speech and language disorder meaning

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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What Are Language Disorders?

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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Children come to the world almost pre-programmed to learn the language of their environment. But while it appears automatic for a child to learn to read, speak, and understand communication around them—the pace at which these skills are learned vary among children. In some cases, children may not meet certain developmental milestones .

A language disorder occurs when a child is unable to compose their thoughts , ideas, and messages using language. This is known as an expressive language disorder. When a child faces difficulty in understanding what is communicated via language, this is called a receptive language disorder.

Sometimes, a child may live with a mix of expressive and receptive language disorders. A lack of understanding or poor expression of language does not always indicate a language disorder, however. This could simply be the result of a speech delay.

Read on to learn about the types, characteristics, causes, and trusted treatment methods to manage language disorders in children .

Types of Language Disorders in Children 

With language , there are specific achievements expected when children mark a certain age. At 15 months, it is likely that a child can recognize between five to ten people when they are named by parents or caregivers. At 18 months, it is expected that a child can respond to simple directives like ‘let’s go outside’ without challenges. This is an already receptive child.

If at 18 months, a child is unable to pronounce ‘mama’ and ‘dada’, or if at 24 months, this child does not have at least 25 words in their vocabulary—this could signal an expressive language disorder.

Receptive Language Disorder

When a child struggles to understand the messages communicated to, or around them, this can be explained as a receptive disorder. Children with receptive challenges will usually display these difficulties before the age of four.  

Receptive difficulties may be observed where a child does not properly understand oral communication directed at, or around them.

In such cases, the child struggles to understand the spoken conversations or instructions directed around them. Likewise, written words may be difficult to process. Simple gestures to come, go, or sit still may also prove challenging to comprehend.

Expressive Language Disorders

Expressive language disorders occur when a child is unable to use language to communicate their thoughts or feelings.

In this sense, oral communication is just one of the affected areas. A child may also consider written communications difficult to express.

Children with expressive disorders will find it difficult to name objects, tell stories, or make gestures to communicate a point. This disorder can cause challenges with asking or answering questions, and may lead to improper grammar usage when communicating.

Symptoms of Language Disorders

Language disorders are a common observation in children. Up to 1 out of 20 children exhibit at least one symptom of a language disorder as they grow. The symptoms of receptive disorders include:

• Difficulty understanding words that are spoken
• Challenges with following spoken directions
• Experiencing strain with organizing thoughts

Expressive language disorders are identified through the following traits in children:

• Struggling to piece words into a sentence
• Adopting simple and short words when speaking 
• Arranging spoken words in a skewed manner
• Difficulty finding correct words when speaking
• Resorting to placeholders like ‘er’ when speaking
• Skipping over important words when communicating
• Using tenses improperly 
• Repeating phrases or questions when answering

Causes of Language Disorders

With a language disorder, the child does not develop the normal skills necessary for speech and language. The factors responsible for language disorders are unknown, this explains why they are often termed developmental disorders .  

Disabilities or Brain Injury

Despite the uncertainty around the causes of these disorders, certain factors have strong links to these conditions. In particular, other developmental disorders like autism and hearing loss commonly co-occur with language disorders. Likewise, a child with learning disabilities may also live with language disorders.

Aphasia is another condition linked with language disorders. This condition develops from damage to the portion of the brain responsible for language. Aphasia may be caused by a stroke, blows to the head, and brain infections.  The injury may increase the chances of developing a language disorder.  

Diagnosis of Language Disorders

To determine if a child has a language disorder, the first step is to receive an expert’s assessment of their condition.

A speech-language pathologist or a neuropsychologist may administer standardized tests. These are to review the child’s levels of language reception and expression.

The Link Between Deafness and Language Problems

In making their assessment, the health expert will conduct a hearing test to discover if the child suffers from hearing loss. This is because deafness is one of the most common causes of language problems.  

Treatment of Language Disorders

Language disorders can have far-reaching effects on the life of a child. These disorders can lead to poor social interactions, or a dependence on others as an adult. Challenges with reception and expression can also lead to reading challenges, or problems with learning .

To manage this condition, parents/guardians should exercise patience and care when dealing with children managing language disorders. While it can be challenging, children already experience frustration when dealing with others and expressing themselves. Caregivers can provide a place of comfort for children who have learning challenges.

For expert guidance, a speech-language pathologist can work with children and their guardians to improve communication and expression.

Because language disorders can be emotionally taxing, parents and children with these disorders can try therapy . This will help in navigating the emotional and behavioral issues caused by language impairments.

NCBI. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program .

MedlinePlus. Language Disorders in Children .

Ritvo A, Volkmar F, Lionello-Denolf K et al. Receptive Language Disorders . Encyclopedia of Autism Spectrum Disorders . 2013:2521-2526. doi:10.1007/978-1-4419-1698-3_1695

Reindal L, Nærland T, Weidle B, Lydersen S, Andreassen O, Sund A. Structural and Pragmatic Language Impairments in Children Evaluated for Autism Spectrum Disorder (ASD) .  J Autism Dev Disord . 2021. doi:10.1007/s10803-020-04853-1

National Institute on Deafness and Other Communication Disorders. Aphasia .

Centers for Disease Control and Prevention. Language and Speech Disorders in Children .

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

Language Disorder

Reviewed by Psychology Today Staff

Language disorder is a communication disorder in which a person has persistent difficulties in learning and using various forms of language such as spoken, written, or signed. They may struggle to understand the words they hear or see. While they do not have trouble physically making sounds, they may not be able to use language effectively to communicate.

Individuals with language disorder have language abilities significantly below those expected for their age, limiting their ability to effectively communicate or participate in many social, academic, or professional activities. However, they are not necessarily less intelligent than other children.

Language learning and use relies on both expressive and receptive abilities. Expressive ability refers to the production of verbal or gestural signals, while receptive ability refers to the process of receiving and understanding language. Individuals with language disorder may have impairments in either ability, or both, and the symptoms first appear early in childhood development.

People with language disorder have difficulty both learning and using written, spoken, or sign language. They also typically have a limited vocabulary, have trouble constructing sentences and using tenses, and may put words in the wrong order. Because they typically have a limited understanding of vocabulary and grammar, they may also have a limited capacity for engaging in conversation.

Children with language disorder are usually delayed in learning or speaking their first words and phrases. When they do speak, their sentences are shorter and less complex than would be expected for their age. Individuals with language disorder typically speak with grammatical errors, have a small vocabulary, and may have trouble finding the right word at times. In conversation, they may not be able to provide adequate information about the events they’re discussing or tell a coherent story. Because children with language disorder may have difficulty understanding what other people say, they may have an unusually hard time following directions.

Not necessarily. Language skills are highly variable in young children, and many children who are late in speaking their first words or phrases do not develop language disorder. Delayed language acquisition is not predictive of language disorder until age 4, when individual differences in language ability become more stable. Language disorder that is diagnosed at age 4 or later is likely to be stable over time and to persist into adulthood.

No. Language disorder is typically present from early childhood, but because the communication demands and expectations for young children are low, the symptoms may not become obvious until later. Also, deficits in comprehension are often underestimated, because people with language disorder may be good at finding strategies to cope with their difficulties, such as using context to infer meaning.

Children with language disorder may appear shy or reserved and so they may struggle to make friends, which can eventually lead to feelings of social anxiety or depression . Because of their communication deficits, they may prefer to speak only with family members or other familiar people. Such shyness is itself not indicative of language disorder, but when hesitancy to communicate is consistent, it is recommended that parents bring their child to a speech-language pathologist for a full language assessment.

As many as 1 in 20 children have a language disorder. In many cases, the cause is unknown. A brain injury, birth defects, or problems in pregnancy may lead to language disorder, but, as with other communication disorders, the condition has a strong genetic component: Individuals with language disorder are more likely to have family members with a history of language impairment.

Yes. Language disorder is strongly associated with other neurodevelopmental disorders, such as specific learning disorder (literacy and numeracy), attention -deficit/hyperactivity disorder, autism spectrum disorder, and developmental coordination disorder.

The treatment for language disorder is often effective (although less so when the condition is caused by brain injury or similar trauma ). Treatment primarily consists of speech and language therapy in order to improve expressive and receptive language skills and with effective treatment, significant improvement can be achieved, although some symptoms may remain in adulthood. Receptive language deficits (difficulty understanding language) is generally more difficult to treat than expressive impairments (difficulty producing speech).

Psychotherapy can be a helpful tool to manage the emotional and behavioral issues that may arise in children with language disorder. For those whose language disorder symptoms lead to social anxiety or depression, cognitive-behavioral therapy can often be helpful.

Treatment for language disorder should begin as early as possible, as research suggests that children whose deficits are addressed early have better prognoses. A speech-language pathologist will typically ask parents to work with their child daily to help promote their comprehension and speech, such as reading aloud to them every day, listening closely and responding when their child talks, encouraging them to ask questions, and pointing out words all around them.

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Language Disorders in Children

What are language disorders in children?

Most infants or toddlers can understand what you’re saying well before they can clearly talk. As they get older and their communication skills develop, most children learn how to put their feelings into words.

But some children have language disorders. They may have:

Receptive language disorder. A child has trouble understanding words that he or she hears and reads.

Expressive language disorder. A child has trouble speaking with others and expressing thoughts and feelings.

A child will often have both disorders at the same time. Such disorders are often diagnosed in children between the ages of 3 and 5.

What causes language disorders in a child?

Language disorders can have many possible causes. A child’s language disorder is often linked to a health problem or disability such as:

A brain disorder such as autism

A brain injury or a brain tumor

Birth defects such as Down syndrome, fragile X syndrome, or cerebral palsy

Problems in pregnancy or birth, such as poor nutrition, fetal alcohol syndrome, early (premature) birth, or low birth weight

Sometimes language disorders have a family history. In many cases, the cause is not known.

It’s important to know that learning more than one language does not cause language disorders in children. But a child with language disorder will have the same problems in all languages.

Which children are at risk for language disorders?

The cause often is not known, but children at risk for a language disorder include those with:

A family history of language disorders

Premature birth

Low birth weight

Hearing loss

Thinking disabilities

Genetic disorders such as Down syndrome

Fetal alcohol spectrum disorder

Brain injury

Cerebral palsy

Poor nutrition

Failure to thrive

What are the symptoms of language disorders in a child?

Children with receptive language disorder have trouble understanding language. They have trouble grasping the meaning of words they hear and see. This includes people talking to them and words they read in books or on signs. It can cause problems with learning. It needs to be treated as early as possible.

A child with receptive language disorder may have trouble:

Understanding what people say

Understanding gestures

Understanding concepts and ideas

Understanding what he or she reads

Learning new words

Answering questions

Following directions

Identifying objects

A child with expressive language disorder has trouble using language. The child may be able to understand what other people say. But he or she has trouble when trying to talk, and often can’t express what he or she is feeling and thinking. The disorder can affect both written and spoken language. And children who use sign language can still have trouble expressing themselves.

A child with expressive language disorder may have trouble:

Using words correctly

Expressing thoughts and ideas

Telling stories

Using gestures

Asking questions

Singing songs or reciting poems

Naming objects

How are language disorders diagnosed in a child?

Your child’s healthcare provider will ask about your child’s language use. He or she will also look at your child’s health history. Your child may have a physical exam and hearing tests. Your child’s healthcare provider will likely refer your child to a speech-language pathologist (SLP). This specialist can help diagnose and treat your child.

An SLP will evaluate your child during play. This may be done in a group setting with other children. Or it may be done one-on-one with your child. The SLP will look at how your child:

Follows directions

Understands the names of things

Repeats phrases or rhymes

Does in other language activities

How are language disorders treated in a child?

To treat your child, the speech-language pathologist (SLP) will help him or her to learn to relax and enjoy communicating through play. The SLP will use different age-appropriate methods to help your child with language and communication. The SLP will talk with your child and may:

Use toys, books, objects, or pictures to help with language development

Have your child do activities, such as craft projects

Have your child practice asking and answering questions

The SLP will explain more about the methods that are best for your child’s condition.

How can I help my child live with a language disorder?

A language disorder can be frustrating for parents and teachers, and also for the child. Without diagnosis and treatment, children with such a disorder may not do well in school. They may also misbehave because of their frustration over not being able to communicate. But language disorders are a common problem in children. And they can be treated.

If you think your child might have a language disorder, talk with your child’s healthcare provider right away. Research has shown that children who start therapy early have the best outcome. Make sure that the SLP you choose is certified by the American Speech-Language-Hearing Association.

The SLP will guide your child’s treatment. But it’s important to know that parents play a critical role. You will likely need to work with your child to help him or her with language use and understanding. The SLP will also talk with caregivers and teachers to help them work with your child.

Ask the SLP what you should be doing at home to help the process. The SLP may advise simple activities such as:

Reading and talking to your child to help him or her learn words

Listening and responding when your child talks

Encouraging your child to ask and answer questions

Pointing out words on signs

When should I call my child’s healthcare provider?

Call your child’s healthcare provider if your child has:

Symptoms that don’t get better, or get worse

New symptoms

Key points about language disorders in children

Children who have a language disorder have trouble understanding language and communicating.

There are 2 kinds of language disorders: receptive and expressive. Children often have both at the same time.

A child with a receptive language disorder has trouble understanding words that they hear and read.

A child with an expressive language disorder has trouble speaking with others and expressing thoughts and feelings.

Language disorders can have many possible causes, such as a brain injury or birth defect.

A speech-language pathologist can help diagnose and treat a language disorder.

Parents can help their child with language use and understanding through simple activities.

Tips to help you get the most from a visit to your child’s healthcare provider:

Know the reason for the visit and what you want to happen.

Before your visit, write down questions you want answered.

At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also write down any new instructions your provider gives you for your child.

Know why a new medicine or treatment is prescribed and how it will help your child. Also know what the side effects are.

Ask if your child’s condition can be treated in other ways.

Know why a test or procedure is recommended and what the results could mean.

Know what to expect if your child does not take the medicine or have the test or procedure.

If your child has a follow-up appointment, write down the date, time, and purpose for that visit.

Know how you can contact your child’s provider after office hours. This is important if your child becomes ill and you have questions or need advice.

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Communication / speech / language disorders.

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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, intellectual disabilities, drug abuse, physical impairments such as cleft lip or palate and vocal abuse or misuse.

More than one million of the students served in the public schools' special education programs in the 1998-99 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 intellectual disabilities, autism or cerebral palsy. It is estimated that communication disorders affect one of every 10 people in the United States.

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. Speech disorders refer to difficulties producing speech sounds or problems with voice quality. 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.

Examples, Subsets and Synonyms for Communication Disorders:

• Expressive Language Disorders
• Receptive-Expressive Language Disorders
• Phonologic Disorders (speech disorders)

Hearing Loss Overview:

It is especially important to diagnose and treat a hearing loss in children as early as possible. Early management of hearing loss limits the potential impact of the hearing loss on learning and development. Hearing loss can be categorized by which part of the auditory system is affected. The three main components of the ear are the external ear, middle ear and inner ear. There are three basic types of hearing loss: conductive hearing loss, sensorineural hearing loss, and mixed hearing loss. A conductive hearing loss is caused by problems in the external or middle ear. Hearing loss can be caused by impacted cerumen, middle ear fluid, or damage to the three bones in the middle ear. Oftentimes, conductive hearing loss can be treated medically. When not medically treatable, hearing aids are a good option. Sensorineural hearing loss is caused by damage to the inner ear or nerve of hearing. It is treatable with hearing aids or medically with a cochlear implant. Mixed hearing loss is a combination of conductive and sensorineural hearing loss. All three types of hearing loss can be present at birth or acquired over time.

Children with hearing loss will find it much more difficult than children who have normal hearing to learn vocabulary, grammar, word order, idiomatic expressions, and other aspects of verbal communication. It is well recognized that hearing is critical to speech and language development, communication, and learning. Children with listening difficulties due to hearing loss or auditory processing problems continue to be an under identified and underserved population. Auditory processing disorders may be present despite the presence of normal peripheral auditory sensitivity. Children with auditory processing disorders may have difficulty understanding speech in noisy environments, following directions, and discriminating (or telling the difference between) similar-sounding speech sounds. Sometimes they may behave as if a peripheral hearing loss is present, often asking for repetition or clarification. The earlier hearing loss occurs in a child's life, the more serious the effects on the child's development. Similarly, the earlier the problem is identified and intervention begun, the less serious the ultimate impact.

There are four major ways in which hearing loss affects children: a) the hearing loss can result in delays in the development of receptive and expressive communication; b) The language deficit causes learning problems that result in reduced academic achievement, c) Communication difficulties often lead to social isolation and poor self-concept, and, d) It may have an impact on vocational choices.

Additional Resources:

• Audiology at Kennedy Krieger
• American Speech-Language-Hearing Association
• The American Academy of Audiology
• Handspeak.com

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Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Speech Disorders and Language Disorders; Board on the Health of Select Populations; Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine; Rosenbaum S, Simon P, editors. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program. Washington (DC): National Academies Press (US); 2016 Apr 6.

Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program.

• Hardcopy Version at National Academies Press

1 Introduction

Speech and language are central to the human experience; they are the vital means by which people convey and receive knowledge, thoughts, feelings, and other internal experiences. Acquisition of communication skills begins early in childhood and is foundational to the ability to gain access to culturally transmitted knowledge, to organize and share thoughts and feelings, and to participate in social interactions and relationships. Speech and language skills allow a child to engage in exchanges that lead to the acquisition of knowledge in his or her community and the educational arena. Communication skills are crucial to the development of thinking ability, a sense of self, and full participation in society.

Speech and language disorders—disruptions in communication development—can have wide-ranging and adverse impacts on the ability not only to communicate but also to acquire new knowledge and participate fully in society. Most children acquire speech and language by a seemingly automatic process that begins at birth and continues through adolescence. Typically, basic communication skills are developed (although not complete) by the time a child enters kindergarten, enabling the child to begin learning from teachers and interacting fluently with peers and caregivers ( Oller et al., 2006 ). Severe disruptions in speech or language acquisition thus have both direct and indirect consequences for child and adolescent development, not only in communication but also in associated abilities such as reading and academic achievement that depend on speech and language skills. When combined with other developmental risks, such as poverty ( Williams, 2013 ), severe speech and language disabilities can become high-impact, adverse conditions with long-term cognitive, social, and academic sequelae and high social and economic costs.

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Like other entitlement programs, the Supplemental Security Income (SSI) program has generated considerable and recurring interest in its growth, effectiveness, accuracy, and sustainability. Questions have arisen in both the media and policy-making settings regarding the appropriateness of SSI benefits for children with speech and language disorders.

As an example, the Boston Globe published a series of articles in December 2010 describing the experiences and challenges of families who either were currently receiving or had sought to become eligible to receive SSI benefits for their children. These articles focused on the growing number of children enrolled in SSI on the basis of speech and language disorders. In response to issues raised in these articles, members of Congress directed the U.S. Government Accountability Office (GAO) to conduct an assessment of the SSI program for children. This assessment was designed to examine decade-long trends in the rate of children receiving SSI benefits based on mental impairments; 1 the role played by medical and nonmedical information, such as medication use and school records, in the initial eligibility determination; and steps taken by the Social Security Administration (SSA) to monitor children's continued eligibility based on disability.

The GAO assessment was conducted between February 2011 and June 2012. Midway through the assessment, on October 27, 2011, the Subcommittee on Human Resources of the House Ways and Means Committee convened a hearing on SSI for children, including an interim report by the GAO on its findings regarding the SSI program for children. In that report, the GAO found that between 2000 and 2011, the annual number of children applying for SSI benefits had increased from 187,052 to 315,832. Of these applications, 54 percent had been denied.

The GAO also found that mental impairments constituted approximately 65 percent of all child SSI allowances. The three most prevalent primary mental impairments 2 for children found eligible were attention deficit hyperactivity disorder (ADHD), speech and language impairments, 3 and autism/developmental delays. 4 From December 2000 to December 2011, the total number of children receiving SSI benefits for mental impairments had increased annually, from approximately 543,000 in 2000 to approximately 861,000 in 2011, an almost 60 percent increase. Secondary impairments were present for many of those found medically eligible. In addition, the GAO estimated that in 2010, 55 percent of children with speech and language impairments who received SSI benefits had an accompanying secondary impairment recorded; 94 percent of those recorded secondary impairments were other mental disorders.

In its final report, the GAO suggested that several factors may have contributed to the observed changes in the size of the SSI program for children, including

• long-term receipt of assistance, with fewer children leaving the disability program prior to age 18;
• increased numbers of children living in poverty in the United States;
• increased awareness and improved diagnosis of certain mental impairments;
• a focus on identifying children with disabilities through public school special education services; and
• increased health insurance coverage of previously uninsured children.

The GAO found an increase between 2000 and 2010 in both applications and allowances (applicants determined to meet the disability criteria) for children with speech and language impairments ( GAO, 2012 ). During this period, the number of applications for speech and language impairments increased from 21,615 to 49,664, while the number of children found to meet the disability criteria increased from 11,565 to 29,147 ( GAO, 2012 ). The cumulative number of allowances for children with speech and language impairments has continued to increase. In December 2014, 213,688 children were receiving benefits as the result of a primary speech or language impairment (16 percent of all children receiving SSI benefits) ( SSA, 2015 ). The factors that contributed to these changes are a primary focus of this report and are discussed at length in Chapters 4 , 5 , and 6 .

Based on the GAO findings, the SSA determined that additional study was needed to understand the increases in the total number of children receiving SSI benefits as a result of speech and language disorders. This study was requested to meet that need.

• STUDY CHARGE AND SCOPE

In 2014, the SSA's Office of Disability Policy requested that the Institute of Medicine (IOM) of the National Academies of Sciences, Engineering, and Medicine convene a consensus committee to (1) identify past and current trends in the prevalence and persistence of speech and language disorders among the general U.S. population under age 18 and compare those trends with trends among the SSI childhood disability population; and (2) provide an overview of the current status of the diagnosis and treatment of speech and language disorders and the levels of impairment due to these disorders in the U.S. population under age 18. (See Box 1-1 for the committee's full statement of task.)

Statement of Task.

This report addresses the charge defined in the committee's statement of task. It should be noted that this report is not intended to provide a comprehensive discussion of speech and language disorders in children, but to provide the SSA with information directly related to the administration of the SSI program for children with these disorders. In addition, this committee was not charged with providing an evaluation of the SSI program or addressing any other questions related to policy or rulemaking.

Finally, it is important to note that this study was conducted at the same time that the Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Mental Disorders study was under way. Although the two studies have related statements of task and were both sponsored by the SSA, the work was conducted by two distinct committees, which held separate meetings and underwent independent report review processes. The report Mental Disorders and Disabilities Among Low-Income Children was released in September 2015 ( NASEM, 2015 ). A brief summary of that report's key findings and conclusions is included in Appendix G .

The following subsections describe how the committee used its statement of task to guide its review and analysis and to determine the inclusion or exclusion of related or noteworthy topics.

Speech and Language Disorders and Corresponding Treatments

Numerous childhood speech and language disorders and other conditions associated with these disorders are worthy of rigorous examination. Similarly, many approaches are used to treat childhood speech and language disorders. As noted above, however, this report does not provide an exhaustive review of all such disorders or of their corresponding treatments. Rather, in accordance with the committee's statement of task, this report describes primary categories of childhood speech and language disorders that occur most commonly in the population of children served by the SSI program and provides an overview of treatments for these disorders. Therefore, the exclusion of any conditions or treatments should not be viewed as an oversight, but as a necessary narrowing of the focus of this study to the issues of greatest relevance to the SSI program.

Data and Data Sources

The committee consulted a variety of data sources to identify trends in the prevalence and persistence of speech and language disorders (prevalence and trends in prevalence are discussed below). These sources included data from clinical samples (i.e., Pennington and Bishop, 2009 ), population-based studies (i.e., Law et al., 2000 ; Tomblin et al., 1997 ), nationally representative surveys (e.g., the National Survey of Children's Health), and administrative or service-based data from federal programs (Medicaid Analytic eXtract [MAX] data, Individuals with Disabilities Education Act [IDEA] child count data, and the SSA's program data). These sources differ substantially with respect to how they define and/or designate speech and language disorders in children, how they collect information (e.g., parental reporting, medical records, test results), which variables are examined (e.g., level of severity or duration of disorders, child and/or family demographic information), and the period(s) of time examined, among other factors. As a result, readers of this report will encounter numbers and estimates that appear quite different from chapter to chapter. Recognizing the challenge this variation presents to readers, the committee carefully describes the different types of data and how estimates were derived throughout the report. (A full discussion of data limitations is included in Chapter 5 .)

In addition to the challenges that the committee encountered in using available data, the absence of other relevant data limited the committee's ability to generate more precise population estimates, to compare changes over time, and to conduct further analyses. This absence of data included data sources and data collection efforts that do not currently exist, as well as data that were unavailable to the committee (or to the general public).

For example, the committee's efforts to determine prevalence estimates of children with speech and language disorders could have been improved by access to a national data source derived from health services or health insurance records. Similarly, the committee's efforts to describe trends in childhood speech and language disorders could have been improved through an analysis of longitudinal data from programs (i.e., Medicaid and SSI) or national surveys. At this time, no such national-level data sources or longitudinal data collection efforts exist for these conditions.

Furthermore, the committee's efforts to document the persistence of speech and language disorders among children who receive SSI benefits and the types of treatment received by these children would have been improved by access to certain types of unpublished SSA administrative data, such as age-18 redeterminations and continuing disability reviews. However, these data were not available to the committee for the purpose of this study. Finally, the committee had access to an analysis of MAX data that included limited analyses related to speech and language disorders (see Chapter 5 ). Because these data are drawn from a study that was commissioned for another report (see NASEM, 2015 ), this committee was unable to conduct additional analyses, which would have allowed for comparisons between speech and language disorders and other health conditions.

Severity of Speech and Language Disorders

This report frequently refers to “severe” speech and language disorders in children. However, the word “severe” has different meanings depending on the context in which it is used. In clinical research, severity may be measured according to how far below average children score on tests compared with children of the same age (i.e., in standard deviations from a norm-referenced score or quotient) or “percentage of delay” relative to chronological age. In the context of the SSI program, however, the word “severe” has a specific legal meaning that is related to the standard of disability for children in the Social Security Act. Specifically, the regulations explain that “an impairment or combination of impairments must cause ‘marked and severe functional limitations' in order to be found disabling.” 5 Elsewhere, the regulations explain that “a child's impairment or combination of impairments is ‘of listing-level severity' if it causes marked limitation in two areas of functioning or extreme limitation in one such area.” 6 These areas of functioning include acquiring and using information, attending to and completing tasks, interacting and relating with others, moving about and manipulating objects, caring for himself or herself, and maintaining health and physical well-being. Chapter 4 includes an in-depth review of how children are evaluated for disability as part of the SSI eligibility determination process. Readers of the report should therefore consider the word “severe” as a clinical expression of impairment level except when it is used in the context of the SSI program.

Identifying Severe Speech and Language Disorders

When prevalence estimates (for any condition) are based on a threshold or cutoff score imposed on a continuous normal distribution, the cutoff score will necessarily determine the percentage of individuals falling above and below it. The committee used cutoffs (two and three standard deviations below the mean) that are consistent both with conventional definitions of severe disorders in medicine, psychology, and other fields and with the quantitative standards used by the SSA for defining severe speech and language disorders (see Chapter 4 ). Many researchers and organizations have noted the need to consider additional sources of evidence, including subjective judgments of functioning, in addition to norm-referenced cutoff scores. For example, the World Health Organization's International Classification of Functioning, Disability and Health is one widely accepted approach to describing the severity of medical and developmental conditions ( WHO, 2001 ). This, too, is consistent with the SSA's approach, which requires qualitative evidence that is consistent with quantitative scores when the latter are available. Unfortunately, high-quality data from large, representative populations that have been assessed with both quantitative and qualitative metrics are not available.

Prevalence and Trends in Prevalence

As part of its charge, the committee was asked to “identify past and current trends in the prevalence and persistence of speech disorders and language disorders for the general U.S. population (under age 18) and compare those trends to trends in the SSI childhood disability population.” Prevalence is defined as “the number or proportion of cases or events or attributes among a given population” ( CDC, 2014 ). The term “prevalence” is often used to describe “point prevalence,” which refers to “the amount of a particular disease present in a population at a single point in time” ( CDC, 2014 ).

Given the lack of longitudinal data on speech and language disorders in SSI administrative data and the paucity of similar data for the general population, the committee determined that the best way to identify trends in prevalence using available data sources would be to examine trends in point prevalence—that is, the number of children with speech and language disorders at a given time and over time both for the general U.S. population (under age 18) and in the SSI childhood disability population. To identify trends in prevalence in these groups, the committee reviewed multiple estimates of point prevalence over time from a variety of sources, including studies using clinical samples, nationally representative surveys, and administrative or service data from federal programs (see Chapter 5 ). When these estimates are arranged in chronological order, they produce a trend line—or a trend in prevalence.

However, comparing trends in prevalence between these two populations posed a number of challenges beyond a lack of longitudinal data. These challenges, described in Chapters 4 and 5 , include inherent differences in the sample populations (e.g., socioeconomic status, levels of severity) and differences in how children with speech and language disorders are identified and categorized. In addition, many of the estimates of prevalence and trends in prevalence presented in this report lack statements of precision, such as confidence intervals or error bars. Recognizing this limitation, the committee provides detailed information regarding sample sizes and methods used to calculate estimates. These can be found in Chapters 2 and 5 and Appendixes C and D. Despite the numerous challenges and limitations, the committee used the available data to describe changes in both groups 7 over time, in accordance with its charge.

Because financial need is a basic condition of eligibility for SSI, the first step in determining eligibility is assessment of family financial status. As a result, the majority of children who receive SSI benefits are from families with a household income less than 200 percent of the federal poverty level (FPL). The number of families with incomes less than 200 percent of the FPL changes over time. That is, as economic conditions deteriorate, more families join the ranks of those with incomes at or below a defined poverty level. This most recently occurred following the 2008-2009 recession in the United States. Table 1-1 presents the absolute number of children under age 18 living in poverty and the percentage of children who were below the FPL annually from 2004 to 2013. The pattern shows that the percentage of children in poverty increased after 2006, peaked in 2010, and declined afterward, although by 2013 it was well above the 2006 level ( NASEM, 2015 ).

U.S. Children Living in Poverty (below 100 percent of the federal poverty level), 2004-2013 (numbers in thousands).

This pattern suggests that more children would have met the financial eligibility criteria for SSI benefits during the period that followed the 2008-2009 recession in the United States. Thus, an increase in the number of children with speech and language disorders receiving SSI may not reflect an increase in these disorders, but instead may arise from an increased number of children with these disorders who meet the poverty threshold for SSI eligibility ( NASEM, 2015 ). However, there are no reliable estimates of the number of children living in poverty who also have speech and language disorders.

Therefore, this report examines the interaction of poverty and disability as well as changes in childhood poverty rates and the changes observed in the SSI program for children with speech and language disorders. Additional data provided in this report allow for comparisons and analyses of SSI determinations, allowances, and total child SSI recipients as a proportion of low-income populations within the United States. This discussion can be found in Chapters 4 and 5 .

Limitation of Review of the SSI Program to Children Under Age 18

As noted in the committee's statement of task, this review was limited to children under age 18, the age range served by the SSI childhood program. Therefore, data on redetermination at age 18 are not included in this report, although at age 18, SSI recipients must be reevaluated for eligibility to continue receiving SSI disability benefits as adults. One notable exception is that the committee includes program data on children and youth with disabilities served under IDEA Parts B and C; these data, which could not be disaggregated, include children and youth aged 0-21. Data related to topics beyond the scope of this review, such as continuing disability reviews and age-18 redeterminations, were not made available to the committee by the SSA.

Age of Onset

As part of its task, the committee was asked to identify the average age of onset of speech and language disorders. The onset of a disorder and its chronicity may have important implications related to the burden placed by the disorder on an individual and his or her family, as well as the types and duration of supports an individual will require. Chapter 3 reviews the evidence on persistence of speech and language disorders in children. However, the committee found that in most cases, a simplistic concept of onset does not apply to speech and language or other developmental disorders. The notion of onset of a condition implies that prior to the onset, affected individuals had these functions but then experienced a decline or loss of function. In general, developmental disorders are identified when expected functional skills in children fail to emerge. These expectations usually are based on ages when children typically begin to show these skills. The criteria for determining that a child is presenting severe and long-lasting developmental problems often allow for a period of uncertainty. The underlying factors that contribute to developmental disorders are likely to have been present well before the signs are manifest in the child's development. For example, the babbling of infants who later display severe speech disorders often lacks the consonant-like sounds (closants) seen in typically developing children ( Oller et al., 1999 ). However, there is considerable variability in typical development, so that babbling features alone cannot be used as an accurate diagnostic test for speech disorder.

A major effort in clinical research on developmental disorders has been to identify early risk factors and subclinical signs, so as to support earlier identification and treatment. This research also supports the general assumption that for most developmental disorders, identification is likely to occur during very early stages of development. Therefore, this report reviews what is known about the age of identification of speech and language disorders as it relates to expected developmental milestones. It is generally more accurate to describe the “age of identification” of a speech or language disorder than to focus on the “age of onset.” It is worth noting that the age at which a speech or language disorder is identified may be further influenced by a number of factors, including access to care, socioeconomic status, and other demographic factors.

The committee was charged with identifying the “gender distribution” of speech and language disorders in children and with assessing “how gender may play a role in the progression” of these disorders. This report highlights findings on gender distribution from clinical research and national survey data. However, the evidence base on the effects of gender on the efficacy of treatment and the progression or persistence of speech and language disorders is limited. In its review of the literature, the committee found that few studies examined differential effects of treatment on males and females or included longitudinal data that demonstrated gender differences in the persistence or progression of speech and language disorders.

State-to-State Variation in the SSI Program

Determinations of eligibility for the SSI program are managed at the state level. Through its examination of the evidence, the committee became aware that states vary considerably in the number and rate of applications leading to determinations and in the rate of allowances. This report includes some state-level data to provide an overall perspective, but it does not explore the potential factors contributing to state-to-state variation in the rates of SSI disability, which was beyond the scope of this study. Readers can refer to a recent research brief by the Office of the Assistant Secretary for Planning and Evaluation, The Child SSI Program and the Changing Safety Net ( Wittenburg et al., 2015 ), or to Mental Disorders and Disabilities Among Low-Income Children ( NASEM, 2015 ) for further information on geographic variation in child SSI program growth and participation.

Exclusion of Recommendations

Finally, the committee was not asked to provide the SSA with recommendations on the SSI program for children. Doing so would be beyond not only the scope of this study as laid out in the statement of task but also the expertise of this committee. Rather, the committee was tasked with gathering information and reporting on the current state of knowledge on the diagnosis, prognosis, and treatment of speech and language disorders in children, as well as trends in the prevalence of these disorders in children. The information presented in this report (and in the recent Academies report on trends in low-income children with mental disorders in the SSI program [ NASEM, 2015 ]) provides a solid evidentiary basis that can inform the SSA's programs and policies, as well as the work of an array of related stakeholders.

• STUDY APPROACH

The study committee included 13 members with expertise in speech-language pathology, auditory pathology, pediatrics, developmental-behavioral pediatrics, epidemiology, biostatistics, neurology, neurodevelopmental disabilities, adolescent health, health policy, and special education. (See Appendix H for biographies of the committee members.)

A variety of sources informed the committee's work. The committee met in person five times: two of those meetings included public workshops to provide the committee with input from a broad range of experts and stakeholders, including parents and professional organizations; federal agencies (e.g., the Centers for Disease Control and Prevention, the SSA, and the National Institute of Deafness and Other Communication Disorders); and researchers from a range of relevant disciplines, including speech and language pathology and epidemiology. In addition, the committee conducted a review of the literature to identify the most current research on the etiology, epidemiology, and treatment of pediatric speech and language disorders. The committee made every effort to include the most up-to-date research in peer-reviewed publications. However, strong evidence was sometimes found in older studies that had not been replicated in recent years. In these instances, the older studies are cited. The committee also reviewed findings from a supplemental study using Medicaid data to create an approximate national comparison group for the SSI child population. 8 (See Chapter 5 for additional information about this supplemental study.) Finally, the committee reviewed data collected from SSI case files of children who were eligible for SSI benefits under the category of “speech and language impairment.” (See Chapter 4 and Appendix C for more information about this review.)

• DEFINITIONS OF KEY TERMS

Language has long been described as a verbal or written code for conveying information to others, and speech refers to oral communication ( Bloomfield, 1926 ). All languages include words (vocabulary), word endings (morphology), and sentence structure (syntax), and speech includes the pronunciation of the sounds (phonemes) of the language. Language development also encompasses acquisition of the social rules for communicating and conversing in society (pragmatics). These rules include participating appropriately in conversations, as well as using and comprehending appropriate gestures and facial expressions during social interaction ( Gallagher and Prutting, 1983 ). The communication and social aspects of speech and language must be coordinated rapidly and fluently when one is speaking.

Given the complex nature of speech and language development, multiple factors can contribute to deficits in their acquisition and use (e.g., motor impairments, processing deficits, cognitive impairments). Disruptions in communication development are broadly classified as speech disorders and language disorders.

Speech disorder is defined as disruption in the production of the phonetic aspects of words, phrases, and sentences so that communication is partially or, in severe cases, completely unintelligible to listeners. Stuttering is a form of speech disorder that involves disruptions in the rate and/or fluency of speaking due to hesitations and repetitions of speech sounds, words, and/or phrases.

Language disorder is defined as impairment of expression and comprehension because of a disruption in the acquisition of vocabulary (words), word endings, and sentence structure. In severe cases of language disorder, a child experiences extreme difficulty using correct words and proper grammar and may also have difficulty comprehending what others are saying.

Box 1-2 presents the clinical definitions of speech and language disorders.

Clinical Definitions of Speech and Language Disorders.

Furthermore, speech and language disorders can be categorized as primary, meaning the disorder does not arise from an underlying medical condition (e.g., cerebral palsy, Down syndrome, hearing impairment), or secondary, meaning the disorder can be attributed to another condition (see Box 1-3 ). This report discusses both primary and secondary speech and language disorders, but it focuses mainly on speech and language disorders that are identified as the primary condition. This corresponds with the categories of speech and language disorders in the SSI program that the report examines.

Primary Versus Secondary Speech and Language Disorders.

• SIGNIFICANCE AND IMPACT OF SEVERE SPEECH AND LANGUAGE DISORDERS

Speech and language disorders can have a significant adverse impact on a child's ability to have meaningful conversations and engage in age-appropriate social interaction. These disorders are serious disabilities with long-term ramifications for cognitive and social-emotional development and for literacy and academic achievement and have lifelong economic and social impacts, and these disruptions are evidenced in increased risk for learning disabilities, behavior disorders, and related psychiatric conditions. The following sections describe the variety of ways in which speech and language disorders can impact children and their families.

Impact on Social-Emotional and Cognitive Development

Child development is best viewed in the context of a dynamic interaction between social-emotional and cognitive development ( Karmiloff-Smith et al., 2014 ). A seminal paper by Sameroff (1975) brought attention to the critical role of parent–child interactions and social-communicative exchanges in children's social and emotional development. In this communicative-interactive model, social development is the direct product of parent–child (or caregiver–child) interaction ( Sameroff, 2009 ). Specifically, parent–child communication interactions, including speech and language skills, are foundational to emotional attachment, social learning, and cognitive development in addition to communication development. Communication interactions—social “back and forth” exchanges—are a natural part of parent-child communication, with more than 1 million of these parent–child exchanges occurring in the first 5 years of a child's life ( Hart and Risley, 1995 ). Figure 1-1 illustrates how social interaction between parent and child leads to the development of speech.

Example of communication-interaction for speech development.

In the decades since Sameroff's (1975) original article, the communication-interaction model has been applied to multiple aspects of development, including speech ( Camarata, 1993 ), language ( Nelson, 1989 ), the development of self ( Damon and Hart, 1982 ), and cognitive development ( Karmiloff-Smith et al., 2012 ). Karmiloff-Smith (2011) adapted the communication-interaction perspective as a means of mapping developmental processes across multiple domains of genetics and neuroimaging, as well as cognitive and linguistic abilities. In essence, she argues that dynamic communication interactions between parent and child serve not only as learning opportunities but also as the core of the genetically mediated neural phenomena occurring for childhood brain development, often referred to as neural plasticity and remodeling. Viewed in this way, communicative interchanges are fundamental to the developmental experiences that shape a child's neural architecture and, more important, brain function. Severe speech and language disorders can derail this typical cascade of development and have profound and wide-ranging adverse impacts ( Clegg et al., 2005 ).

Impacts on Literacy and Academic Achievement

Figure 1-2 illustrates the importance of language development for the development of literacy skills and the relationship of both to academic achievement across a range of subject areas. Considerable data suggest that severe speech and language disorders are associated with reading disabilities and general disruptions in literacy ( Fletcher-Campbell et al., 2009 ). In essence, reading involves mapping visual symbols (letters) onto linguistic forms (words). When the acquisition and mastery of oral vocabulary are impaired, it is not surprising that the mapping of symbols such as letters onto words is also disrupted. In addition, broader language and speech disorders can make processing the visual symbols much less efficient and disrupt their mapping onto meaning. Even after vocabulary has been acquired, cognitive problems with translating text to language can continue ( Briscoe et al., 2001 ). In languages such as English that use phonetic text, severe speech disorders also can disrupt the phonological processing associated with reading ( Pennington and Bishop, 2009 ). In sum, severe speech and language disorders often have direct or indirect adverse impacts on the development of literacy and fluid reading.

The relationship among language development, literacy skills, and academic achievement.

In addition to their direct impact on literacy, severe speech and language disorders can have a deleterious cascading effect on other aspects of academic achievement. To illustrate, in a 15-year follow-up study of children with speech and language disorders, a high percentage (52 percent) of the children initially identified with such disorders had residual learning disabilities and poor academic achievement later in life ( King, 1982 ). Similarly, Hall and Tomblin (1978) report poor overall long-term achievement in language-impaired children. More recently, a study of preterm infants with language disorders indicated multiple disruptions in subsequent achievement ( Wolke et al., 2008 ). And Stoeckel and colleagues (2013) found a strong correlation between early language problems and later diagnosis of written-language disorders. Because so much of academic achievement is predicated on acquiring information through reading and listening comprehension, early severe speech and language disorders often are associated with poor achievement beyond reading problems.

As illustrated in Figure 1-3 , the most recent data from the Institute of Education Sciences of the U.S. Department of Education indicate that 21 percent of all special education eligibility in the United States is for speech and language impairments—three times greater than eligibility for autism or intellectual disability. Speech and language disorders are among the highest-incidence conditions among children in special education. Moreover, these data may underestimate the prevalence of speech and language disorders because the highest-incidence condition—specific learning disability—includes many students who were previously categorized as having a speech or language impairment ( Aram and Nation, 1980 ; Catts et al., 2002 ). Although mild speech and language impairments in preschool will sometimes be transient, severe forms of the disorders have a high probability of being long-term disabilities ( Beitchman et al., 1994 ; Bishop and Edmundson, 1987 ), with that probability rising with the disorder's severity.

Percentage distribution of children aged 3-21 served under the Individuals with Disabilities Education Act (IDEA) Part B, by disability type: school year 2011-2012. SOURCE: Kena et al., 2014.

Economic and Family Impacts

In a review of the economic impact of communication disorders on society, Ruben (2000 , p. 241) estimates that “communication disorders may cost the United States from $154 billion to $186 billion per year.” Severe speech and language disorders elevate risk for a wide variety of adverse economic and social outcomes, such as lifelong social isolation and psychiatric disorders, learning disabilities, behavior disorders, academic failure, and chronic underemployment ( Aram and Nation, 1980 ; Baker and Cantwell, 1987 ; Beitchman et al., 1996 ; Johnson et al., 1999 ; Stothard et al., 1998 ; Sundheim and Voeller, 2004 ). Following a cohort of individuals with severe language disorders in childhood longitudinally through school age and adolescence and into early adulthood, Clegg and colleagues (2005 , p. 128) found that “in their mid-30s, those who had language disorders as children had significantly worse social adaptation with prolonged unemployment and a paucity of close friendships and love relationships.”

Research shows that children living in poverty are at greater risk for a disability relative to their wealthier counterparts, and that childhood disability increases the risk of a family living in poverty ( Emerson and Hatton, 2005 ; Farran, 2000 ; Fujiura and Yamaki, 2000 ; Lustig and Strauser, 2007 ; Msall et al., 2006 ; NASEM, 2015 ; Parish and Cloud, 2006 ). For example, data from the U.S. Census 2010 showed that families raising children with a disability experienced poverty at higher rates than families raising children without a disability (21.8 and 12.6 percent, respectively) ( Wang, 2005 ). At the same time, childhood poverty and the accompanying deprivations have significant adverse implications for children with disabilities and their families. Families with children with disabilities are also more likely to incur increased out-of-pocket expenses; for example, for child care or for transportation to locations with specialized medical care ( Kuhlthau et al., 2005 ; Newacheck and Kim, 2005 ). Data from the National Survey of Children with Special Health Care Needs help illustrate the impact on families of caring for children with communication disorders. For example, the survey asked whether family members cut back on or stopped working because of their child's health needs. Fifty-two percent of the survey respondents whose children had “a lot of difficulty speaking, communicating, or being understood” responded affirmatively to this question ( Wells, 2015 ).

In sum, given the complex multidimensional nature of language acquisition and the integral role of speech and language across multiple domains of early child development, speech and language disorders occur at relatively high rates ( Kena et al., 2014 ). In 2011-2012, 21 percent of children served under IDEA Part B had speech or language impairments ( Kena et al., 2014 ). These disorders also are associated with a wide range of other conditions ( Beitchman et al., 1996 ), such as intellectual disabilities ( Georgieva, 1996 ), autism spectrum disorder ( Geurts and Embrechts, 2008 ; Sturm et al., 2004 ), hearing loss ( Yoshinaga-Itano et al., 1998 ), learning disabilities ( Pennington and Bishop, 2009 ; Schuele, 2004 ), ADHD ( Cohen et al., 2000 ), and severe motor conditions such as cerebral palsy ( Pirila et al., 2007 ).

• NOTABLE PAST WORK

As noted earlier, in the period between 2000 and 2011, speech and language impairments were among the three most prevalent impairments in children in the SSI disability program (preceded by ADHD and followed by autism spectrum disorder) ( GAO, 2012 ). In an effort to understand these trends in comparison with trends in the general population, the SSA requested that the IOM conduct two studies: the previously mentioned study on childhood mental disorders (including ADHD and autism spectrum disorder) 9 and this study on childhood speech and language disorders. While these impairments frequently co-occur and may have similar diagnostic characteristics, the separate studies allowed two independent committees to examine distinct literatures and data sources and to review different standards of care and treatment protocols. The study on children with mental health disorders was conducted from January 2014 through August 2015; the final report of that study was released in September 2015 ( NASEM, 2015 ).

While this report is the first examination of the SSI disability program for children with speech and language disorders conducted by the Academies, the IOM, and the National Research Council (NRC) have a long history of studying issues related to disability in children and adults and the SSA's disability determination process. In addition to the recently released Mental Disorders and Disabilities Among Low-Income Children ( NASEM, 2015 ), earlier reports by the IOM and the NRC that informed this committee's work include The Dynamics of Disability: Measuring and Monitoring Disability for Social Security Programs ( IOM and NRC, 2002 ), The Future of Disability in America ( IOM, 2007b ), Improving the Social Security Disability Decision Process ( IOM, 2007a ), HIV and Disability: Updating the Social Security Listings ( IOM, 2010b ), Cardiovascular Disability: Updating the Social Security Listings ( IOM, 2010a ), and Psychological Testing in the Service of Disability Determination ( IOM, 2015 ). Along with this earlier work of the Academies, the committee drew important lessons from the body of data and research aimed at identifying trends in the prevalence and persistence of speech and language disorders, as well as addressing diagnosis and treatment of and levels of impairment associated with these disorders.

• FINDINGS AND CONCLUSIONS

1-1. Developmental disorders are identified when expected functional skills in children fail to emerge. 1-2. Underlying factors that contribute to developmental disorders are likely to have been present well before the signs are manifest in the child's development. 1-3. In a 15-year follow-up study of children with speech and language disorders, 52 percent of the children initially identified with such disorders had residual learning disabilities and poor academic achievement later in life. 1-4. Twenty-one percent of all special education eligibility in the United States is for speech and language impairments—three times greater than eligibility for autism or intellectual disability.

Conclusions

1-1. It is generally more accurate to describe the “age of identification” of a speech or language disorder than to focus on the “age of onset.” 1-2. Mild speech and language impairments in preschool will sometimes be transient; severe forms of these disorders have a high probability of being long-term disabilities.

• ORGANIZATION OF THE REPORT

This report consists of six chapters. It is organized to provide readers with important background information on speech and language disorders in children in the general population before describing the subset of children with severe speech and language disorders who receive SSI benefits. To take readers through this progression, the report describes the SSI program in some detail. This description is intended to orient readers to the determination process that shapes the population served by the program: children with severe speech and language disorders who are also from low-income, resource-limited families. The report then compares changes over time in the prevalence of speech and language disorders in the general and SSI child populations, based on the best evidence available. The report culminates with a summary of the committee's overall findings and conclusions. The contents of each chapter are as follows:

• Chapter 2 provides an overview of childhood speech and language disorders in the general U.S. population. The chapter begins with an overview of speech and language development in children. It then examines the diagnosis of speech and language disorders in children, causes and risk factors, and prevalence. The chapter also includes evidence related to common comorbidities of childhood speech and language disorders.
• Chapter 3 reviews what is known about the treatment and persistence of speech and language disorders in children. This review includes current standards of care for these disorders, an overview of treatment approaches for different speech and language disorders, and expected responses to treatment.
• Chapter 4 provides an overview of the SSI program for children, how it has changed over time, and how those changes have shaped the population of children receiving SSI benefits. It describes the eligibility determination process and the speech and language-related criteria that are used to evaluate children. Finally, the chapter includes case examples and a review of a random sample of case files of children who receive SSI benefits based on speech and language disorders. This information offers insight into the characteristics of children with speech and language disorders who apply for SSI and helps demonstrate the evidence considered by the SSA when making a disability determination for a case.
• Chapter 5 compares trends in speech and language disorders among children (under age 18) in the general population with trends in these disorders among participants in the SSI childhood disability program. The chapter reviews the data sources used by the committee to describe the epidemiology of speech and language disorders in children in both populations. It also identifies gaps in the evidence that impede more precise estimates of trends in prevalence for speech and language disorders and comorbid conditions.
• Finally, Chapter 6 provides a summary of the committee's overall findings and conclusions and their implications in the following three areas: speech and language disorders in children in the general population, speech and language disorders among children who receive SSI benefits, and comparisons between these two groups.

The report includes several appendixes. Appendix A provides a glossary of terms used throughout the report, while Appendix B includes summaries of data sources that informed the committee's work. Appendix C includes administrative/service data that the committee used to examine changes in program participation over time and national survey data that the committee used to estimate changes in prevalence over time. Appendix D provides the methods that the committee used to calculate trends in the national survey data. Appendix E includes a description of the methods used to review case files, and Appendix F lists the agendas and speakers for the committee's public workshops. A brief summary of Mental Disorders and Disabilities Among Low-Income Children , the report of the Committee on the Evaluation of the Supplemental Security Income Disability Programs for Children with Mental Disorders, is included in Appendix G . Finally, Appendix H contains biographical sketches of the committee members.

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The SSI program categorizes “speech and language impairments” as mental disorders.

See the report Mental Disorders and Disabilities Among Low-Income Children for trends in prevalence for mental disorders ( NASEM, 2015 ).

Impairment code 3153 was changed from “speech and language delays” to “speech and language impairments” in August 2015.

“Autism/developmental delays” is language drawn directly from the GAO report. However, autism spectrum disorder is a distinct neurodevelopmental disorder with distinct clinical characteristics. For further reading on autism spectrum disorder, see Mental Disorders and Disabilities Among Low-Income Children ( NASEM, 2015 ).

20 C.F.R. 416.902.

20 C.F.R. 416.925(b)(2).

In accordance with the committee's charge, this includes children with speech and language disorders of any level of severity in the general population and children with these disorders in the SSI population, whose impairments are inherently severe.

This supplemental study was commissioned by the Committee on the Evaluation of the Supplemental Security Income Disability Program for Children with Mental Disorders.

Information on the Committee on the Evaluation of the Supplemental Security Income Disability Program for Children with Mental Disorders can be found online at http://iom ​.nationalacademies ​.org/activities ​/mentalhealth/ssidisabilityprograms ​.aspx .

• Cite this Page Committee on the Evaluation of the Supplemental Security Income (SSI) Disability Program for Children with Speech Disorders and Language Disorders; Board on the Health of Select Populations; Board on Children, Youth, and Families; Institute of Medicine; Division of Behavioral and Social Sciences and Education; National Academies of Sciences, Engineering, and Medicine; Rosenbaum S, Simon P, editors. Speech and Language Disorders in Children: Implications for the Social Security Administration's Supplemental Security Income Program. Washington (DC): National Academies Press (US); 2016 Apr 6. 1, Introduction.
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Developmental Language Disorder

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What is developmental language disorder (DLD)?

What causes dld, what are the symptoms of dld, how is dld diagnosed, is dld the same thing as a learning disability, is dld a lifelong condition, what treatments are available for dld, what research does nidcd support on dld, where can i find more information on dld.

Developmental language disorder (DLD) is a communication disorder that interferes with learning, understanding, and using language. These language difficulties are not explained by other conditions, such as hearing loss or autism, or by extenuating circumstances, such as lack of exposure to language. DLD can affect a child’s speaking, listening, reading, and writing. DLD has also been called specific language impairment, language delay, or developmental dysphasia. It is one of the most common developmental disorders, affecting approximately 1 in 14 children in kindergarten. The impact of DLD persists into adulthood.

DLD is a neurodevelopmental disorder. Neurodevelopmental disorders are caused by complex interactions between genes and the environment that change brain development. The exact causes of the brain differences that lead to DLD are unknown.

Neurodevelopmental disorders tend to run in families. Children with DLD are more likely than those without DLD to have parents and siblings who have also had difficulties and delays in language development. In fact, 50 to 70 percent of children with DLD have at least one family member with the disorder. In addition, other potentially related neurodevelopmental disorders, such as dyslexia or autism, are more common in the family members of a child with DLD.

Learning more than one language at a time does not cause DLD. The disorder can, however, affect both multilingual children and children who speak only one language. For multilingual children, DLD will impact all languages spoken by a child. Importantly, learning multiple languages is not harmful for a child with DLD. A multilingual child with DLD will not struggle more than a child with DLD who speaks only one language.

A child with DLD often has a history of being a late talker (reaching spoken language milestones later than peers). Although some late talkers eventually catch up with peers, children with DLD have persistent language difficulties.

Younger children with DLD may:

• Be late to put words together into sentences.
• Struggle to learn new words and make conversation.
• Have difficulty following directions, not because they are stubborn, but because they do not fully understand the words spoken to them.
• Make frequent grammatical errors when speaking.

Symptoms common in older children and adults with DLD include:

• Limited use of complex sentences.
• Difficulty finding the right words.
• Difficulty understanding figurative language.
• Reading problems.
• Disorganized storytelling and writing.
• Frequent grammatical and spelling errors.

Language difficulties may be misinterpreted as a behavioral issue. For example, a child who struggles with language may avoid interactions, leading others to think that the child is shy. A child may not follow directions because they don’t understand the instructions, but others may interpret this as misbehavior. A child who struggles to communicate may become frustrated and act out. When a child is struggling at home or in school, it is important to determine if language difficulties may be part of the problem.

If a doctor, teacher, or parent suspects that a child has DLD, a speech-language pathologist (a professional trained to assess and treat people with speech or language problems) can evaluate the child’s language skills. The type of evaluation depends on the child's age and the concerns that led to the evaluation. In general, an evaluation includes:

• Direct observation of the child.
• Interviews and questionnaires completed by parents and/or teachers.
• Assessments of the child’s learning ability.
• Standardized tests of current language performance.

These tools allow the speech-language pathologist to compare the child's language skills to those of same-age peers, identify specific difficulties, and plan for potential treatment targets.

DLD is not the same thing as a learning disability . Instead, DLD is a risk factor for learning disabilities since problems with basic language skills affect classroom performance. This means that children with DLD are more likely to be diagnosed with a learning disability than children who do not have DLD. They may struggle with translating letters into sounds for reading. Their writing skills may be weakened by grammatical errors, limited vocabulary, and problems with comprehension and organizing thoughts into coherent sentences. Difficulties with language comprehension can make mathematical word problems challenging. Some children with DLD may show signs of dyslexia. By the time they reach adulthood, people with DLD are six times more likely to be diagnosed with reading and spelling disabilities and four times more likely to be diagnosed with math disabilities than those who do not have DLD.

DLD is a developmental disorder, which means that its symptoms first appear in childhood. This does not mean that, as children develop, they grow out of the problem. Instead, the condition is apparent in early childhood and will likely continue, but change, as they get older.

For instance, a young child with DLD might use ungrammatical sentences in conversation, while a young adult with DLD might avoid complex sentences in conversations and struggle to produce clear, concise, well-organized, and grammatically accurate writing.

Early treatment during the preschool years can improve the skills of many children with language delays, including those with DLD. Children who enter kindergarten with significant language delays are likely to continue having problems, but they and even older children can still benefit from treatment. Many adults develop strategies for managing DLD symptoms. This can improve their daily social, family, and work lives.

Treatment services for DLD are typically provided or overseen by a licensed speech-language pathologist. Treatment may be provided in homes, schools, university programs for speech-language pathology, private clinics, or outpatient hospital settings.

Identifying and treating children with DLD early in life is ideal, but people can benefit from treatment regardless of when it begins. Treatment depends on the age and needs of the person. Starting treatment early can help young children to:

• Acquire missing elements of grammar.
• Expand their understanding and use of words.
• Develop social communication skills.

For school-age children, treatment may focus on understanding instruction in the classroom, including helping with issues such as:

• Following directions.
• Understanding the meaning of the words that teachers use.
• Organizing information.
• Improving speaking, reading, and writing skills.

Adults entering new jobs, vocational programs, or higher education may need help learning technical vocabulary or improving workplace writing skills.

The National Institute on Deafness and Other Communication Disorders (NIDCD) supports a wide variety of research on the causes, symptoms, diagnosis, and treatment of DLD. For example, NIDCD funds research that seeks to understand how brain and learning patterns differ for children with DLD compared to children with typical language development. Other research focuses on understanding why socioeconomic disparities increase the risk of DLD in children from low-income families. NIDCD-supported scientists are also determining how to accurately diagnose DLD, especially in culturally diverse children who speak a variety of dialects or languages. The institute also funds research to ascertain, at a highly practical and specific level, the best ways to teach language to children with DLD, including how many times a language structure (e.g., using proper tense) should be practiced, how instructional sessions should be organized, and how often teaching should occur. NIDCD-supported programs are also researching how to coach parents or peers of children with DLD to support language growth at home or school.

The NIDCD maintains a directory of organizations providing information on the normal and disordered processes of hearing, balance, taste, smell, voice, speech, and language.

For more information, contact us at:

NIDCD Information Clearinghouse 1 Communication Avenue Bethesda, MD 20892-3456 Toll-free voice: (800) 241-1044 Toll-free TTY: (800) 241-1055 Email: [email protected]

NIH Pub. No. 22-DC-8194 October 2022

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Is a Language Disorder a Speech Disorder?

It is common to hear the words “speech” and “language” used interchangeably, but the truth is they are actually two separate things. While they may mean the same thing when we are talking about oral communication in a general sense, in the Speech-Language Pathology community these two terms have important distinguishing factors. Speech and language disorders are relatively common among children and adults and speech-language pathologists are experts when it comes to providing help and support to those affected. You can learn more about speech and language disorders and how speech therapy can help by scheduling your free introductory call today! 

What is the Difference Between a Speech Disorder and a Language Disorder?

‘Speech’ refers to the ability to produce specific sounds and sound combinations. It is the oral form of communication, the sound of spoken word, it is the act of talking using the lips, tongue, jaw, and vocal tract to produce specific and properly articulated sounds. ‘Language’ on the other hand refers to the complex system of words and symbols, their appropriate uses, and their meanings. Language can be written, spoken, or expressed through gestures and facial expressions to convey meaning. 

So, just as there are differences between speech and language, there are differences between speech and language disorders. A speech disorder usually means that there are difficulties and challenges related to producing certain sounds or sound combinations. A speech disorder can also affect the fluency and accuracy of speech, such as a stutter or lisp. Language disorders relate to challenges around the comprehension of the meaning of words or phrases, and someone affected by a language disorder may also struggle to express themselves appropriately and correctly through language. A child who can speak well and articulate their sounds clearly and correctly can still struggle with word meaning and have a language disorder. Conversely, a child who has a strong understanding of language and word meaning as well as an extensive vocabulary, can still struggle with sound production and have a speech disorder. Speech and language disorders can occur separately (meaning one can be affected by only one of these) however they can also both be diagnosed in one individual. 

What Type of Disorder is a Language Disorder?

Language disorders are a type of communication disorder. Those who aren’t familiar with the term may think a language disorder is related to speech production, but it is actually related to the ability to understand and employ the use of language. 

Is Expressive Language Disorder a Speech Disorder?

Expressive Language disorder is one of the three most common types of language disorders. In most cases language disorders are developmental and signs can be identified in early childhood. However, illness or traumatic brain injury can also result in a language disorder . While it is unlikely for one to grow out of this disorder, it is possible for a person with an expressive language disorder to develop a solid understanding of language through support and treatment from a Speech-language pathologist. Some of the most common signs of an expressive language disorder are: 

• Having a vocabulary with a lower number of words than average
• Trouble finding or retrieving words
• Using words inappropriately or incorrectly
• Using very vague or generic words like “stuff” or “thing”
• Speaking in short sentences or offering one-word answers
• Is generally late to begin talking as a very young child
• Leaving out or skipping words when speaking

In most cases, people with an expressive language disorder have difficulty expressing themselves and getting their message across. 

What Causes a Language Disorder?

Language disorders can be either developmental or acquired. An acquired language disorder means that it was the result of another medical condition (such as a stroke ), brain injury, or neurological illness. A developmental language disorder could be hereditary and will often appear in early childhood. It does not indicate any lack of intelligence or mental capacities, and children with a language disorder will often manage quite well academically and struggle only to be understood by others when they are speaking. 

Both developmental and acquired language disorders can be helped through time with a speech-language pathologist.  

How Can I Support my Child with a Language Disorder?

There are a few key simple things you can do with your child to work on their speech and language skills every day. The most obvious of this is to simply talk to your child frequently, and listen with your full attention and patience when they are communicating with you. Reading is another great activity that children love and has major benefits for their language development. Allow your child space to ask you questions, and also allow them time to answer yours. You can read more about activities that help with speech and language development here . If you want to learn more about how you can support your child’s learning and development when it comes to language skills, schedule your free introductory call today!

How Can Speech Therapy Help with a Language Disorder?

It is common for people affected by a language disorder to avoid or completely stop speaking altogether. They may have become so frustrated or ashamed that they give up. They may also choose not to interact with friends, family, classmates, and colleagues. Working with a speech-language pathologist is a very important part of helping someone with a language disorder to build their expression and comprehension skills, as well as helping them to build confidence and a sense of mastery over time. 

Speech therapists are experts in the delivery and comprehension of spoken language. They possess a deep understanding of verbal cues and cognitive links to communication problems. Speech therapists can also help to train the mind to understand the complex and plentiful rules of language. These skills are acquired through listening, observing, and interacting with others. In some cases, the brain has difficulty creating those connections. A speech therapist can help someone with a language disorder understand and master the common patterns of oral speech and language techniques.

Language disorders can be treated, but early intervention is deeply important. If left untreated, a language disorder can cause problems for your child academically, socially, and emotionally. If you wonder if your child has a language disorder , it is best to seek help and guidance from a speech-language pathologist as soon as possible. Get started today and schedule your free introductory call now. We look forward to speaking with you.