Spoken Language Disorders

See the Assessment section of the Spoken Language Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective.

Screening

Screening of spoken language skills is conducted if a language disorder is suspected. Screening does not result in a diagnosis, but rather indicates the potential need for further assessment.

Screening typically includes

  • gathering information from parents and/or teachers regarding concerns about the child's languages and skills in each language;
  • conducting a hearing screening to rule out hearing loss as a possible contributing factor to language difficulties;
  • administering formal screening assessments that have normative data and/or cutoff scores and demonstrated evidence of adequate sensitivity and specificity;
  • using informal measures, such as those designed by the clinician and tailored to the population being screened (e.g., preschool vs. school age/adolescence);
  • screening of articulation if indicated.

Screening may result in recommendations for

  • complete audiologic assessment;
  • comprehensive language assessment;
  • comprehensive speech sound assessment, if the child's speech sound system is not appropriate for his/her age and/or linguistic community.

Comprehensive Assessment

Individuals suspected of having a language impairment based on screening results are referred for a comprehensive, linguistically appropriate assessment by a speech-language pathologist and other professionals as needed. Assessment of language skills should be culturally relevant and functional and involve the collaborative efforts of families/caregivers, classroom teachers, SLPs, special educators, and other professionals as needed. See assessment and evaluation of speech-language disorders in schools.

Assessment typically includes the following, with consideration made for the age and linguistic development of the child:

  • relevant case history, including
    • birth and medical history;
    • family history of speech, language, reading, or academic difficulties;
    • family's concerns about the child's language (and speech),
    • languages and/or dialects used in the home, including
      • age of introduction of a second language, as appropriate,
      • circumstances in which each language is used;
    • teachers' concerns regarding the impact of child's language difficulties in the classroom;
  • hearing screening, if not available from prior screening;
  • oral mechanism examination;
  • spoken language testing, including
    • phonology, including phonological awareness,
    • semantics,
    • morphology,
    • syntax,
    • pragmatics, including discourse-level language skills (conversation, narrative, expository).

A literacy assessment (reading and writing) is included in the comprehensive assessment for language disorders because of the well-established connection between spoken and written language. Components of a literacy assessment will vary, depending on the child's age and stage of language development, and can include pre-literacy, early literacy, and advanced literacy skills. See the assessment section of the Written Language Disorders Practice Portal page.

A speech sound assessment may also be included, given that speech sound errors can be a result of a phonological disorder, an articulation disorder, or a combined phonological/articulation disorder. See speech sound disorders: articulation and phonology.

The following procedures and data sources may be utilized in the comprehensive assessment for spoken language disorders (SLD):

Standardized Assessment—an empirically developed evaluation tool with established reliability and validity. Standardized language assessments can be used to identify the broad characteristics of language functioning, but should not be used solely to make the diagnosis of SLD. Given the nuanced and subtle nature of strengths and deficits that many children demonstrate, standardized assessments alone are not sufficient to capture the variety of language details that constitute an individual's profile.

At this time, there are very few standardized assessments for individuals who speak a language other than English or who speak a dialect of English. It is essential to consider the language spoken and/or dialect used by the child before selecting a standardized assessment. Translation of a standardized assessment invalidates the results. Standard scores may not be reported when the assessment has been translated. See cultural competence and bilingual service delivery.

Language Sampling—techniques to elicit spontaneous language in various communication contexts (e.g., free play, conversation/dialogue, narration, expository speech) and derive measures (e.g., Mean Length of Utterance [MLU], Type-Token Ratio [TTR], Developmental Sentence Scoring [DSS], clausal density, use of subordinate clauses) to complement data obtained from standardized language assessments.

Dynamic Assessment—a language assessment method in which an individual is tested, skills are addressed, and then the individual is re-tested to determine treatment outcome (i.e., test-teach and re-test). Dynamic assessment can help distinguish between a language difference and a language disorder and can be used in conjunction with standardized assessment and language sampling.

Systematic Observation/Contextual Analysis—observation in the classroom and in various other contexts to describe communication and identify specific problem areas. Descriptions of language functioning across a variety of settings and tasks are used to identify contextual variables that play a part in the student's communication abilities and to complement findings from other assessment procedures.

Ethnographic Interviewing—a technique for obtaining information from the student and the student's family/caregiver and teachers that avoids the use of leading questions and "why" questions and uses open-ended questions, restatement, and summarizing for clarification. The ethnographic technique is used to obtain information from the perspective of the student and other individuals in the student's environment and to validate other assessment findings.

Parent/Teacher/Child Report Measures—checklists and/or questionnaires completed by the family member(s)/caregiver, teacher, and/or student. These report measures enable the clinician to obtain a comprehensive profile of language skills by comparing findings from multiple sources (e.g., family vs. teacher vs. self-report). For individuals who speak a language other than English in the home, the clinician needs to gather detailed information about use of the primary language and English.

Curriculum-Based Assessment—a technique that uses probes, protocols, and direct assessment to determine the language demands of the curriculum and assess the student's ability to handle those demands.

Assessment may result in

  • diagnosis of a spoken language disorder (receptive language disorder only, expressive language disorder only, or expressive-receptive mixed);
  • determination of a language delay in the absence of a language disorder (i.e., language delay due to environmental influences);
  • description of the characteristics and severity of the disorder or delay;
  • determination of performance variability as a function of communicative situations/contexts;
  • identification of literacy problems;
  • diagnosis of a speech sound disorder;
  • identification of possible hearing problems;
  • recommendations for intervention and support;
  • referral to other professionals as needed.

Special Considerations For Diagnosis of SLD

Early Identification

Not all children with early language delay (late talkers) have significant language problems when they reach school age (Paul, 1989, 1996; Rescorla, 2002), making it difficult to diagnose a language disorder before the age of about 3 years (Leonard, 1998). However, given the risk that language disorders pose for students, children need to be assessed for language difficulties early and monitored periodically at critical educational stages (e.g., in preschool; then in kindergarten, second grade, and third grade; early middle school; and high school) to track language development and identify any problems that might arise.

It is especially important to monitor and assess young children on a regular basis, if multiple risk factors are evident (e.g., family history of language problems, chronic otitis media, cognitive delay, social communication difficulties, and environmental risks; Paradise et al., 2000; Paul, 1996, 2007).

Changing Nature of SLD

Children with SLD demonstrate differing patterns of strengths and weaknesses across listening, speaking, reading, and writing; those patterns of strengths and weaknesses may vary over time. In some cases, the language skills of children with SLD become seemingly similar to those of children without SLD.

However, as the complexity of the language demands increase, difficulty may resurface in one or more language domains. This phenomenon is referred to as illusory recovery (Scarborough & Dobrich, 1990). Although children may acquire new vocabulary or improve their use of grammatical forms following language intervention, they may not actually catch up to their peers. In fact, their rate of language growth may slow or level off when they reach early adolescence, resulting in language levels below those expected for their age groups (Rice, 2013).

For this reason, it is important that practitioners use valid and reliable standardized assessments with normative data, in addition to other data sources (e.g., informal measures, benchmarking, progress reports, etc.), when evaluating the language skills of children with SLD over time.

Cultural and Linguistic Considerations

A communication difference/dialect is a variation of a symbol system—used by a group of individuals—that reflects and is determined by shared regional, social, or cultural/ethnic factors. This variation should not be considered a disorder of speech or language.

In addition, children who demonstrate typical patterns of dual language learning, are learning English as a second language, or speak a non-standard dialect of English should not be considered as having a spoken language disorder, based only on those differences (ASHA, 1993).

Clinicians face unique challenges when identifying SLD in children who speak a dialect of English, are bilingual, or are learning English as a second language. Distinguishing difference from disorder requires familiarity with the rules of the spoken dialect, awareness of typical dual language acquisition from birth, and understanding of the sequential process of second language acquisition. For children who speak a non-standard dialect of English, special consideration is given to the influence of the rules of that dialect on assessment measures, which are typically based on standard American English. Results are not valid, if the norming sample of an assessment is not representative of the child being assessed.

Some linguistic characteristics of dual language learning (simultaneous bilingualism) and second language (L2) acquisition (sequential bilingualism) may be the same as those of monolingual children with language impairment.

There is little research/information regarding bilingualism and the broader scope of spoken language disorders, as defined in this Portal page. However, a number of studies have identified potential areas of overlap between second language learners and monolingual children with SLI—one type of spoken language disorder:

  • similar morphosyntactic profiles (Paradis & Crago, 2000, 2004),
  • reduced processing efficiency (Windsor & Kohnert, 2004),
  • superficial impairment in vocabulary development—when combined vocabularies in both languages are not taken into account (Paradis, Genesee, & Crago, 2011).

Bilingualism is not a cause of language impairment. Typical processes of bilingualism, such as code-mixing, will be seen in bilingual children who have SLI (Gutiérrez-Clellen, Simon-Cereijido, & Leone, 2009). Language dominance may vary across the different domains of language—for example, dominance in L1 in receptive language and dominance in L2 expressively. This also may shift over time relative to environmental linguistic demands. See cultural competence, bilingual service delivery, and phonemic inventories across languages for assistance in distinguishing difference from disorder.

Special Considerations for the School Setting

Disproportionality of Identification

Given the overlap in linguistic characteristics of children during typical bilingual language acquisition and those of monolingual children with language impairment and the reliance on standard measures that are based on rules of standard American English for diagnosis, there is a disproportionate number of linguistically diverse children (e.g., those who speak English as a second language or a dialect of English) who have been (and likely continue to be) identified with speech-language impairment in the school setting. Non-normed (criterion) measures, ethnographic interviewing, and dynamic assessment procedures are fundamental to differentiating a difference from a disorder. Children who have been identified with a difference and not a disorder are not eligible for publicly funded speech-language pathology services.

Cognitive Referencing

In the schools, children and adolescents with SLD should be eligible for speech-language services, due to the pervasive nature of language impairment, regardless of cognitive abilities or performance on standardized testing. As mandated by the Individuals with Disabilities Education Improvement Act (IDEA, 2004), categorically applying a priori criteria (e.g., discrepancies between cognitive abilities and communication functioning, chronological age, or diagnosis) in making decisions on eligibility for services is not consistent with the law and IDEA regulations. Also see National Joint Committee for the Communication Needs of Persons With Severe Disabilities (2002) for information related to a priori criteria.

For more information about eligibility for services in the schools, see eligibility and dismissal in schools, IDEA Part B Issue Brief: Individualized Education Programs and Eligibility for Services , and 2011 IDEA Part C Final Regulations.

The practice of cognitive referencing, or denying individuals with disabilities access to communication services and supports because their language skills are determined to be commensurate with their cognitive skills, purports that a language delay warrants intervention only when language skill development lags behind cognitive skill development.

Concerns regarding the use of cognitive referencing include

  • the relationship between language and cognition is neither straightforward nor static,
  • tests purporting to assess cognitive and linguistic performance often measure the same fundamental skills,
  • assessments typically used for deriving cognitive/language profiles yield sizable variation in discrepancy determinations,
  • children with impaired cognitive and language skills that are commensurate would not receive the diagnosis of language impairment or the associated language services they need.

Common Core State Standards

The Common Core State Standards (CCSS) are internationally benchmarked learning standards being implemented in most states across the country. The standards constitute a framework of knowledge and skills thought necessary to prepare students to enter college and the work force.

Students who have language disorders may require specialized instruction and support to access the CCSS, because language skills are addressed across subject areas and the English Language Arts standards focus on the use of language for communication and academic success. See common core state standards: a resource for SLPs for information and guidance on integrating the CCSS into intervention for students with language disorders.

Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.