LANGUAGE
AND SPEECH DISORDERS
Developmental
Articulation Disorder
The essential feature of this disorder is
a consistent failure to make correct
articulations of speech sounds, at the
developmentally appropriate age, that is not
due to a Pervasive Developmental Disorder,
Mental Retardation, impairment of the oral
speech mechanism, or neuralgic, intellectual,
or hearing impairments. The disorder is
manifested by frequent misarticulations,
substitutions, or omissions of speech sounds,
giving the impression of "baby
talk."
The speech sounds that are most frequently
misarticulated are those acquired later in
the developmental sequence (r, sh, th, f, z,
I, and ch); but in more severe cases or in
younger children, sounds such as b, m, t, d,
n, and h may be mispronounced. One or many
speech sounds may be affected, but vowel
sounds are not among them.
There is a considerable range in the severity
of the disturbance. The child's speech may be
completely intelligible, partially
intelligible, or unintelligible.
Associated features. Other
Specific Developmental Disorders are commonly
present, including: Developmental Expressive
Language Disorder, Developmental Receptive
Language Disorder, Developmental Reading
Disorder, and Developmental Coordination
Disorder. Functional Enuresis may also be
present.
A delay in reaching speech milestones (such
as "first word" and "first
sentence") has been reported in some
children with Developmental Articulation
Disorder, but most children with this
disorder begin speaking at the appropriate
age.
Age at onset. In severe
cases, the disorder is recognized at about
age three. In less severe cases, the disorder
may not be apparent until age six.
Course. With speech therapy,
complete recovery occurs in virtually all
cases In milder cases, spontaneous recovery
may occur before the age of eight years.
Prevalence. A conservative
estimate is that approximately 10% of
children below age eight, and approximately
5% of children aged eight years or older,
have the disorder.
Familial pattern. The
disorder is more common among first-degree
biologic relatives than in the general
population.
Differential diagnosis. Misarticulations
caused by physical abnormalities can be ruled
out by physical examination: if there is a
hearing impairment, audiometric testing will
reveal an abnormality; with dysarthria or
apraxia, there will be muscular weaknesses,
oral mechanism defects, or a neuralgic
disorder, and there may be problems with
chewing or sucking, drooling, and rate of
speech.
In Mental Retardation there is a general
impairment in intellectual functioning that
is not present in Developmental Articulation
Disorder. In Pervasive Developmental
Disorders there are pervasive behavioral
abnormalities not present in Developmental
Articulation Disorder.
Diagnostic Criteria for
Developmental Articulation Disorder
A. Consistent failure to use
developmentally expected speech sounds. For
example, in a three-year-old, failure to
articulate p, b, and t, and in a
six-year-old, failure to articulate r, sh,
th, f, z, and L.
B. Not due to a Pervasive
Developmental Disorder, Mental Retardation,
defect in hearing acuity, disorders of the
oral speech mechanism, or a neuralgic
disorder.
Developmental
Expressive Language Disorder
The essential feature of this disorder is
marked impairment in the development of
expressive language that is not explainable
by Mental Retardation or inadequate schooling
and that is not due to a Pervasive
Developmental Disorder, hearing impairment,
or a neuralgic disorder. The diagnosis is
made only if this impairment significantly
interferes with academic achievement or with
activities of daily living that require the
expression Of verbal (or sign) language.
The linguistic features of Developmental
Expressive Language Disorder are varied arid
depend on the severity of the disorder and
the age of the child. Nonlinguistic
functioning, however, is usually within
normal limits. Among the expressive language
limitations that may be present are: limited
size of vocabulary, difficulty acquiring new
words, vocabulary errors (such as
substitutions, circumlocutions,
overgeneralizations or jargon), shortened
sentences, simplified grammatical structures,
limited varieties of grammatical structures
(such as verb forms), limited varieties of
sentence types (such as imperatives,
questions, etc.), omissions of critical parts
of sentences, unusual word order, tangential
responses, and slow rate of language
development (speech beginning late, and
advancement through stages of language
development progressing slowly).
Associated Features. Developmental
Articulation Disorder is often present. In
older children, school and learning problems
(particularly in tasks involving perceptual
or sequencing skills) may be present. A
history of delay in reaching some motor
milestones, Developmental Coordination
Disorder, and Functional Enuresis are not
uncommon. Emotional problems, social
withdrawal, and behavioral difficulties may
be present.
Age at onset. Severe forms
usually occur before age three and are easily
recognized. Less severe forms may not occur
until early adolescence, when language
ordinarily becomes more complex.
Course. For a young child
with mild Developmental Expressive Language
Disorder, the prognosis is very good. As many
as 50% of the children with this disorder may
spontaneously catch up in their expressive
language abilities before they reach school
age and thus not require any specialized
help. In more severe cases, recovery is
slower; but most children with Developmental
Expressive Language Disorder not complicated
by Developmental Receptive Language Disorder
do acquire normal language abilities by late
adolescence.
Prevalence. Estimates range
from 3% to 10% of school-age children.
Familial pattern. It appears
that the disorder is more likely to occur in
people who have a family history of
Developmental Articulation Disorder or other
Specific Developmental Disorders.
Differential diagnosis. In
Mental Retardation there may be impaired
language functioning, but it is associated
with the general impairment in intellectual
functioning. Impaired hearing may also
produce abnormal expressive language
functioning, and should be ruled out by
audiometric testing. In Pervasive
Developmental Disorders, in which expressive
language impairment may be present, there is
little or no attempt to communicate
nonverbally (e.g., through gestures).
Elective Mutism involves limited expressive
output that may mimic Developmental
Expressive Language Disorder, but upon formal
testing, comprehension is found to be within
normal limits. Acquired aphasia is
distinguished from Developmental Expressive
Language Disorder by a history of onset
associated with head trauma, seizures, or EEG
abnormalities, or by "hard"
neuralgic signs such as hemiplegia.
Diagnostic Criteria For
Developmental Expressive Language Disorder
A. The score obtained from a
standardized measure of expressive language
is substantially below that obtained from a
standardized measure of nonverbal
intellectual capacity (as determined by an
individually administered lQ test).
B. The disturbance in (A)
significantly interferes with academic
achievement or activities of daily living
requiring the expression of verbal (or sign)
language. This may be evidenced in severe
cases by use of a markedly limited
vocabulary, by speaking only in simple
sentences, or by speaking only in the present
tense. In less severe cases, there may be
hesitations or errors in recalling certain
words, or errors in the production of long or
complex sentences.
C. Not due to a Pervasive
Developmental Disorder, detect in hearing
acuity, or a neuralgic disorder (aphasia).
Developmental
Receptive Language Disorder
The essential feature of this disorder is
marked impairment in the development of
language comprehension that is not
explainable by Mental Retardation or
inadequate schooling and that is not due to a
Pervasive Developmental Disorder, hearing
impairment, or neuralgic disorder. The
diagnosis is made only if this impairment
significantly interferes with academic
achievement or with activities of daily
living that require comprehension of verbal
(or sign) language.
The comprehension deficit varies depending on
the severity of the disorder and the age of
the child. In mild cases there may be only
difficulties in understanding particular
types of words (such as spatial terms) or
statements (for example, complex
if-then" sentences). In more severe
cases, there may be multiple disabilities,
including an inability to understand basic
vocabulary or simple sentences, and deficits
in various areas of auditory processing
(e.g., discrimination of sounds, association
of sounds and symbols storage, recall, and
sequencing)
Associated features. Developmental
Articulation Disorder, Developmental
Expressive Language Disorder, and Academic
Skills Disorders are often present. Less
commonly present are Functional Enuresis,
Developmental Coordination Disorder,
Attention-deficit Hyperactivity Disorder, EEG
abnormalities, and other social and
behavioral problems.
Age at onset. The disorder
typically appears before the age of four
years. Severe forms of the disorder are
apparent by age two; mild forms of the
disorder, however, may not be evident until
the child is seven (second grade) or older,
when language ordinarily becomes more
complex.
Course. Although many
children with Developmental Receptive
Language Disorder do eventually acquire
normal language abilities, some of the more
severely affected do not.
Prevalence. Estimates range
from 3% to 10% of school-age children.
Familial pattern. No information.
Differential diagnosis. Mental
Retardation involves impaired language
comprehension that is commensurate with the
general impairment in intellectual
functioning. Hearing impairment, identified
by audiometric testing, may also produce
abnormal functioning in language
comprehension. In Pervasive Developmental
Disorders, when there is impairment in
language comprehension, there are usually few
or no attempts to communicate nonverbally
(eg, through gestures) and little or no
imaginary play. Elective Mutism involves
limited expressive output that may suggest
Developmental Receptive Language Disorder,
but upon formal testing, comprehension is
found to he within normal limits. Acquired
aphasia is distinguished from Developmental
Receptive Language Disorder by a history of
onset associated with head trauma, seizures,
or EEG abnormalities, or by "hard"
neuralgic signs such as hemiplegia.
Diagnostic Criteria For
Developmental Receptive Language Disorder
A. The score obtained from a
standardized measure of receptive language is
substantially below that obtained from a
standardized measure of nonverbal
intellectual capacity (as determined by an
individually administered lQ test).
B. The disturbance in (A)
significantly interferes with academic
achievement or activities of daily living
requiring the comprehension of verbal (or
sign) language. This may be manifested in
more severe cases by an inability to
under-stand simple words or sentences. In
less severe cases, there may be difficulty in
understanding only certain types of words,
such as spatial terms, or an inability to
comprehend longer or more complex statements.
C. Not due to a Pervasive
Developmental Disorder, detect in hearing
acuity, or a neuralgic disorder (aphasia).
SPEECH
DISORDERS
NOT ELSEWHERE CLASSIFIED
Cluttering
The essential feature of Cluttering is a
disturbance of fluency involving an
abnormally rapid rate and erratic rhythm of
speech that impedes intelligibility. Faulty
phrasing patterns are usually present so that
there are bursts of speech consisting of
groups of words that are not related to the
grammatical structure of the sentence. The
affected person is usually unaware of any
communication impairment.
Associated features.
Common associated features include:
(a) articulation errors
(with sounds or syllables being omitted,
substituted, or transposed);
(b) expressive language
errors involving lapses in syntax (Example:
entire words may be omitted, or replaced with
"uh");
(c) Academic Skills
Disorders;
(d) Attention-deficit
Hyperactivity Disorder; and
(e) auditory-perceptual or
visual-motor impairments.
Age at onset. Usual onset of
the disorder is after the age of seven.
Course, impairment, complications,
predisposing factors, prevalence, and sex
ratio. No information.
Familial Pattern. There may
be a family history of Cluttering or of
impairment in spoken or written language.
Differential diagnosis.
Normal childhood dysfluency is an
intermittent and transient condition
occurring around the age of two years.
Stuttering and spastic dysphonia are
characterized by an awareness or distress
about the speech dysfluency that is not
present in Cluttering.
Diagnostic Criteria for Cluttering
A disorder of speech fluency
involving both the rate and the rhythm of
speech and resulting in impaired speech
intelligibility. Speech is erratic and
dysrhythmic, consisting of rapid and jerky
spurts that usually involve faulty phrasing
patterns (e.g., alternating pauses and bursts
of speech that produce groups of words
unrelated to the grammatical structure of the
sentence).
Stuttering
The essential feature of this disorder is
a marked impairment in speech fluency
characterized by frequent repetitions or
prolongations of sounds or syllables. Various
other types of speech dysfluencies may also
be involved, including blocking of sounds or
interjections of words or sounds. The extent
of the disturbance varies from situation to
situation and is more severe when there is
special pressure to communicate, as during a
job interview. There are anecdotal reports
that in even the most severe cases,
Stuttering is often absent during oral
reading, singing, or talking to inanimate
objects or to pets. In the United States,
stammering is not distinguished from
Stuttering.
Associated features. With
the initial onset of the disorder, the
speaker is usually unaware of the problem.
Later, awareness and even fearful
anticipation of the problem occur.
The speaker may attempt to avoid stuttering
by:
- linguistic mechanisms (e.g., altering
the rate of speech, avoiding certain
speech situations such as telephoning
or public speaking, or avoiding
certain words or sounds); and
- motor movements accompanying the
speech dysfluencies (eye blinks,
tics, tremors of the lips or face,
jerking of the head, breathing
movements, or fist clenching).
Other disorders commonly associated with
Stuttering in childhood include Developmental
Articulation Disorder, Developmental
Expressive Language Disorder,
Attention-deficit Hyperactivity Disorder, and
Anxiety Disorders.
Age at onset. Stuttering
begins during the course of speech and
language development. Retrospective studies
of people with Stuttering report onset
typically between ages two and seven (with
peak onset at around age five). Onset occurs
before age ten in 98% of cases.
Course. The onset of
Stuttering is usually insidious, covering
many months during which time episodic,
unnoticed speech dysfluencies become a
chronic problem. Typically, the disturbance
starts gradually, with repetition of initial
consonants, whole words that are usually the
first words of a phrase, or long words. The
child is generally not aware of the
Stuttering. As the disorder progresses, the
repetitions become more frequent, and the
Stuttering occurs on the most important words
or phrases. As the child becomes aware of the
speech difficulty, mechanisms for avoiding
the dysfluencies, motor responses, and
emotional responses may appear.
Approximately 80% of people with Stuttering
recover (60% spontaneously), recovery
typically occurring before age 16. Aside from
gender, recovery being more common in
females, no factors (including treatment, age
at onset, or seventy) have been shown to be
clearly associated with recovery.
Impairment and complications.
Impairment of social functioning may result
from associated anxiety, frustration, or low
self-esteem. In adults, limitation in
occupational choice or advancement is the
principal complication.
Predisposing factors. Recent
research involving family and twin studies
provides strong evidence of a genetic factor
in the etiology of Stuttering. The presence
of Developmental Articulation or
Developmental Expressive Language Disorder,
or a family history of these, increases the
likelihood of Stuttering. Stress or anxiety
have been shown to exacerbate Stuttering, but
are not thought to play a role in the
etiology.
Prevalence. Approximately 5%
of children have Stuttering. Stuttering is
more common in younger children than in older
ones, an estimated 10% of
elementary-school-age children being
affected. The prevalence for adults is
estimated at 1%.
Sex ratio. The
male-to-female ratio is approximately three
to one.
Familial pattern. There is a
strong familial incidence, some studies
reporting as many as 50% of first-degree
biologic relatives being affected. There is
high concordance in monozygotic twins.
Differential diagnosis. Stuttering
must be distinguished from normal childhood
dysfluency, an intermittent speech dysfluency
with no associated features occurring around
age two. The clinical features are virtually
indistinguishable from Stuttering. Therefore,
most speech pathologists consider stuttering
behavior, when it occurs before age three, to
be "normal childhood dysfluency"
rather than Stuttering. Cluttering is
distinguished from Stuttering by a rapid rate
of speech, severe impairment of speech
intelligibility, and lack of awareness of the
disturbance. Spastic dysphonia, a speech
disorder similar to Stuttering, is
distinguished from the latter by the presence
of an abnormal pattern of breathing.
Diagnostic Criteria for Stuttering
Frequent repetitions or prolongations of
sounds or syllables that markedly impair the
fluency of speech.
MOTOR
SKILLS DISORDERS
Developmental
Coordination Disorder
The essential feature of this disorder is
a marked impairment in the development of
motor coordination that is not explainable by
Mental Retardation and that is not due to a
known physical disorder. The diagnosis is
made only if this impairment significantly
interferes with academic achievement or with
activities of daily living.
The manifestations of this disorder vary with
age and development: young children exhibit
clumsiness and delays in developmental motor
milestones (including tying shoelaces,
buttoning shirts, and zipping pants); older
children display difficulties with the motor
aspects of puzzle assembly, model-building,
playing ball, and printing or handwriting.
Associated features. Commonly
associated problems include delays in other
nonmotor milestones, Developmental
Articulation Disorder, and Developmental
Receptive and Expressive Language Disorders.
Age at onset. Recognition of
the disorder usually occurs when the child
first attempts such tasks as running, holding
a knife and fork, or buttoning clothes.
Course. the course is
variable. In some cases, lack of coordination
continues through adolescence and adulthood.
Prevalence. Prevalence has
been estimated to be as high as 6% for
children in the age range of 5-11 years.
Familial pattern. No
information.
Differential diagnosis. In
specific neuralgic disorders that may be
associated with problems in coordination
(e.g., cerebral palsy, progressive lesions of
the cerebellum), there is definite neural
damage and abnormal findings on conventional
neuralgic examination. In Attention-deficit
Hyperactivity Disorder, there may be falling,
bumping into things, or knocking things over
because of distractibility and impulsiveness.
In Mental Retardation, there may be delays in
motor milestones, but these are associated
with the general impairment in intellectual
functioning. Similarly, in Pervasive
Developmental Disorders, an abnormal gait and
delays in motor milestones are part of a
marked and pervasive history of abnormal
development.
Diagnostic Criteria For
Developmental Coordination Disorder
A. The person's performance in daily
activities requiring motor coordination is
markedly below the expected level, given the
person's chronological age and intellectual
capacity. This may be manifested by marked
delays in achieving motor milestones
(walking, crawling, sitting), dropping
things, "clumsiness," poor
performance in sports, or poor handwriting.
B. The disturbance in (A)
significantly interferes with academic
achievement or activities of daily living.
C. Not due to a known
physical disorder, such as cerebral palsy,
hemiplegia or muscular dystrophy.
SPECIFIC
DEVELOPMENTAL DISORDER
NOT OTHERWISE SPECIFIED
Disorders in the development of language,
speech, academic, and motor skills that do
not meet the criteria for a Specific
Developmental Disorder. Examples include
aphasia with epilepsy acquired in childhood
("Landau syndrome") and specific
developmental difficulties in spelling.
OTHER
DEVELOPMENTAL DISORDERS NOT OTHERWISE
SPECIFIED
Disorders in development that do not meet
the criteria for either Mental Retardation or
a Pervasive or a Specific Developmental
Disorder.
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