudes, practical obstacles) should be considered for
intervention planning but not for diagnosis.

Etiology of DLD
• No single cause of DLD—multiple risk factors interact.
• Some children with the same intellectual ability or hearing level show different
language abilities, suggesting no direct cause-effect relationship.
• Primary and secondary DLD likely result from a combination of biological, cognitive,
behavioral, and environmental factors.
• Different levels of explanation help understand DLD:
• Biological: Genetic in uences, neurological differences in brain structure and function.
• Cognitive: Differences in perception, processing, storage, and learning impact language
development.
• Behavioral: The obser vable characteristics of DLD that clinicians assess.
• Environmental: Factors like maternal education, cultural background, and learning
experiences can shape language abilities.
• Interventions can change brain function and improve cognitive skills.
• Research shows that intensive reading inter ventions can alter brain structure (e.g.,
increased gray matter).
• Environmental in uences (e.g., cultural and language exposure) can shape cognitive
abilities like social cognition.
Genetic
• DLD is highly heritable, but environment also plays a role
• Runs in families, but shared environment makes genetic in uence harder to isolate
• Twin studies con rm strong genetic component (heritability estimates: 0.50 - 0.75)
• Heritability varies depending on how DLD is de ned (clinical diagnosis vs. standardized
tests)
• Speci c genes are linked to language de cits
• Chromosome 16q → linked to non-word repetition (NWR)
• Chromosome 19q → linked to expressive language scores
• FOXP2 gene (Chromosome 7) → crucial for speech & language but not common DLD
• ATP2C2 & CMIP (Chromosome 16) → impact NWR ability
• BDNF & risk genes (Chromosome 13) → interaction increases risk for DLD
• DLD shares genetic links with ADHD, dyslexia, and ASD
• Genetic overlap explains high comorbidity rates
• Same genes can have different effects (e.g., genes linked to ASD or epilepsy can also
impact language)
• Genes in uence brain development, not direct behaviors
• No single “gene for DLD”—multiple genetic variations affect brain function
• Genetic in uences impact underlying cognitive traits (endophenotypes)
• Some aspects of language are highly heritable (e.g., NWR, morphosyntax), while
others (e.g., auditory processing) are more in uenced by environment

Neurobiological

Language in the Brain

• Brain development is shaped by both genetics and environment
• Neural specialization happens through activity-dependent processes
• Synaptic pruning strengthens key connections for language
• Language is mostly processed in the left hemisphere
• Left hemisphere larger in language areas (e.g., Broca’s & Wernicke’s areas)
• Arcuate fasciculus connects frontal (speech production) & temporal
(comprehension) areas
• DLD is linked to subtle brain differences, not major lesions
• No large-scale brain damage like in stroke patients
• Brain anomalies increase risk but don’t always lead to DLD

Brain Structure & Function

• MRI studies show subtle brain differences in DLD
• Atypical asymmetry & structural anomalies in language areas
• Basal ganglia & hippocampus may play a role in learning vulnerabilities
• Neurological variations may be heritable risk factors
• Some individuals with brain differences develop normal language
• Investigating subcortical structures (e.g., striatum, hippocampus) may
explain DLD vulnerabilities
 Cognitive Models of DLD

Auditory Processing : Children with DLD may struggle with rapid, brief, and low-salience
sounds
• Possible impact on phonemic categorization and grammar processing
• Many grammatical contrasts (e.g., tense markers) rely on unstressed, brief
sounds, making them harder for children with auditory de cits
• Not all children with DLD have auditory de cits, and not all with auditory de cits
have DLD → suggests auditory processing alone is not the cause of DLD
• Studies show that improving auditory skills does not necessarily improve language
or literacy, challenging the idea that auditory de cits are the root issue

Limited Processing Capacity

• Perceptual de cits + limited working memory = greater dif culty with language
processing
• Struggle more with longer & complex sentences due to trade-off bet ween
processing and memory capacity
• Example: In working memory tasks, children must process a statement (“balls are
round”) while also recalling key words (“round”)
• Poor performance on nonword repetition (NWR) tasks
• NWR measures phonological short-term memory, which is important for word
learning & syntax acquisition

• Children with DLD show increased dif culty as syllable length increases (e.g.,
“hampent” vs. “blonterstaping”)
• Some argue bottom-up models (starting with perception) do not fully explain DLD
→ prior knowledge and language experience also in uence processing

Procedural De cits
• DLD linked to procedural memory de cits, affecting rule-based learning (e.g., grammar,
motor sequences)
• Procedural memory (rules, sequences) vs. declarative memory (facts, vocabulary)
• Children with DLD may rely more on declarative memory to compensate for procedural
weaknesses
• Evidence supports procedural de cits, especially in sequence-based learning tasks
• Interventions targeting cognitive processes (e.g., working memory) are not more
effective than direct language inter ventions
1. DLD is linked to procedural memory de cits, which affect rule-based learning (e.g., grammar).
This means children with DLD struggle with learning implicit rules rather than just memorizing
facts.
1. • Procedural learning impairments are strongest in sequence-based tasks, meaning
tasks that involve patterns or ordered steps (e.g., motor sequences) are particularly dif cult.
This supports the idea that DLD is not just about language but also impacts other skills that rely
on procedural memory.
1. • Cognitive-based inter ventions (like working memory training) are not more effective
than direct language inter ventions. This means focusing on language-speci c strategies (rather
than trying to x underlying memory or auditory processing issues) is a better approach for
improving language skills in children with DLD.
Procedural De cits & DLD
• DLD is linked to procedural memory de cits, which affect rule-based learning (e.g.,
grammar). This means children with DLD struggle with learning implicit rules rather than just
memorizing facts.
• Procedural learning impairments are strongest in sequence-based tasks, meaning tasks
that involve patterns or ordered steps (e.g., motor sequences) are particularly dif cult. This supports
the idea that DLD is not just about language but also impacts other skills that rely on procedural
memory.
• Cognitive-based inter ventions (like working memory training) are not more effective than
direct language inter ventions. This means focusing on language-speci c strategies (rather than
trying to x underlying memory or auditory processing issues) is a better approach for improving
language skills in children with DLD.

Comorbidity in DLD

Children with DLD often have co-occurring disorders → possible independent or related origins

Common co-occurring conditions:

• Behavior problems (e.g., attention issues)
• Motor / coordination de cits
• Reading disorders (high overlap with DLD).

Undiagnosed language disorders common in mental health clinic patients (30%)

• Many children with DLD will present with additional developmental concerns, impacting
diagnosis & inter vention