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AACAPOFFICIALACTION
ofChildrenandAdolescentsWithLanguage andLearningDisorders
ABSTRACT
These parameters describe the aims and approach to diagnosis,treatment, and monitoring of children and adolescents
with language and learning disorders (LLDs). LLDs are among the most common developmental disorders the clinician
is likely toencounter.About 50% of children with an LLD also have a comorbid Axis I psychiatric disorder.The diagnosis
of an LLD requires a discrepancy, based on age and intelligence, between potential and achievement. The clinician
remediation,and monitorprogress.The clinician is instrumental in identifying and treating comorbid conditions. including
determiningthe appropriatenessof medication.Long-term prognosisdepends on the type and severity of the LLD.the
availabilityof remediation.and the presence of a supportive familyand school environment.
J.Am.Acad.ChildAdo/esc.
Psychiatry.1998, 37(10KeyWords:language.learning,disorders.disabilities,diagnosis, treatment, children, adolescents,practice parameters,guidelines. Languageand learning disorders (LLDs) are among the most common ofthe psychiatric anddevelopmentaldisordersthat a clinicianis likely toencounter(Cantwell and Baker,1987; Fornessand Kavale, 1989). Many children who are referred for evaluation because ofbehavioraldifficulties at school or conflictsaroundcompletinghomeworkhave unrecognized languageor learning difficulties (Gresham, 1988;Kauffman,
1997;Little, 1993;Pearland Bryan. 1994).Indeed.somestudies
haveshown that as many as one third ofchildren referredto mental health centers have undiagnosedspeech and language problems(Cohener al., 1993). ChildrenwithdocumentedLLDs may be referred for emo tional or behavioralproblems associated orcomorbidwith
those disorders. Performance anxiety,poor peer relationships,Theseumr developedbyjoseph H.Beitchman,M.D.,DennisP.
Cantwell:M.D.. Steoen R.Forness, Ed.D..Ph.D.,andfames M. lWuffinan.Ed.D.,principalauthors.andw\'rkGroupon QualityIssues: WilliamBernet,M.D.• Chair,and johnE.Dunne, M.D..formerChair; MaurunM.D.,Arnold,M.D.,R.Scott Benson,M.D.•Oscar
Bukstein,
M.D..joanKinlan,M.D.•jonMcClrllan,M.D.,and DavidRu". M.D.MCAPStaff.L.ElizabethSwan,L.p.eTh"authorsthank MinaDulcan, M.D.. jackM.Fletcher;Ph.D.,RichardMattison, M.D.•H.A.P.Myers,M.D..
BrucePennington, M.D.•Lawrence
Silva,M.D.,johnj.Stine, M.D.,and
madeavailableto thr entireAcademymembrrshipfOrreoino in October/997 and toMCAPmemberson theWorldWitk(www.aacap.org). ReprintrtqumstoMCAP.Communications Department,3615Wisconsin
N.w..Washington,DC20016.
0890·8567/98/3710-0046S/$03.00/0©1998by the American Academy
ofChildand Adolescent Psychiatry. familyconflicts, and decreasedself-esteem arecommoncon comitants ofLLDs,even if criteriafor an Axis I disorder are not met(
Falik, 1995).For at least someofthesechildren,
parents and teachers maynot recognizetheimportance ofthe LLDs in theemotionalor behavioral problems.These prob lems are more likely toemerge aschildren mature and aca demictasksbecomemorecomplexand peerinteractions become moreimportant. Theclinician can be pivotalin helping the child and family address the social,emotional,behavioral, and family prob lems that arecommonamong children with LLDs. Clinicians shouldbe familiarwiththeIndividuals
WithDisabilities
EducationAct (IDEA) (Public Law 94-142) (U.S.Depart ment ofEducation,1995;Yelland Shriner, 1997), which defines the levelof disability necessary for a child or adoles cent tobe eligible for specialeducationservices inpublic schools and mandates thedevelopmentandimplementation of an IndividualEducationPlan (IEP)(Council ofAdmini strators ofSpecialEducation,1992;Yelland Shriner. 1997;
Zirkel,1995).LITERATUREREVIEW
Eight books and two special issuesofa learning disabilities journalwere evaluated in depth.Computerizedsearcheswere conducted using
Medline,PsychInfo,andERICfor the period
1980through1995 using the keywords
aphasia,languagedis orders, speechdisorders. communication disorders,academic d and secondary literature citations yielded more than 1,000 pertinentabstracts.
Ofthese,225 abstracts were selected and
46SJ.AM.ACAD.CH ILDADOLESC.PSYCHIATRY.37:10SUPPLEMENT.OCTOBER1998
82 articles from these andothersecondary sources were re
viewed. In addition, following feedback from expert reviewers, new articles and recent seminalcontributionswere selected forexaminationand inclusionasappropriate.
Definitions
Therehas been controversyaboutthe inclusionofLLDs in classifications ofmental disorders,such asDSM-IV(Ameri can PsychiatricAssociation, 1994).LLDs do fit the defini tion ofmentaldisorderinDSM-IV:"a clinically significant behavioral or psychologicalsyndromeorpatternthat occurs in anindividualand that is associated with present distress ...or disability ...or with a significantly increased riskof suffering.. . ." (p xxi).
Disorders
oflanguage and learning are similar in a variety ofways,includingthe essentialand associated features, risk factors,prevalence inepidemiologicalsamples, and possible eciologicalfactors. Similaritiesalsoare found in the assessment techniquesthat are needed,outcomes,and natural history. Thecentral clinical featureofa languageor learning disorder is the lack ofnormaldevelopmentofaparticulardevelop mental skill, either cognitive or linguistic.
Thenatureofthe
skill differs with each disorder.Developmentalexpressivelan guagedisorder, for example, isanimpairmentin the acquisi tion oflanguageproductionability. Developmentalreading disorder,on the otherhand, isasig nificantimpairmentin readingacquisitionthat is not due to a physical,neurological, orenvironmentalcause. Moreover, LLDs range in type and severity from subtle to markedimpairment. Some LLDs are easilyobservable on clinical assessment, while others are diag nosable onlythroughstandardized testing (Hyndand Sernrud
Clikernan,1989;
ObrzutandBolick, 1991;Petersonand
Marquardt,1990).
learning disorders, is still a controversialtopic that has been discussed by severalauthors(Beitchmanand Young, 1997; Cantwell and Baker,1987,1991;Hammill,1990; Kavaleet al.,
1991;Kavale and Forness, 1995;Shaw eral.,1995).Among
the mostimportantdefinitionsis thatincludedin thecurrent IDEA,which stresses that learning disabilitiesare processing disorders thatresult in asignificantdiscrepancybetween potentialand acquisition ofvariousacademicor language skills.
Theextentofdiscrepancy in anindividualchild, and
thepointat which a clinicalcutoffis reached,isopen to con siderableinterpretation (A1gozzineet al.,1982; C1arizioand Phillips,1989;Evans, 1990;Hallahanand Kauffman, 1997; Kavaleer al.,1994; Shaywitz etal.,1992a,b; Wong, 1989). It alsoshouldbe noted that each state is free tointerpretclinical cutoffpointsfor discrepancyand for processingdisorders, such that considerable variabilityexistsfrom state to state (Chalfant,
1987;Coutinho,1995;Frankenbergerand Fronzaglio, 1991;
Mercer et aI., 1990). Inaddition,the emphasis on processing LLD isunfortunate,sincemeasurementofso-called "processing" disorders isnotoriouslydifficult(Felton andWood,1989; Kavaleand Forness, 1995; Kirbyer al.,1996; Swanson,1987,
1988).
TheDSM-IVrequires delays in expressiveor receptive lan guage,not due to sensory ormotordeficit orenvironmental deprivation,in excess ofthat based on scoresofnonverbal intelligence.Thisdefinition oflanguage disorders is some times referred to as specific languageimpairment.However, there are few empirical data tosupportthisdefinition,and Bishop (1994) concludes that there may be nofundamental difference between children with languageimpairmentswho have a large discrepancy between
IQand verbalfunctioning
and those who do not. Sincecurrentlythere isinsufficient empiricalinformationtodemonstratewhere theboundaries defining languagedisordersshould be drawn, it seemspreferable to consider all children whoshow evidence ofage-discrepant language skillsas in need ofassessmentand possible interven tion.Future studiesshouldclarifythedistinctionsand relative merits ofthe differentdefinitionsoflanguageimpairment. TheDSM-IVdefinitionoflearningdisorders also requires anIQ-achievementdiscrepancy.Effectively this defines two groups ofpoor readers, those who read poorly incomparison to their
IQand those who read poorly incomparisonto their
age ,irrespective oftheirIQ.Rutterand Yule (1975) have shown that readingachievementfalls on abimodalcontin uum. Themajorityofreaders fallalong a bell-shaped normal distribution,but a second distribution,appearingasa"hump" at thebottom ofthe normaldistribution,reflectsthe excessof children who read more poorly than would be expected on the basis oftheirIQscores,i.e.,the so-calledIQ-achievement discrepancydefinitiongroup. Researchduringthe past 10 years has challenged the IQ (see Fletcher et al., 1994; Shaywirz, 1996; Shaywitz et al.,
1992a, 1996; and Sranovich,1991,forfurtherdiscussion). In
brief,research has failed todemonstratevaliddifferences between groups ofchildrendefined with orwithoutanIQ lated evidence fromnumerousstudies indicates that in most cases,childrenwitha readingdisabilityhave a deficitin phonological-processingskills.Theseskills are necessary for detecting andmanipulatingindividualspeechsoundsor phonemes(the smallestsoundsegment oflanguage that can change the meaning ofa word) and arethoughtto be the main source ofimpaired word recognition and difficultydecoding or "sounding out"unfamiliarwords (Love and Webb, 1992; Shaywirz,1996;Torgesen etal.,1994).Accordingto this viewpoint.reading disability represents the lower tail ofthe normaldistribution ofreading ability, and the same processes thatareinvolvedinreadingalso areinvolvedinreading disability. J.AM.ACAD.CHILDADOLESC.PSYCHIATRY.37:10SUPPLEMENT.OCTO BER1998475
AACAPPRACTICEPARAMETERS
achievers as also have beenfoundtoidentifychildrenwithmore specific language deficitscomparedwith agediscrepancydefinitions, thoughthisaccountsfor little variance onneuropsychological measures(Penningtonet al., 1992).
Despitecriticisms
ofthediscrepancy-baseddefinitions.a consensuson howlearningdisabilitiesshouldbe defined does not yet exist.Thislack ofconsensus isoneofthe mostimpor tantissues facingeducators.clinicians.parents.andchildren, because thedefinitionuseddetermineswhichchildren,with whichlevel ofreadingability, qualify asreading-disabledand based definitions excludelargegroups oflow-achievingchildren (e.g.•childrenwithborderline
IQscores). who often are more
impairedthanotherchildrenwho qualify asreading-impaired. Cliniciansmustbe sensitive to these issues to ensurethatlow
Recentresearchinreading
andacademicachievement LLDs. earlyidentification andearlyremediation.incontrastto fordiagnosis andremediation.Thedomain-basedapproach also focuses oncognitiveabilities. such asphonologicalaware ness,listeningcomprehension,and word retrieval.allowing remediationefforts to target directly the areas ofdeficit.
Etiology
Exactetiologiesareunknownfor the LLDs.butfamily.
genetic,cognitive, andneuroanatomicalfactors have been suggested (Hallahanet al.,1996;LoveandWebb,1992; Murdoch.1991; Rourke. 1989; Swanson, 1987. 1988; Zernlin,
1988).Environmentalfactors have long been recognized for
theirrole in thedevelopment oflanguageandlearning.For example,the bestsinglepredictor ofgrowthinchildren's vocabulary duringthe early stagesoflanguagelearningis the numberofwords heard perunitoftime fromtheirmothers (Huttenlocherer aI., 1991). Positive benefits ofreadingto childrenontheirvocabularyknowledge andknowledgeof the world have beendocumented,confirmingthewidespread conclusion only a weakrelationshipisevidentbetweenreading to chil dren andtheir success at learningto read (BradyandMoats, pared withcontrols,have beendescribedasneedingahigher threshold ofexposure to novel words (i.e.,numberoftimes they hearaword)for successfulacquisition(Rice er al.,1994). Thislatterview isconsonantwith recent researchthat hasquestionedthe etiological role ofenvironmentalfactors in thedevelopment oflanguage disorders (Bishop et al.,1995;
Tomblinand Buckwalter, 1994).
Asecondline
ofresearch suggeststhatchildrenwith lan guage stimuli(Tallal et aI.,1985),suggestingthatauditorytemporal processingabilitiesrepresenta biologicalriskmarkerfor languageimpairment.Deficits in rapid (tens ofmilliseconds) temporalprocessing ofauditoryinformationmayunderlie problemsin thereception andproductionofspeechinfor mation(Fitch et al., 1997).
Thedifficultyinprocessingquick
tonal changes may beresponsiblefor thedeficientphonemic discrimination andlowphonologicalawarenessassociated with poorreadingskillsanddyslexia (Tallal et al., 1985). (Johnson.1994) or a specific deficit in thephonologicalloop
1990) have been offered asalternativetheories.
Thestrongestevidence to datesupportS(1)theheritability oflanguagedisorders(Hurstet al.,1990;Tomblinand Buckwalter, 1994) andreadingdisorders(Pennington.1995) and(2) the roleofdeficits inphonologicalawareness as the basiccomponent ofreadingdisability. A recentstudyoftwins with languageimpairmentshowedhigherconcordancerates amongmonozygoticthandizygotictwins(Bishopet aI.,
1995).Inparticular,disorders
ofexpressive language, with andwithoutdisorders ofarticulation,showedstrongevidence lationdisordersalso isfoundin thestudiesofLewisand
Thompson,1992).
Evidence from family and twinstudiesalso suggeststhat reading disabilities are familial andheritable andthatthey are geneticallyheterogeneous(Pennington,1995). Across family studies. thefamilialrisk tofirst-degreerelatives has been foundto bebetween35%and45%.comparedwiththe populationriskof3% to 10%.Theprecise modeoftransmis sion is notknown, butthere is evidence for a singlemajor locus(Penningtonet aI., 1991),apolygenicor amultifac torial mode oftransmission(Pennington.1995),and aquan titativetrait locus(Cardonet al.,1994).
Available data on thegenetictransmission
ofreadingskiIls anddisabilitiesdo notclarifywhetherthe same genes are involvedin thetransmission ofreadingdisabilitiesandof normalreadingvariation.Unlike amajorgene effect (or a disease gene). aquantitativetraitlocus isneithernecessary forreadingdisabilitiesmay be categorical orcontinuous.A small numberofquantitativetraitloci mayunderliethe transmission ofbothreadingdisabilitiesandnormalvaria tionsinreadingskill (Pennington.1995).Morerecently,
485].AM.ACAD.CH ILDADOLESC.PSYCHIATRY. 37:10SUPPLEM ENT,OCTOBER1998
Grigorenkoet al. (1997) have shown linkage between chro mosome6 andphonologicalawareness (the linguistic precur sor todecodingsingle words). andchromosome15and single word reading.Theseresults replicate previous reports ofa genetic association between reading disabilities andchromo somes 6 and 15. Since LLDs are heterogeneous. there is likely to be more biological basis for a deficit does not mean that itcannotbe remedied butdoessuggestthatatheoreticallygrounded instructionisnecessaryto remedy oraccommodatethe deficit. Onset AlldevelopmentalLLDs have onset in earlychildhood, thoughreadingproblemsare frequently discovered only after a child enters school.
TheacquiredtypeofLLDs can have
onset at any time.Althoughthere isconsiderablevariability in clinicalpresentation,a child with an LLD may resemble a normalthoughyoungerchild.Thus,a child aged 9 yearswith a reading disorder may exhibit the reading skills ofa normal childaged 6 years. Likewise,a child aged 10 years with a languagedisordermay exhibit the languageproductionskills ofanormalchild aged7years.
EPIDEMIOLOGY
TheprevalenceofLLDs in the generalpopulationvaries dependingon the samples, diagnostic criteria. andinstruments and assessment procedures used (Bernstein andTiegerman,
1985;Hallahanand Kauffman. 1997;Hallahanet al., 1996;
KavaleandForness,1995;Murdoch. 1991;Myersand Hammill.
1992).As agroup,LLDscomprisea verycommonset
of problems,withestimates that as many as 10% to20%of childrenandadolescentshave a languageand/orlearning disorder(Beitchmanet al., 1986b). LLDs make up the two mostcommondisability categories in the public schools. and theyaccountfor2.3%(language disorders) and 5.3% (learning disabilities) ofthe 10.3%of school-age children in specialeducation(U.S.Departmentof Education,1995).Thesefigures refer only tochildrencur rently receiving school services for the disorders,and there is evidence thatthenumberswouldbehigherifsufficient services were available (Shaywirz er al., 1992a).
From 1% to 13%
ofthepopulationhave either a develop mental expressive or receptive languagedisorder(Cantwell and Baker,1991; Myers andHammill,1992). Some 3% to 5% ofchildrenare specified inDSM-IVashaving a develop mental expressive language disorder. the majorityquotesdbs_dbs17.pdfusesText_23
[PDF] Specific Speech & Language Disorder Fact-Sheet