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What Is a Speech Sound Disorder?

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

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

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Speech sound disorders are a blanket description for a child’s difficulty in learning, articulating, or using the sounds/sound patterns of their language. These difficulties are usually clear when compared to the communication abilities of children within the same age group.

Speech developmental disorders may indicate challenges with motor speech. Here, a child experiences difficulty moving the muscles necessary for speech production. This child may also face reduced coordination when attempting to speak.

Speech sound disorders are recognized where speech patterns do not correspond with the movements/gestures made when speaking.  

Speech impairments are a common early childhood occurrence—an estimated 2% to 13% of children live with these difficulties. Children with these disorders may struggle with reading and writing. This can interfere with their expected academic performance. Speech sound disorders are often confused with language conditions such as specific language impairment (SLI).

This article will examine the distinguishing features of this disorder. It will also review factors responsible for speech challenges, and the different ways they can manifest. Lastly, we’ll cover different treatment methods that make managing this disorder possible.

Symptoms of Speech Sound Disorder

A speech sound disorder may manifest in different ways. This usually depends on the factors responsible for the challenge, or how extreme it is.

There are different patterns of error that may signal a speech sound disorder. These include:

• Removing a sound from a word
• Including a sound in a word
• Replacing hard to pronounce sounds with an unsuitable alternative
• Difficulty pronouncing the same sound in different words (e.g., "pig" and "kit")
• Repeating sounds or words
• Lengthening words
• Pauses while speaking
• Tension when producing sounds
• Head jerks during speech
• Blinking while speaking
• Shame while speaking
• Changes in voice pitch
• Running out of breath while speaking

It’s important to note that children develop at different rates. This can reflect in the ease and ability to produce sounds. But where children repeatedly make sounds or statements that are difficult to understand, this could indicate a speech disorder.

Diagnosis of Speech Sound Disorders

For a correct diagnosis, a speech-language pathologist can determine whether or not a child has a speech-sound disorder.

This determination may be made in line with the requirements of the DSM-5 diagnostic criteria . These guidelines require that:

• The child experience persistent difficulty with sound production (this affects communication and speech comprehension)
• Symptoms of the disorder appear early during the child’s development stages
• This disorder limits communication. It affects social interactions, academic achievements, and job performance.
• The disorder is not caused by other conditions like a congenital disorder or an acquired condition like hearing loss . Hereditary disorders are, however, exempted. 

Causes of Speech Sound Disorders

There is no known cause of speech sound disorders. However, several risk factors may increase the odds of developing a speech challenge. These include:

• Gender : Male children are more likely to develop a speech sound disorder
• Family history : Children with family members living with speech disorders may acquire a similar challenge.
• Socioeconomics : Being raised in a low socioeconomic environment may contribute to the development of speech and literacy challenges.
• Pre- and post-natal challenges : Difficulties faced during pregnancy such as maternal infections and stressors may worsen the chances of speech disorders in a child. Likewise, delivery complications, premature birth, and low-birth-weight could lead to speech disorders.
• Disabilities : Down syndrome, autism , and other disabilities may be linked to speech-sound disorders.
• Physical challenges : Children with a cleft lip may experience speech sound difficulties.
• Brain damage : These disorders may also be caused by an infection or trauma to a child’s brain . This is seen in conditions like cerebral palsy where the muscles affecting speech are injured.

Types of Speech Sound Disorders

By the time a child turns three, at least half of what they say should be properly understood. By ages four and five, most sounds should be pronounced correctly—although, exceptions may arise when pronouncing “l”, “s”,”r”,”v”, and other similar sounds. By seven or eight, harder sounds should be properly pronounced. 

A child with a speech sound disorder will continue to struggle to pronounce words, even past the expected age. Difficulty with speech patterns may signal one of the following speech sound disorders:

This refers to interruptions while speaking. Stuttering is the most common form of disfluency. It is recognized for recurring breaks in the free flow of speech. After the age of four, a child with disfluency will still repeat words or phrases while speaking. This child may include extra words or sounds when communicating—they may also make words longer by stressing syllables.

This disorder may cause tension while speaking. Other times, head jerking or blinking may be observed with disfluency. 

Children with this disorder often feel frustrated when speaking, it may also cause embarrassment during interactions. 

Articulation Disorder

When a child is unable to properly produce sounds, this may be caused by inexact placement, speed, pressure, or movement from the lips, tongue, or throat.  

This usually signals an articulation disorder, where sounds like “r”, “l”, or “s” may be changed. In these cases, a child’s communication may be understood by only close family members.

Phonological Disorder

A phonological disorder is present where a child is unable to make the speech sounds expected of their age. Here, mistakes may be made when producing sounds. Other times, sounds like consonants may be omitted when speaking.  

Voice Disorder

Where a child is observed to have a raspy voice, this may be an early sign of a voice disorder. Other indicators include voice breaks, a change in pitch, or an excessively loud or soft voice.  

Children that run out of breath while speaking may also live with this disorder. Likewise, children may sound very nasally, or can appear to have inadequate air coming out of their nose if they have a voice disorder.

Childhood apraxia of speech occurs when a child lacks the proper motor skills for sound production. Children with this condition will find it difficult to plan and produce movements in the tongue, lips, jaw, and palate required for speech.  

Treatment of Speech Sound Disorder

Parents of children with speech sound disorders may feel at a loss for the next steps to take. To avoid further strain to the child, it’s important to avoid showing excessive concern.

Instead, listening patiently to their needs, letting them speak without completing their sentences, and showing usual love and care can go a long way.

For professional assistance, a speech-language pathologist can assist with improving a child’s communication. These pathologists will typically use oral motor exercises to enhance speech.

These oral exercises may also include nonspeech oral exercises such as blowing, oral massages and brushing, cheek puffing, whistleblowing, etc.

Nonspeech oral exercises help to strengthen weak mouth muscles, and can help with learning the common ways of communicating.

Parents and children with speech sound disorders may also join support groups for information and assistance with the condition.

A Word From Verywell

It can be frustrating to witness the challenges in communication. But while it's understandable to long for typical communication from a child—the differences caused by speech disorders can be managed with the right care and supervision. Speaking to a speech therapist, and showing love o children with speech disorders can be important first steps in overcoming these conditions.

Eadie P, Morgan A, Ukoumunne OC, Ttofari Eecen K, Wake M, Reilly S. Speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children . Dev Med Child Neurol . 2015;57(6):578-584. doi:10.1111/dmcn.12635

McLeod S, Harrison LJ, McAllister L, McCormack J. Speech sound disorders in a community study of preschool children . Am J Speech Lang Pathol . 2013;22(3):503-522. doi:10.1044/1058-0360(2012/11-0123)

Murphy CF, Pagan-Neves LO, Wertzner HF, Schochat E. Children with speech sound disorder: comparing a non-linguistic auditory approach with a phonological intervention approach to improve phonological skills . Front Psychol . 2015;6:64. Published 2015 Feb 4. doi:10.3389/fpsyg.2015.00064

Penn Medicine. Speech and Language Disorders-Symptoms and Causes .

PsychDB. Speech Sound Disorder (Phonological Disorder) .

Sices L, Taylor HG, Freebairn L, Hansen A, Lewis B. Relationship between speech-sound disorders and early literacy skills in preschool-age children: impact of comorbid language impairment . J Dev Behav Pediatr . 2007;28(6):438-447. doi:10.1097/DBP.0b013e31811ff8ca

American Speech-Language-Hearing Association. Speech Sound Disorders: Articulation and Phonology .

American Speech-Language-Hearing Association. Speech Sound Disorders .

MedlinePlus. Phonological Disorder .

National Institute on Deafness and Other Communication Disorders. Articulation Disorder .

National Institute of Health. Phonological Disorder.

Lee AS, Gibbon FE. Non-speech oral motor treatment for children with developmental speech sound disorders . Cochrane Database Syst Rev . 2015;2015(3):CD009383. Published 2015 Mar 25. doi:10.1002/14651858.CD009383.pub2

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

General Information About Speech and Language Disorders

Definition of speech and language disorders.

Speech and language disorders refer to problems in communication and related areas such as oral motor function. These delays and disorders range from simple sound substitutions to the inability to understand or use language or use the oral-motor mechanism for functional speech and feeding. Some causes of speech and language disorders include hearing loss, neurological disorders, brain injury, mental retardation, drug abuse, physical impairments such as cleft lip or palate, and vocal abuse or misuse. Frequently, however, the cause is unknown.

One quarter of the students served in the public schools’ special education programs (almost 1 million children in the 1993-94 school year) were categorized as having a speech or language impairment. This estimate does not include children who have speech/language problems secondary to other conditions such as deafness. Language disorders may be related to other disabilities such as mental retardation, autism or cerebral palsy. It is estimated that communication disorders (including speech, language and hearing disorders) affect one of every 10 people in the United States.

Characteristics

A child’s communication is considered delayed when the child is noticeably behind his or her peers in the acquisition of speech and/or language skills. Sometimes a child will have greater receptive (understanding) than expressive (speaking) language skills, but this is not always the case.

Speech disorders refer to difficulties producing speech sounds or problems with voice quality. They might be characterized by an interruption in the flow or rhythm of speech, such as stuttering, which is called dysfluency. Speech disorders may be problems with the way sounds are formed, called articulation or phonological disorders, or they may be difficulties with the pitch, volume or quality of the voice. There may be a combination of several problems. People with speech disorders have trouble using some speech sounds, which can also be a symptom of a delay. They may say “see” when they mean “ski” or they may have trouble using other sounds like “l” or “r”. Listeners may have trouble understanding what someone with a speech disorder is trying to say. People with voice disorders may have trouble with the way their voices sound.

A language disorder is an impairment in the ability to understand and/or use words in context, both verbally and nonverbally. Some characteristics of language disorders include improper use of words and their meanings, inability to express ideas, inappropriate grammatical patterns, reduced vocabulary and inability to follow directions. One or a combination of these characteristics may occur in children who are affected by language learning disabilities or developmental language delay. Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate.

Educational implications

Because all communication disorders carry the potential to isolate individuals from their social and educational surroundings, it is essential to find appropriate timely intervention. While many speech and language patterns can be called “baby talk” and are part of a young child’s normal development, they can become problems if they are not outgrown as expected. In this way an initial delay in speech and language or an initial speech pattern can become a disorder which can cause difficulties in learning. Because of the way the brain develops, it is easier to learn language and communication skills before the age of 5. When children have muscular disorders, hearing problems or developmental delays, their acquisition of speech, language and related skills is often affected.

Speech-language pathologists assist children who have communication disorders in various ways. They provide individual therapy for the child; consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and work closely with the family to develop goals and techniques for effective therapy in class and at home. Technology can help children whose physical conditions make communication difficult. The use of electronic communication systems allow nonspeaking people and people with severe physical disabilities to engage in the give and take of shared thought.

Vocabulary and concept growth continues during the years children are in school. Reading and writing are taught and, as students get older, the understanding and use of language becomes more complex. Communication skills are at the heart of the education experience. Speech and/or language therapy may continue throughout a student’s school year either in the form of direct therapy or on a consultant basis. The speech-language pathologist may assist vocational teachers and counselors in establishing communication goals related to the work experiences of students and suggest strategies that are effective for the important transition from school to employment and adult life.

Communication has many components. All serve to increase the way people learn about the world around them, utilize knowledge and skills, and interact with colleagues, family and friends.

Berkowitz, S. (1994). “The cleft palate story: A primer for parents of children with cleft lip and palate.” Chicago, IL: Quintessence. (Telephone: 1-800-621-0387.)

Bernthal, J.E. & Bankson, N.W. (1993). “Articulation and phonological disorders” (3rd ed.). Englewood Cliffs, NJ: Prentice Hall. (Available from Prentice Hall, Englewood Cliffs, NJ 07632. Telephone: 1-800-947-7700.)

Beukelman, D.R., & Mirenda, P. (1992). “Augmentative and alternative communication: Management of severe communication disorders in children and adults.” Baltimore, MD: Paul H. Brookes. (Telephone: 1-800-638-3775.)

Organizations

• Alliance for Technology Access 2175 E. Francisco Blvd., Suite L San Rafael, CA 94901 (415) 455-4575
• American Speech-Language-Hearing Association (ASHA) 10801 Rockville Pike Rockville, MD 20852 (301) 897-5700 (V/TT); 1-800-638-8255 E-Mail: [email protected]
• Learning Disabilities Association of America (LDA) 4156 Library Road Pittsburgh, PA 15234 (412) 341-1515; (412) 341-8077
• Division for Children with Communication Disorders c/o Council for Exceptional Children (CEC) 1920 Association Drive Reston, VA 22091-1589 (703) 620-3660
• National Easter Seal Society 230 West Monroe Street, Suite 1800 Chicago, IL 60606-4802 (312) 726-6200; (312) 726-4258 (TT) 1-800-221-6827 (Toll Free); (312) 726-6200 (312) 726-4258 (TTY) E-Mail: [email protected]
• Scottish Rite Foundation Southern Jurisdiction, U.S.A., Inc. 1733 Sixteenth Street, N.W. Washington, DC 20009-3199 (202) 232-3579
• Trace Research and Development Center University of Wisconsin - Madison S-151 Waisman Center Madison, WI 53705-2280 (608) 262-6966; (608) 263-5408 (TTY)

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Language and Speech Disorders in Children

Helping children learn language, what to do if there are concerns.

• Detecting problems

Children are born ready to learn a language, but they need to learn the language or languages that their family and environment use. Learning a language takes time, and children vary in how quickly they master milestones in language and speech development. Typically developing children may have trouble with some sounds, words, and sentences while they are learning. However, most children can use language easily around 5 years of age.

Parents and caregivers are the most important teachers during a child’s early years. Children learn language by listening to others speak and by practicing. Even young babies notice when others repeat and respond to the noises and sounds they make. Children’s language and brain skills get stronger if they hear many different words. Parents can help their child learn in many different ways, such as

• Responding to the first sounds, gurgles, and gestures a baby makes.
• Repeating what the child says and adding to it.
• Talking about the things that a child sees.
• Asking questions and listening to the answers.
• Looking at or reading books.
• Telling stories.
• Singing songs and sharing rhymes.

This can happen both during playtime and during daily routines.

Parents can also observe the following:

• How their child hears and talks and compare it with typical milestones for communication skills external icon .
• How their child reacts to sounds and have their hearing tested if they have concerns .

Learn more about language milestones .  Watch milestones in action.

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Some languages are visual rather than spoken. American Sign Language uses visual signals, including gestures, facial expressions, and body movement to communicate.

Some children struggle with understanding and speaking and they need help. They may not master the language milestones at the same time as other children, and it may be a sign of a language or speech delay or disorder.

Language development has different parts, and children might have problems with one or more of the following:

• Not hearing the words (hearing loss).
• Not understanding the meaning of the words.
• Not knowing the words to use.
• Not knowing how to put words together.
• Knowing the words to use but not being able to express them.

Language and speech disorders can exist together or by themselves. Examples of problems with language and speech development include the following:

• Difficulty with forming specific words or sounds correctly.
• Difficulty with making words or sentences flow smoothly, like stuttering or stammering.
• Language delay – the ability to understand and speak develops more slowly than is typical
• Aphasia (difficulty understanding or speaking parts of language due to a brain injury or how the brain works).
• Auditory processing disorder (difficulty understanding the meaning of the sounds that the ear sends to the brain)

Learn more about language disorders external icon .

Language or speech disorders can occur with other learning disorders that affect reading and writing. Children with language disorders may feel frustrated that they cannot understand others or make themselves understood, and they may act out, act helpless, or withdraw. Language or speech disorders can also be present with emotional or behavioral disorders, such as attention-deficit/hyperactivity disorder (ADHD) or anxiety . Children with developmental disabilities including autism spectrum disorder may also have difficulties with speech and language. The combination of challenges can make it particularly hard for a child to succeed in school. Properly diagnosing a child’s disorder is crucial so that each child can get the right kind of help.

Detecting problems with language or speech

If a child has a problem with language or speech development, talk to a healthcare provider about an evaluation. An important first step is to find out if the child may have a hearing loss. Hearing loss may be difficult to notice particularly if a child has hearing loss only in one ear or has partial hearing loss, which means they can hear some sounds but not others. Learn more about hearing loss, screening, evaluation, and treatment .

A language development specialist like a speech-language pathologist external icon will conduct a careful assessment to determine what type of problem with language or speech the child may have.

Overall, learning more than one language does not cause language disorders, but children may not follow exactly the same developmental milestones as those who learn only one language. Developing the ability to understand and speak in two languages depends on how much practice the child has using both languages, and the kind of practice. If a child who is learning more than one language has difficulty with language development, careful assessment by a specialist who understands development of skills in more than one language may be needed.

Treatment for language or speech disorders and delays

Children with language problems often need extra help and special instruction. Speech-language pathologists can work directly with children and their parents, caregivers, and teachers.

Having a language or speech delay or disorder can qualify a child for early intervention external icon (for children up to 3 years of age) and special education services (for children aged 3 years and older). Schools can do their own testing for language or speech disorders to see if a child needs intervention. An evaluation by a healthcare professional is needed if there are other concerns about the child’s hearing, behavior, or emotions. Parents, healthcare providers, and the school can work together to find the right referrals and treatment.

What every parent should know

Children with specific learning disabilities, including language or speech disorders, are eligible for special education services or accommodations at school under the Individuals with Disabilities in Education Act (IDEA) external icon and Section 504 external icon , an anti-discrimination law.

Get help from your state’s Parent Training and Information Center external icon

The role of healthcare providers

Healthcare providers can play an important part in collaborating with schools to help a child with speech or language disorders and delay or other disabilities get the special services they need. The American Academy of Pediatrics has created a report that describes the roles that healthcare providers can have in helping children with disabilities external icon , including language or speech disorders.

More information

CDC Information on Hearing Loss

National Institute on Deafness and Other Communication Disorders external icon

Birth to 5: Watch me thrive external icon

The American Speech-Language-Hearing Association external icon

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• Last edited on March 29, 2021

Speech Sound Disorder (Phonological Disorder)

Table of contents, dsm-5 diagnostic criteria, pathophysiology, differential diagnosis, for patients, for providers.

Speech Sound Disorder (also known as Phonological Disorder) is a disorder where speech sound production is not consistent with what is expected based on the child's developmental stage and age. Additionally, the speech production deficits must not be due to a physical, structural, neurological, or hearing impairment. Children with the disorder may not have knowledge of phonological speech sounds, or be unable to coordinate movements (i.e. - articulation) for speech.

Epidemiology

There is a prevalence of speech sound disorders in young children is 8 to 9 percent. [1]

Comorbidity

Language disorder (especially in those expressive deficits) may co-occur with speech sound disorder. Individuals may also have a history of delay or poor coordination involving facial musculature (e.g. - chewing, maintaining mouth closure, and nose blowing).

What is the Timeline of Development of Speech?

Criterion a.

Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication of messages.

Criterion B

The disturbance causes limitations in effective communication that interfere with social participation, academic achievement, or occupational performance, individually or in any combination.

Criterion C

Onset of symptoms is in the early developmental period.

Criterion D

The difficulties are not attributable to congenital (i.e. - during fetal development) or acquired conditions, such as cerebral palsy, cleft palate, deafness or hearing loss, traumatic brain injury , or other medical or neurological conditions. Hereditary and genetic disorders (e.g. - Down syndrome ) are excluded from this criterion.

Speech sound disorder can be due to various etiologies, and thus is a heterogeneous condition. For example, individuals with genetic disorders such as Down syndrome , DiGeorge (22q11.2 Deletion) syndrome , and the FoxP2 gene mutation may have speech sound disorder.

• Consider regional, social, or cultural/ethnic variations of speech before giving the diagnosis
• Hearing impairment or deafness may result in abnormalities of speech. Only when the language deficits are in excess of what is expected, should a diagnosis of speech sound disorder may be made.
• Speech impairment can be caused by structural deficits such as cleft palate.
• Speech impairment can be due to a motor disorder such as cerebral palsy. This is dysarthria and not speech sound disorder.
• Limited speech might be due to selective mutism. Selective mutism may develop concurrently in children with speech disorder due to embarrassment about their impairments. Most children with selective mutism have normal speech in comfortable environments, such as at home or with friends.

Most children with speech sound disorder respond well to speech therapy. Speech difficulties often improve over time, and the disorder may not be lifelong. For some, certain speech errors can persist into adulthood.

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6.1: Definitions of Communication Disorders

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The Individuals with Disabilities Education Act (IDEA) defines a speech or language impairment as the following:

Speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance (Individuals With Disabilities Education Act, Part B, Subpart A § 300.8(c)(11)(2004)).

This definition is used to determine whether a student with a communication disorder is eligible for special education and related services. However, many professionals also use the following definitions from the ASHA. ASHA provides the following more detailed definition of communication disorder.

A communication disorder is an impairment in the ability to receive, send, process, and comprehend concepts or verbal, nonverbal and graphic symbol systems. A communication disorder may be evident in the processes of hearing, language, and/or speech. A communication disorder may range in severity from mild to profound. It may be developmental or acquired. Individuals may demonstrate one or any combination of communication disorders. A communication disorder may result in a primary disability, or it may be secondary to other disabilities (ASHA, 1993).

ASHA also provides detailed definitions of the different types of communication disorders, including speech disorders, language disorders, and central auditory processing disorders.

A speech disorder is an impairment of the articulation of speech sounds, fluency and/or voice.

• An articulation disorder is the atypical production of speech sounds characterized by substitutions, omissions, additions or distortions that may interfere with intelligibility.
• A fluency disorder is an interruption in the flow of speaking characterized by atypical rate, rhythm, and repetitions in sounds, syllables, words, and phrases. This may be accompanied by excessive tension, struggle behavior, and secondary mannerisms.
• A voice disorder is characterized by the abnormal production and/or absences of vocal quality, pitch, loudness, resonance, and/or duration, which is inappropriate for an individual’s age and/or sex.

A language disorder is impaired comprehension and/or use of spoken, written and/or other symbol systems. The disorder may involve (1) the form of language (phonology, morphology, syntax), (2) the content of language (semantics), and/or (3) the function of language in communication (pragmatics) in any combination.

• Phonology is the sound system of a language and the rules that govern the sound combinations.
• Morphology is the system that governs the structure of words and the construction of word forms.
• Syntax is the system governing the order and combination of words to form sentences, and the relationships among the elements within a sentence.
• Semantics is the system that governs the meanings of words and sentences.
• Pragmatics is the system that combines the above language components in functional and socially appropriate communication.

Central auditory processing disorders (CAPD) are deficits in the information processing of audible signals not attributed to impaired peripheral hearing sensitivity or intellectual impairment. This information processing involves perceptual, cognitive, and linguistic functions that, with appropriate interaction, result in effective receptive communication of auditorily presented stimuli. Specifically, CAPD refers to limitations in the ongoing transmission, analysis, organization, transformation, elaboration, storage, retrieval, and use of information contained in audible signals. CAPD may involve the listener’s active and passive (e.g., conscious and unconscious, mediated and unmediated, controlled and automatic) ability to do the following:

• attend, discriminate, and identify acoustic signals;
• transform and continuously transmit information through both the peripheral and central nervous systems;
• filter, sort, and combine information at appropriate perceptual and conceptual levels;
• store and retrieve information efficiently; restore, organize, and use retrieved information;
• segment and decode acoustic stimuli using phonological, semantic, syntactic, and pragmatic knowledge; and
• attach meaning to a stream of acoustic signals through use of linguistic and nonlinguistic contexts (ASHA, 1993).

Finally, ASHA differentiates a communication disorder from communication variations including communication difference/dialect and augmentative/alternative communication.

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. A regional, social, or cultural/ethnic variation of a symbol system should not be considered a disorder of speech or language.

Augmentative/alternative communication systems attempt to compensate and facilitate, temporarily or permanently, for the impairment and disability patterns of individuals with severe expressive and/ or language comprehension disorders. Augmentative/alternative communication may be required for individuals demonstrating impairments in gestural, spoken, and/or written modalities (ASHA, 1993).

APA Definition

In addition, the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association includes disorders of communication which include language disorder, speech sound disorder, childhood-onset fluency disorder (stuttering), social (pragmatic) communication disorders, and unspecified communication disorders. The diagnostic criteria for each are included below.

Language Disorder

• Reduced vocabulary (word knowledge and use).
• Limited sentence structure (ability to put words and word endings together to form sentences based on the rules of grammar and morphology).
• Impairments in discourse (ability to use vocabulary and connect sentences to explain or describe a topic or series of events or have a conversation).
• 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.
• Onset of symptoms is in the early developmental period.
• 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 (DSM-5-TR, 2022, p. 47).

Speech Sound Disorder

• Persistent difficulty with speech sound production that interferes with speech intelligibility or prevents verbal communication or messages.
• The disturbance causes limitation in effective communication that interferes with social participation, academic achievement, or occupational performance, individually or in any combination.
• Onset of symptoms in the early developmental period.
• 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 (DSM-5-TR, 2022, p. 50).

Childhood-Onset Fluency Disorder (Stuttering)

• Sound and syllable repetitions.
• Sound prolongations of consonants as well as vowels.
• Broken words (e.g., pauses within a word).
• Audible or silent blocking (filled or unfilled pauses in speech).
• Circumlocutions (word substitutions to avoid problematic words).
• Words produced with an excess of physical tension.
• Monosyllabic whole-word repetitions (e.g., “I-I-I-I see him”).
• The disturbance causes anxiety about speaking or limitations in effective communication, social participation, or academic or occupational performance, individually or in any combination.
• The onset of symptoms is in the early developmental period.
• The disturbance is not attributable to a speech-motor or sensory deficit, disfluency associated with neurological insult (e.g., stroke, tumor, trauma), or another medical condition and is not better explained by another mental disorder (DSM-5-TR, 2022, p. 51-52).

Social (Pragmatic) Communication Disorder

• Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context.
• 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 the use of overly formal language.
• Difficulties following rules for conversation and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction.
• Difficulties understanding what is not explicitly stated (e.g., making inferences) and nonliteral and ambiguous meanings of language (e.g., idioms, humor, metaphors, multiple meanings that depend on the context for interpretation).
• The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination.
• 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).
• 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 (DSM-5-TR, 2022, p. 54).

The Illinois Definition of Speech or Language Impairment

Speech or Language Impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance (ISBE, 2022).

Activity \(\PageIndex{1}\): Compare and Contrast

Directions: Compare and contrast the IDEA, ASHA, APA, and Illinois definitions of communication disorders. Consider the differences and similarities between diagnostic criteria.

 Individuals With Disabilities Education Act, Part B, Subpart A § 300.8(c)(11)(2004).

American Speech-Language-Hearing Association. (1993). Definitions of communication disorders and variations [Relevant Paper] . https://www.asha.org/policy/rp1993-00208/

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed. Text Revision). https://doi.org/10.1176/appi.books.9780890425596

Illinois State Board of Education. (2022, October 7). Special education disability areas . https://www.isbe.net/Pages/Special-Education-Disability-Areas.aspx

Am Fam Physician. 2024;109(4):361-362

As published by the USPSTF.

The full recommendation statement is available at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/speech-and-language-delay-and-disorders-in-children-age-5-and-younger-screening .

The USPSTF recommendations are independent of the U.S. government. They do not represent the views of the Agency for Healthcare Research and Quality, the U.S. Department of Health and Human Services, or the U.S. Public Health Service.

This series is coordinated by Joanna Drowos, DO, contributing editor.

A collection of USPSTF recommendation statements published in AFP is available at https://www.aafp.org/afp/uspstf .

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‘Prejudice, Islamophobia’: Free speech fears as UK redefines extremism

Experts say a new definition disproportionately targets groups that advocate for Muslims’ civil rights.

The United Kingdom government’s new definition of “extremism”, touted as a bid to tackle rising Islamophobia and anti-Semitism in the aftermath of Israel’s war on Gaza, has ignited fierce debate across the political spectrum, with critics on all sides claiming it will erode freedom of speech and civil liberties.

Communities Secretary Michael Gove last month named several UK-based far-right organisations, including the neo-Nazi British National Socialist Movement and the Patriotic Alternative, which will be held “to account to assess if they meet our definition of extremism and [we] will take action as appropriate”.

Keep reading

Being branded as ‘extremist’ won’t deter palestine action, uk attack survivors warn against ‘equating muslims with extremism’, what’s in the uk’s new definition of ‘extremism’, taking a page from the french anti-islam playbook, uk redefines ‘extremism’.

Amid heightened domestic tensions since October 7, he also named several prominent groups advocating for Muslims’ civil rights, including the Muslim Council of Britain, the Muslim Association of Britain – which he described as the UK affiliate of the Muslim Brotherhood, Cage, and Muslim Engagement and Development (MEND).

“The fact that there are immediately Muslim organisations who are labelled as [‘extremist’] tells you exactly what this piece of legislation is intended for,” said Imran Khan QC, the British lawyer who rose to prominence representing the family of Stephen Lawrence, whose racist murder in 1993 exposed institutional racism in the Metropolitan Police.

Organisations deemed “extreme” under the new definition will be blacklisted, made ineligible for government funding, and they will be banned from meeting with ministers.

“What is the starting point of ‘extreme views’?” said Khan, who has worked on numerous “extremism” and “terrorism” cases following the July 2005 bombings in London, and represented surviving families of the Grenfell Tower disaster.

“The classic example that’s always used is about [Nelson] Mandela being a freedom fighter in one instance, and a terrorist in another,” he told Al Jazeera.

“It’s based on prejudice, Islamophobia, racism, and it will be those sections of society who are not able to protect themselves, who are going to be subject to further prosecution and persecution.”

Britain is home to a sizeable Muslim minority of about four million people, or 6 percent of the population.

The last definition of extremism in the UK, which placed greater emphasis on acts of violence, was drafted in 2011.

Individuals or groups were seen to be “extremist” if they demonstrated “vocal or active opposition to British fundamental values, including democracy, the rule of law, individual liberty and the mutual respect and tolerance of different faiths and beliefs”.

The revised definition is non-statutory, which means proscribed individuals or groups will not be prosecuted.

The government now says extremism is the “promotion or advancement of an ideology based on violence, hatred or intolerance”, and that groups with the following aims will be considered extremist:

1. negate or destroy the fundamental rights and freedoms of others

2. undermine, overturn or replace the UK’s system of liberal parliamentary democracy and democratic rights

3. or intentionally create a permissive environment for others to achieve the results in 1 and 2.

The development comes in the wake of weekly national protests held across the UK in solidarity with Palestinians, as Israel’s war on Gaza, which has to date killed about 33,800 people, rages on.

Pro-Palestine rallies in the UK have been riddled with claims that they play host to anti-Semitism. Former Home Secretary Suella Braverman lamented what she called “hate marches” in November after raising the possibility of banning them.

Gove has previously described those attending pro-Palestinian demonstrations as “good-hearted people” who were “lending credence to extremists”.

Amnesty International, Liberty, and Friends of the Earth warned that the latest definition of extremism was too broad.

Other critics say it unfairly targets left-wing, socialist, environmental and anti-fascist groups, such as Palestine Action , which has targeted the UK’s subsidiary factories and offices of Elbit Systems – Israel’s largest arms manufacturer which supplies the majority of land and air munitions used by the Israeli army.

“My worry is that it cannot only serve to further misrepresent and delegitimise such protests, but securitise and criminalise them, Palestinians, Muslims, and the left,” said Aaron Winter, a senior lecturer in sociology at Lancaster University, referring to the naming of MEND, Cage and other organisations by Gove.

He added that while some far-right organisations are also named, the recent opposition to pro-Palestine protests shows the “equivalence is false and indicates that there will be a double standard”.

“This is something we have already seen in the way counter-extremism has disproportionately targeted Muslims.”

In a joint statement published on March 12, the archbishops of Canterbury and York warned the government that its new extremism definition risks “disproportionately targeting Muslim communities” and “driving us apart”.

“The new definition being proposed not only inadvertently threatens freedom of speech, but also the right to worship and peaceful protest – things that have been hard won and form the fabric of a civilised society,” the statement said.

“Crucially, it risks disproportionately targeting Muslim communities, who are already experiencing rising levels of hate and abuse,” it added.

Across the political spectrum, those on the right have also expressed fears the definition could be used to ban groups with socially conservative values around transgender rights, same-sex marriage, or abortion.

“The definition suggests that extremism can be the ‘promotion’ of an ideology based on ‘intolerance’ – this riskily allows for a great deal of subjectivity,” said Rakib Ehsan, an independent counter-extremism analyst.

“Trans-radical activists would argue that believing a biological male can never be a woman is ‘intolerant’,” he added. “Pro-choice organisations might put forward the view that those who support greater protections for the unborn are a fundamental threat to women’s rights.”

In March, Gove said Britons “cherish free speech” and that conservative religious beliefs, anti or pro-trans activists, and environmental protest groups will not have their rights infringed upon.

Days before the new definition was introduced, 12 anti-extremism experts, including three former Conservative home secretaries – Priti Patel, Sajid Javid and Amber Rudd – signed a statement warning about the risks of politicising the issue in the run-up to this year’s general election.

For Khan, the definition evokes memories of othering and racism he felt as the child of Muslim, Pakistani immigrants.

He fears the revised definition will have “more than just a chilling effect” on British Muslims and other disenfranchised communities.

“I fight on behalf of individuals who believe the system isn’t treating them well.  Am I in danger of being labelled an ‘extremist lawyer’ because of somebody who is an extremist?” Khan said.

“We’re becoming more authoritarian, dictatorial [and] preventing legitimate arguments, legitimate attempts at challenging the status quo.”

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Trump hush money trial

Israel-Hamas war

Columbia University president testifies in House antisemitism probe

By CNN's Matt Egan and Ramishah Maruf

Hearing wraps up

By CNN's Ramishah Maruf

The congressional hearing on Columbia University's response to antisemitism has now been adjourned.

"We're deeply disturbed by what we're seeing at Columbia, any of the things we've heard in today's hearing," US Rep. Virginia Foxx said.

Professor who called Shafik a "coward" is under investigation for harassment of students

From CNN's Ramishah Maruf

US Rep. Ilhan Omar asked Shafik what the school's policies are for professors who harass students online. Shafik said one professor, Columbia Business School assistant professor Shai Davidai, is under investigation for harassment.

Davidai called Shafik a “coward” in a  fiery speech  last year criticizing the university president for failing to quiet “pro-terror” voices at the school.

The same professor has more than 50 complaints against him, Shafik said.

"As president, I'm used to being attacked, but attacking our students is unacceptable," Shafik said.

Columbia did not immediately respond to a request for comment.

Davidai said to CNN that he has never spoken against students by name, only "pro-Hamas" student organizations and professors.

"They're investigating me for the entire reason the entire reason this hearing was held in the first place. Columbia is investigating me for my social media tweets and only my social media tweets," he said.

Columbia officials say they agree on definition of antisemitism

Shafik and David M. Schizer, the former dean of the Columbia University Law School and co-chair of the university’s task force combatting antisemitism, said a March article by the New York Times that said members of Columbia's task force could not settle on the definition of antisemitism is inaccurate but stopped short of calling it false.

"For me personally, any discrimination against people for their Jewish faith is antisemitism," Shafik said.

Shafik told US Rep. Lisa McClain she is "pretty sure" that the rest of the university's task force combatting antisemitism would agree with that definition.

Schizer's definition was more detailed.

"It's bias against Jewish people, which can manifest as ethnic slurs, stereotyping, Holocaust denial, double standards as applies to Israel, and antisemitic tropes," Schizer said.

Shafik says Columbia is firing professor who posted support for Hamas after October 7 attack

From CNN's Matt Egan

Columbia University President Minouche Shafik said the school is firing a professor who allegedly expressed support for Hamas on social media following the October 7 terror attack on Israel.

Rep. Elise Stefanik said Columbia hired Mohamed Abdou as a professor after the terror attack even though she said he posted support for Hamas, Hezbollah and the Islamic Jihad on October 11. 

“I share with you your repugnance at those remarks. I completely understand that. On my watch, for faculty who make remarks that cross the line in terms of antisemitism, there will be consequences,” Shafik said. 

Speaking specifically about Abdou, Shafik said: “He has been terminated.”

Shafik also said that Abdou is grading his students’ papers but will “never teach at Columbia again and that will be on his permanent record.”

Columbia did not immediately respond to a request for comment on when Abdou’s termination takes effect. 

Shafik added that there are five instances of faculty who have either been removed from classrooms or dismissed. 

Columbia Law School dean emeritus draws on family history as antisemitism task force co-chair

From CNN's Lauren Koenig

Former Dean of Columbia University Law School and co-chair of the university’s task force combatting antisemitism David M. Schizer drew on his personal experience with antisemitism in his opening statement to the House Education and the Workforce committee.

“A student wearing a shirt with an Israeli flag was pinned against the wall by a protester and told to keep f-ing running when he broke free,” Professor Schizer told the committee, “when I heard this, my first thought was of my grandfather.”

Schizer said his grandfather grew up in Ukraine, “and his grandfather was lynched in a pogrom.”

 A few years later, he said, his grandfather “almost met the same fate.”

“A group of antisemitic thugs put my grandfather up against the wall and were about to shoot him, but he managed to get away,” he said.

Schizer said that the work of the task force combatting antisemitism “has not been easy.”  

“There is a lot to do, and we aren’t yet where we need to be, but we are making real progress,” he said.

“Being a Zionist should not disqualify someone from a dance group or a theater production,” he said, adding, “this sort of pressure, signifying that Jews are only acceptable if they reject a core part of their religion and identity, well, it sounds like old fashioned bigotry to me.”

The task force issued a report to the university recommending four rules governing protests, which Schizer says the university is implementing, and that the task force plans to issue another report in May following additional listening sessions with students “to describe student encounters with antisemitism, discuss definitions of antisemitism, and recommend changes in orientation, student services and student groups.”

Schizer said the task force will issue more reports in the next academic year. 

Columbia President Shafik condemns professor who praised October 7 attack

Columbia University President Minouche Shafik condemned a professor who praised the October 7 attack by Hamas on Israel.

“I do condemn his statement. I am appalled by what he said,” Shafik said in response to a question from Rep. Tim Walberg. “He has been spoken to.”

The day after the Hamas attack, Columbia professor Joseph Massad described the brutal terror attack as a “stunning victory” in an  online article .

Shafik said Massad is no longer chairing an academic review committee at Columbia. 

Shafik says professor who called Hamas attack "awesome" was removed as committee chair but later walks back answer

From CNN's Elisabeth Buchwald

Republican Rep. Elise Stefanik called Columbia University's response to tenured professor Joseph Massad, who a day after the October 7 attack penned a piece online that labeled it "awesome," is unacceptable.

Columbia's president, Minouche Shafik, said Massad had been "spoken to" by members of his department of Middle Eastern, South Asian and African Studies. Shafik said she did not participate in those discussions.

She declined to say if any further disciplinary actions were taken but said he has "not repeated anything like that ever since." She confirmed Massad is still on the Columbia faculty but was unsure if he's currently teaching.

Massad is still listed as chair of the Academic Review Committee on a Columbia site. In a prior line of questioning Shafik said that "he is no longer chair of that committee and does not have a leadership role."

Stefanik later pointed out the site that still says Massad chairs the committee. Shafik replied that she would "like to confirm that" and she was "not sure" if he had been removed.

Columbia and Massad didn't immediately respond to CNN's request for comment. 

David Greenwald, the co-chair of the board of trustees at Columbia, told Stefanik Massad's comments were "abhorrent" and he should be removed from the position.

Columbia officials unequivocally say calls for genocide of Jews violate code of conduct

All four Columbia officials testifying before Congress unequivocally stated that calls for the genocide of Jews violate the university’s code of conduct.

Rep. Suzanne Bonamici asked Columbia President Minouche Shafik, board co-chairs David Greenwald and Claire Shipman and David Schizer, co-chair of a task force on antisemitism, for a simple yes or no response. All four said “yes,” calls for the genocide of Jews would violate Columbia’s code of conduct.

The response offered a stark contrast to the lawyerly answers that university presidents provided during the December hearing before the same committee. That moment went viral, sparking an uproar that eventually contributed to the ousters of the presidents of Harvard and the University of Pennsylvania.

Of course, the Columbia officials had the advantage of having months to prepare for that question.

Days after the December hearing, Columbia issued a statement saying: “Calls for genocide against the Jewish community or any other group are abhorrent, inconsistent with our values and against our rules.” 

"I am not satisfied with where Columbia is," board co-chair says

Claire Shipman, co-chair of Columbia University’s board of trustees, said it is “difficult and heartbreaking” to hear members of the university community feel unsafe.

“I feel this current climate on our campus viscerally. It’s unacceptable. I can tell you plainly that I am not satisfied with where Columbia is at this moment,” Shipman said. “As co-chair of the Board, I bear responsibility for that.”

The Columbia official noted that the university shut its gates for demonstrations and backed the decision to invite the New York City Police department onto campus for the first time since 1968.

“The last six months on our campus have served as an extreme pressure test. Our systems were not equipped to manage the unfolding situation,” Shipman said.

Shipman added that Columbia plans to continue to hold people accountable.

“We are far from done. I am outraged by the vile sentiments I continue to hear by those who ignore our rules,” she said. 

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A knife attack in Australia against a bishop and a priest is being treated as terrorism, police say

Australian police say suspect arrested after reported stabbing at church in Sydney

Australian police say a knife attack in Sydney that wounded a bishop and a priest during a church service as horrified worshippers watched online and in person and sparked a riot, was an act of terrorism.

Australian Prime Minister Anthony Albanese described a knife attack in Sydney against two clergymen on Tuesday as “disturbing”. Australian police say the attack in a western Sydney church is being treated as terrorism.

The premier of Australia’s New South Wales state has warned the community in Western Sydney not take the law into their own hands after police declared Monday’s stabbings at a Sydney church a “terrorist incident”.

Police in the Australian State of New South Wales have declared Monday’s stabbings at a Sydney church a “terrorist incident”.

Security officers stand guard outside Orthodox Assyrian church in Sydney, Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

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Police officers check vandalized vehicles, including theirs, outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

Policemen stand guard outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

Policeman stand guard outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. (AP Photo/Mark Baker)

Policeman stand guard outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Thursday, May 25, 2023. (AP Photo/Mark Baker)

A Police car is seen vandalised outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. (AP Photo/Mark Baker)

A policeman stands guard outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. (AP Photo/Mark Baker)

Security officers stand guard outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. (AP Photo/Mark Baker)

Riot police drives away after securing outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

The Sydney Opera House is illuminated with a black ribbon Monday, April 15, 2024, as part of the national day of mourning following the stabbing deaths of several people at a shopping mall on April 13. Australian police are examining why a lone assailant who stabbed several people to death in a busy Sydney shopping mall and injured more than a dozen others targeted women while avoiding men. (AP Photo/Mark Baker)

A police officer investigates in a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

Police officers check vandalized vehicles outside a church where a bishop and churchgoers were reportedly stabbed in Sydney Australia, Monday, April 15, 2024. Police in Australia say a man has been arrested after a bishop and churchgoers were stabbed in the church. There are no life-threatening injuries. (AP Photo/Mark Baker)

SYDNEY (AP) — Australian police say a knife attack in Sydney that wounded a bishop and a priest during a church service as horrified worshippers watched online and in person, and sparked a riot was an act of terrorism.

Police arrested a 16-year-old boy Tuesday after the stabbing at Christ the Good Shepherd Church that injured Bishop Mar Mari Emmanuel and a priest. Both are expected to survive.

Security officers stand guard outside Orthodox Assyrian church in Sydney, Australia, Monday, April 15, 2024. (AP Photo/Mark Baker)

New South Wales Police Commissioner Karen Webb said the suspect’s comments pointed to a religious motive for the attack.

“We’ll allege there’s a degree of premeditation on the basis that this person has travelled to that location, which is not near his residential address, he has travelled with a knife and subsequently the bishop and the priest have been stabbed,” Webb said. “They’re lucky to be alive.”

The teenager was known to police but was not on a terror watch list, Webb said.

The Australian Security Intelligence Organization, the nation’s main domestic spy agency, and Australian Federal Police had joined state police in a counter-terrorism task force to investgate who else was potentially involved.

ASIO director-general Mike Burgess said the investigation had yet to uncover any associated threats.

“It does appear to be religiously motivated, but we continue our lines of investigation,” Burgess said.

“Our job is to look at individuals connected with the attacker to assure ourselves that there is no-one else in the community with similar intent. At this stage, we have no indications of that,” Burgess added.

On ASIO’s advice, the risk of a terrorist attack in Australia is rated at “possible.” That is the second lowest level after “not expected” on the five-tier National Terrorism Threat Advisory System.

The boy had been convicted in January of a range of offenses including possession of a switch blade knife, being armed with a weapon with an intention to commit an indictable offence, stalking, intimidation and damaging property, Australian Broadcasting Corp. reported.

A Sydney court released him on a good behavior bond, the ABC reported.

The boy had also used a switch blade, which is an illegal weapon in Australia, in Monday’s attack, the ABC reported.

Juvenile offenders cannot be publicly identified in New South Wales state.

In response to the attack, Prime Minister Anthony Albanese said “there is no place for violence in our community. There’s no place for violent extremism.”

The Christ the Good Shepherd in suburban Wakeley streams sermons online and worshippers watched as a person in black clothes approached the altar and stabbed the bishop and priest Isaac Royel during a church service Monday evening before the congregation overpowered him, police said.

A crowd of hundreds seeking revenge gathered outside the Orthodox Assyrian church, hurling bricks and bottles, injuring police officers and preventing police from taking the teen outside, officials said.

The teen suspect and at least two police officers were also hospitalized, Acting Assistant Police Commissioner Andrew Holland told journalists.

Paramedics treated 30 patients, with seven taken to hospitals, NSW Ambulance commissioner Dominic Morgan said.

“This was a rapidly evolving situation where the crowds went from 50 to a number of hundreds of people in a very rapid period of time,” Morgan said.

“Our paramedics became directly under threat ... and had to retreat into the

church,” Morgan added.

The church in a message on social media said the bishop and priest were in stable condition and asked for people’s prayers. “It is the bishop’s and father’s wishes that you also pray for the perpetrator,” the statement said.

Holland commended the congregation for subduing the teen before calling police. When asked if the teen’s fingers had been severed, he said the hand injuries were “severe.”

More than 100 police reinforcements arrived before the teen was taken from the church in the hours-long incident. Several police vehicles were damaged, Holland said.

“A number of houses have been damaged. They’ve broken into a number of houses to gain weapons to throw at the police. They’ve thrown weapons and items at the church itself. There were obviously people who wanted to get access to the young person who caused the injuries to the clergy people,” he said.

Australians were still in shock after a lone assailant stabbed six people to death in a Sydney shopping mall on Saturday and injured more than a dozen others.

Holland suggested the weekend attack heightened the community’s response to the church stabbing.

“Given that there has been incidents in Sydney the last few days with knives involved, obviously there’s concerns,” he said. “We’ve asked for everyone to think rationally at this stage. “

The church said in a statement on Tuesday the 53-year-old Iraq-born bishop’s condition was “improving.”

Emmanuel has a strong social media following and is outspoken on a range of issues. He proselytizes to both Jews and Muslims and is critical of liberal Christian denominations.

He also speaks out on global political issues and laments the plight of Palestinians in Gaza.

The bishop, described in local media as a figure sometimes seen as divisive on issues such as COVID-19 restrictions, was in national news last year with comments about gender.

A video posted in May 2023 by the ABC about a campaign targeting the LGBTQ+ community showed the bishop in a sermon saying that “when a man calls himself a woman, he is neither a man nor a woman, you are not a human, then you are an it. Now, since you are an it, I will not address you as a human anymore because it is not my choosing, it your choosing.”

McGuirk reported from Melbourne, Australia.

Having remade Twitter, Elon Musk takes his speech fight global

The x owner has become a bridge between american conservatives and the global far right.

SAN FRANCISCO — To Elon Musk, the Brazilian Supreme Court justice is a “dictator.”

In the justice’s view, Musk is allowing his social media platform to support the “digital militias” that are using disinformation to threaten democracy.

Together, they’re making this South American nation the battleground for the global debate on free speech and fake news, a dispute that could affect how people everywhere communicate information, ideas and opinions online.

On one side, there’s Alexandre de Moraes, one of the world’s most aggressive prosecutors of disinformation. In recent years, as right-wing Brazilian leader Jair Bolsonaro and his supporters questioned the integrity of Brazil’s elections, Moraes was granted expanded powers to fight false claims online. As head of the country’s top elections court, he has issued arrest warrants against dozens of figures and demanded that social media companies take down scores of accounts.

Then there’s Musk, the combative tech billionaire who, since taking over Twitter, has loosened the platform’s restrictions on hateful content and allowed misinformation to flood the platform in the name of free speech.

Their opposing worldviews exploded into public view this month, when Musk announced he would no longer countenance judicial orders from Moraes, who he said was breaking Brazilian law, and threatened to shutter the platform, now called X, in one of its most active markets.

Moraes, in response, said he was adding Musk as a target in his ongoing criminal investigation into political groups accused of using false information to attack democracy.

Musk did not respond to a request for comment. Moraes declined to comment.

The dispute could influence how social media platforms police their users in countries that regulate free speech differently than the United States. And it’s cementing Musk’s rise as an avatar of the global right, where he’s found common ground with some of its most prominent and polarizing figures.

Since declaring his independence from Moraes’s orders, Musk has met with Argentine President Javier Milei at a Tesla factory in Texas, been invited to a live online appearance with Bolsonaro and said he will meet soon with Indian Prime Minister Narendra Modi. All are populists bolstered by online armies that have been accused of spreading disinformation.

Musk has spent the past week interacting online with conservative Brazilians whose accounts have been banned by Moraes — a group that has long sought his attention. In the United States, meanwhile, congressional Republicans, who have long sparred with tech giants over online censorship, have subpoenaed X’s records related to its operations in Brazil.

Musk’s politics form “a connective tissue between these far-right figures and movements,” said Emerson Brooking, a disinformation researcher with the Digital Forensic Research Lab of the Atlantic Council. “He is globalizing America’s culture wars.”

Over the weekend, X walked back Musk’s challenge, telling the court in a letter it would continue to comply with all of its orders, according to a copy obtained by The Washington Post.

Musk has not commented publicly on the reversal. X declined to comment.

Musk remains a target of Moraes’s investigation, according to a Supreme Court official, who spoke on the condition of anonymity under rules set by the court. That probe goes beyond X’s content moderation policies into whether Musk is part of an organized threat to the country’s democracy.

Differing definitions of free speech

In Brazil, Latin America’s largest democracy, internet users spend an average of more than nine hours a day online, according to the market research firm Kepios. They enjoy freedom of expression, but it’s not an absolute right.

In the United States, the First Amendment guarantees Americans wide latitude to speak publicly. In Brazil, hate speech and using disinformation to attack people or democracy are crimes.

Bolsonaro and his supporters have strained those limits with misinformation about the coronavirus , unfounded allegations against the electoral system and digital invective. Many who have posted such material have come under investigation by Moraes.

The judge ordered one blogger arrested for allegedly spreading anti-democratic ideas and committing crimes against honor. He ordered the arrest and censure of a federal congressman for calling for a new AI-5, a notorious decree from Brazil’s 20th-century dictatorship that curtailed political freedoms and consolidated the military’s hold on power.

People who have had their social media accounts blocked have also had assets frozen — sometimes, they say, with no explanation of what they did wrong. As a consequence, some have relocated to the United States.

These efforts have drawn criticism not only from the right, but also from tech companies and advocates for free speech. Musk says Moraes has gone too far.

Rolling back the rules

Twitter once enjoyed a reputation for fighting harder than others against demands by foreign governments to censor domestic activists and dissidents. It sued India and Turkey to protect content that was critical of their leaders.

In the United States, the company policed content on coronavirus misinformation and election falsehoods.

But when Musk bought the company in the fall of 2022, he argued that any content should be permitted unless it was expressly illegal. In his first months as chief executive, he rolled back rules against misinformation and restored thousands of banned accounts.

He also began taking steps, including charging for verification and engaging certain users, that have had the effect of boosting the visibility of conservative and right-wing accounts.

The platform’s record since then has been mixed . On the eve of Turkish elections last year, X complied with the demand of President Recep Tayyip Erdogan to restrict accounts. The company reportedly blocked the accounts of more than 100 activists and journalists at the Indian government’s request.

“Musk’s X is willing to comply and censor people much more than Twitter ever did,” Brooking said. In Brazil, “Musk has found a cause that lets him articulate his twisted vision of free speech: Not free speech for democratic activists, or for regular people, but for people who share his politics.”

‘Why are you doing this …?’

Moraes wasn’t always a villain to the Brazilian right. He was appointed to the Supreme Court in 2017 by conservative President Michel Temer.

But in a country haunted by the military dictatorship of 1964 to 1985, the rise of Bolsonaro, an open admirer of the regime, changed everything.

As president during the coronavirus pandemic, he dismissed concerns about the coronavirus, railed against vaccinations and pushed unproven treatments.

For more than a year leading up to the 2022 election, a polarizing choice between Bolsonaro and leftist former president Luiz Inácio Lula da Silva, Bolsonaristas pushed doubts about electronic voting systems in a strategy that mirrored Donald Trump’s unfounded accusations in 2020.

Before the vote, Moraes sought an expanded interpretation of the election court’s authority to investigate, censor and prosecute people suspected of undermining public institutions. The Supreme Court granted him the power to order the immediate removal of problematic content — and fine or suspend companies that did not comply.

The effort has drawn criticism.

The court effectively “changed its stance” from having once protected speech to now controlling speech, said constitutional lawyer André Mardiglia, who has represented a magazine that was censored by Moraes. “We understand ourselves to be a democracy, but we do not have the freedom of expression that full democracies have.”

After Bolsonaro’s loss, thousands of his supporters stormed federal buildings in Brasília in January 2023 in what some said was an effort to overturn the election. Moraes called for stronger regulations on social media companies. Two right-leaning platforms, Rumble and its subsidiary Locals, have since pulled out of Brazil.

In another parallel with Trump, Bolsonaro skipped Lula’s inauguration and traveled to Florida, where he discussed online speech with Trump strategist Stephen K. Bannon and others, deepening ties with the American far right.

When Musk took control of Twitter, Brazilian conservative influencers who had been targeted by Moraes saw an opportunity. They tweeted at Musk for help.

Musk asked staff to look into their claims, according to a person familiar with the discussion, who spoke on the condition of anonymity to describe it. They concluded that reinstating accounts that had been banned by court order would violate Brazilian law.

Then last week, the company’s government affairs team posted that it had been “forced by court decisions to block certain popular accounts” in Brazil, but could not say which ones and was not told why.

Musk followed with a question for Moraes: “Why are you doing this @alexandre?” Then in a cascade of tweets to his 180 million followers, he called the judge a “brutal dictator,” a “shame” and “Brazil’s Darth Vader.” He said he would be reinstating the accounts.

Moraes, in response, accused Musk of starting a disinformation campaign and coordinating with the digital militias that promoted the Jan. 8, 2023, riot.

Paulo Figueiredo, a Brazilian journalist and influencer based in Florida, said Moraes had censored his social media accounts, frozen his bank accounts and taken away his passport so he could not return to Brazil. He says he does not know why.

Until the Brasília riot, he was a popular commentator on Jovem Pan. The São Paulo-based radio network kicked him and other conservative commentators off the air after Jan. 8.

He now broadcasts from his home studio on seven different social channels and has tagged Musk on X several times in the past year.

In a recent post, Figueiredo urged the X owner to ignore Brazil’s restrictions. Last week, Musk finally responded: He agreed.

Figueiredo called Musk’s new interest in Brazil “a complete game changer.”

Thiago de Aragão, a senior associate with the Center for Strategic and International Studies who advises companies on risk in Latin America, warned that Musk’s fight has potential downsides for X and other tech companies.

“What’s going on in Brazil could inspire other countries to … ultimately become more restrictive,” he said.

The country, said Brooking of the Atlantic Council, could become an important cause for right-wing groups worldwide, including in the United States in an election year in which tech companies have largely retreated from policing misinformation.

“If you’ve built your career around Big Tech censorship … you have to find a new enemy somewhere.”

Cat Zakrzewski in Washington contributed to this report.