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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 .

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Speech and Language Impairments

The Individuals with Disabilities Education Act, or IDEA, defines the term “speech or language impairment” as follows:

“(11)  Speech or language impairment  means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects a child’s educational performance.” [34 CFR §300.8(c)(11]

(Parent Information and Resources Center, 2015)

Table of Contents

What is a Speech and Language Impairment?

Characteristics of speech or language impairments, interventions and strategies, related service provider-slp.

• A Day in the Life of an SLP

Assistive Technology

Speech and language impairment  are basic categories that might be drawn in issues of communication involve hearing, speech, language, and fluency.

A speech impairment is characterized by difficulty in articulation of words. Examples include stuttering or problems producing particular sounds. Articulation refers to the sounds, syllables, and phonology produced by the individual. Voice, however, may refer to the characteristics of the sounds produced—specifically, the pitch, quality, and intensity of the sound. Often, fluency will also be considered a category under speech, encompassing the characteristics of rhythm, rate, and emphasis of the sound produced.

A language impairment is a specific impairment in understanding and sharing thoughts and ideas, i.e. a disorder that involves the processing of linguistic information. Problems that may be experienced can involve the form of language, including grammar, morphology, syntax; and the functional aspects of language, including semantics and pragmatics.

(Wikipedia, n.d./ Speech and Language Impairment)

*It’s important to realize that a language delay isn’t the same thing as a speech or language impairment. Language delay is a very common developmental problem—in fact, the most common, affecting 5-10% of children in preschool.  With language delay, children’s language is developing in the expected sequence, only at a slower rate. In contrast, speech and language disorder refers to abnormal language development.  Distinguishing between the two is most reliably done by a certified speech-language pathologist.  (CPIR, 2015)

The characteristics of speech or language impairments will vary depending upon the type of impairment involved. There may also be a combination of several problems.

When a child has an  articulation disorder , he or she has difficulty making certain sounds. These sounds may be left off, added, changed, or distorted, which makes it hard for people to understand the child.

Leaving out or changing certain sounds is common when young children are learning to talk, of course. A good example of this is saying “wabbit” for “rabbit.” The incorrect articulation isn’t necessarily a cause for concern unless it continues past the age where children are expected to produce such sounds correctly

Fluency  refers to the flow of speech. A fluency disorder means that something is disrupting the rhythmic and forward flow of speech—usually, a stutter. As a result, the child’s speech contains an “abnormal number of repetitions, hesitations, prolongations, or disturbances. Tension may also be seen in the face, neck, shoulders, or fists.”

Voice  is the sound that’s produced when air from the lungs pushes through the voice box in the throat (also called the larnyx), making the vocal folds within vibrate. From there, the sound generated travels up through the spaces of the throat, nose, and mouth, and emerges as our “voice.”

A voice disorder involves problems with the pitch, loudness, resonance, or quality of the voice. The voice may be hoarse, raspy, or harsh. For some, it may sound quite nasal; others might seem as if they are “stuffed up.” People with voice problems often notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use.

Language  has to do with meanings, rather than sounds.  A language disorder refers to an impaired ability to understand and/or use words in context. A child may have an expressive language disorder (difficulty in expressing ideas or needs), a receptive language disorder (difficulty in understanding what others are saying), or a mixed language disorder (which involves both).

Some characteristics of language disorders include:

• improper use of words and their meanings,
• inability to express ideas,
• inappropriate grammatical patterns,
• reduced vocabulary, and
• inability to follow directions.

Children may hear or see a word but not be able to understand its meaning. They may have trouble getting others to understand what they are trying to communicate. These symptoms can easily be mistaken for other disabilities such as autism or learning disabilities, so it’s very important to ensure that the child receives a thorough evaluation by a certified speech-language pathologist.

(CPIR, 2015)

• Use the (Cash, Wilson, and DeLaCruz, n.d) reading and/or the [ESU 8 Wednesday Webinar] to develop this section of the summary. 

Cash, A, Wilson, R. and De LaCruz, E.(n,d.) Practical Recommendations for Teachers: Language Disorders. https://www.education.udel.edu/wp-content/uploads/2013/01/LanguageDisorders.pdf 

[ESU 8 Wednesday Webinar] Speech Language Strategies for Classroom Teachers.- video below

Video: Speech Language Strategies for Classroom Teachers (15:51 minutes)’

[ESU 8 Wednesday Webinars]. (2015, Nov. 19) . Speech Language Strategies for Classroom Teachers. [Video FIle]. From https://youtu.be/Un2eeM7DVK8

Most, if not all, students with a speech or language impairment will need  speech-language pathology services . This related service is defined by IDEA as follows:

(15)  Speech-language pathology services  include—

(i) Identification of children with speech or language impairments;

(ii) Diagnosis and appraisal of specific speech or language impairments;

(iii) Referral for medical or other professional attention necessary for the habilitation of speech or language impairments;

(iv) Provision of speech and language services for the habilitation or prevention of communicative impairments; and

(v) Counseling and guidance of parents, children, and teachers regarding speech and language impairments. [34 CFR §300.34(c)(15)]

Thus, in addition to diagnosing the nature of a child’s speech-language difficulties, speech-language pathologists also provide:

• individual therapy for the child;
• consult with the child’s teacher about the most effective ways to facilitate the child’s communication in the class setting; and
• work closely with the family to develop goals and techniques for effective therapy in class and at home.

Speech and/or language therapy may continue throughout a student’s school years either in the form of direct therapy or on a consultant basis.

A Day in the Life of an SLP

Christina is a speech-language pathologist.  She works with children and adults who have impairments in their speech, voice, or language skills. These impairments can take many forms, as her schedule today shows.

First comes Robbie.  He’s a cutie pie in the first grade and has recently been diagnosed with childhood apraxia of speech—or CAS. CAS is a speech disorder marked by choppy speech. Robbie also talks in a monotone, making odd pauses as he tries to form words. Sometimes she can see him struggle. It’s not that the muscles of his tongue, lips, and jaw are weak. The difficulty lies in the brain and how it communicates to the muscles involved in producing speech. The muscles need to move in precise ways for speech to be intelligible. And that’s what she and Robbie are working on.

Next, Christina goes down the hall and meets with Pearl  in her third grade classroom. While the other students are reading in small groups, she works with Pearl one on one, using the same storybook. Pearl has a speech disorder, too, but hers is called dysarthria. It causes Pearl’s speech to be slurred, very soft, breathy, and slow. Here, the cause is weak muscles of the tongue, lips, palate, and jaw. So that’s what Christina and Pearl work on—strengthening the muscles used to form sounds, words, and sentences, and improving Pearl’s articulation.

One more student to see—4th grader Mario , who has a stutter. She’s helping Mario learn to slow down his speech and control his breathing as he talks. Christina already sees improvement in his fluency.

Tomorrow she’ll go to a different school, and meet with different students. But for today, her day is…Robbie, Pearl, and Mario.

Assistive technology (AT) can also be very helpful to students, especially those whose physical conditions make communication difficult. Each student’s IEP team will need to consider if the student would benefit from AT such as an electronic communication system or other device. AT is often the key that helps students engage in the give and take of shared thought, complete school work, and demonstrate their learning. (CPIR, 2015)

Project IDEAL , suggests two major categories of AT computer software packages to develop the child’s speech and language skills and augmentative or alternative communication (AAC).

Augmentative and alternative communication  ( AAC ) encompasses the communication methods used to supplement or replace speech or writing for those with impairments in the production or comprehension of spoken or written language. Augmentative and alternative communication may used by individuals to compensate for severe speech-language impairments in the expression or comprehension of spoken or written language. AAC can be a permanent addition to a person’s communication or a temporary aid.

(Wikipedia, (n.d. /Augmentative and alternative communication)

Center for Parent Information and Resources (CPIR)  (2015), Speech and Language Impairments, Newark, NJ, Author, Retrieved 4.1.19 from https://www.parentcenterhub.org/speechlanguage/

Wikipedia (n.d.) Augmentative and alternative communication. From https://en.wikipedia.org/wiki/Augmentative_and_alternative_communication 

Wikipedia, (n.d.) Speech and Language Impairment. From  https://en.wikipedia.org/wiki/Speech_and_language_impairment 

Updated 8.8.23

Understanding and Supporting Learners with Disabilities Copyright © 2019 by Paula Lombardi is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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Speech Disorders in Children: Definition and Therapy Essay

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Introduction

Defining speech and phonological disorders, the prevalence of speech disorders in different countries and languages, the impact on literacy, psychology, and communication, therapy for children with phonological disorders.

Speech disorders refer to a broad group of health-related conditions that disrupt the normal child’s speech. According to many sources, that is the most common reason a child needs to see a language therapist (Oliveira, Lousada, & Jesus, 2015; Ruscello, 2008). The prevalence of speech disorders differs from country to country but still remains very high. Considering the long-term consequences that speech disorders can possibly bring, they should be addressed with the help of interventions as soon as possible, regardless of their severity or the age, in which a child gets diagnosed.

The Definition of the Concept

The term speech disorder covers a varied group of conditions characterized by the difficulty in creating speech sounds, which an individual faces during the communication process. This group encompasses articulation and phonological disorders, voice disorders, disfluency, and so on (Kaneshiro, 2014b). This paper will focus mainly on phonological disorders. That is a condition when a person does not use (change, substitute, or miss) particular sounds and does not follow some speech rules of his or her native language, even though children are expected to acquire these skills naturally by a certain age (Kaneshiro, 2014a; Spivey, 2012).

Examples of Phonological Disorders

The phonological disorder can manifest itself in many ways. Most commonly, children change, substitute, or miss sounds that are too complicated for them to pronounce. As an example, kids often have difficulties with consecutive consonants; in this case, they just simplify words, skipping something: friend becomes fiend , truck becomes tuck , and so forth (Kaneshiro, 2014a; Spivey, 2012). Another example encompasses too complicated words with several syllables: nana instead of banana (Spivey, 2012, p. 1). Sometimes children also omit the endings: juice changes to joo , book changes to boo , etc. (Spivey, 2012, p. 1). The latter becomes even more complicated when it comes to the past tense with regular verbs or possessive and plural endings. Another common manifestation of the disorder is the substitution of one sound with another. The prime example is the difficulty with s , f , ch and sh ; children tend to ignore those sounds and just use t instead: tin instead of chin , tire instead of fire , and so on (Spivey, 2012, p. 1).

When to Become Concerned?

Admittedly, almost all children face difficulties in forming correct speech sounds. That is normal since their speech is developing. However, all of those difficulties are expected to be overcome by a particular age. For example, when the child is growing, at first, his or her speech is only understood by parents or siblings and is not intelligible to a complete stranger. Still, by the age of three, all children are expected to develop their skills to such an extent that strangers can understand at least half of the words they say (Kaneshiro, 2014a, par. 3). By the age of five, more sounds should be understandable. However, the most difficult ones, such as s , z , r , ch , sh , and th can still be pronounced incorrectly even at the age of seven or eight (Kaneshiro, 2014a, par. 3).

According to Kaneshiro (2014a), if the child’s speech is too difficult to understand at the age of four, if he or she still misses or changes some sounds by seven, or if at any age the speech problems make a child embarrassed, it is better to see a speech-language pathologist (par. 8). Performing particular tests and analyzing how a child puts his or her words together, these specialists come up with the diagnosis and determine the treatment. The phonological disorder can be slight, mild, moderate, or severe (Spivey, 2012, p. 1).

General Statistics

Speech disorders are the most common conditions that language therapists face (Oliveira et al., 2015, p. 174). As Ruscello (2008) states, more that 90% of speech-language pathologists that work in schools deal with exactly this kind of a disorder (p. 3). Approximately 10-15% of children at the pre-school age are diagnosed with these health conditions, and only a half of kids manage to get rid of those before the school age (Oliveira et al., 2015, p. 174). The majority of diagnosed have phonological disorders (Oliveira et al., 2015, p. 174). As for the gender, boys are more likely to face this problem than girls (Kaneshiro, 2014a, par. 2). Although many kids can develop normal language skills by themselves, more that 80% of diagnosed still require treatment services (Ruscello, 2008, p. 3).

Statistics by Countries

Evidently, the prevalence and statistics vary depending on the particular country and language. According to the study conducted by McLaughlin (2011) in the US, state Virginia, approximately 2.3-19% of children at the age from two to seven have speech and language disorders.

A lot of similar studies have been conducted in Brazil. Cavalheiro, Brancalioni, and Keske-Soares (2012) examined 2,880 children at the age of 4-6 years and found out that the prevalence of speech disorder was approximately 9% (p. 442). The highest prevalence had children at the age of five, and boys were almost three times more likely to be diagnosed (Cavalheiro et. al., 2012, p. 442). Another study reveals even higher values. According to Garcia de Goulart and Chiari (2014), 25% of 1,810 children had speech disorders.

In Australia, researchers received some results in this field as well. Eadie et al. (2015) say that only 3.4% of 1,494 participants at the age of four have been diagnosed with the speech disorder, with higher rates among boys (p. 578). Another study conducted in Australia gives higher percentages. McLeod and Harrison (2009) state that among 4,983 children at the age from four to five, there are approximately 25% of those, whose parents are concerned about the quality of their speech (p. 1220). Moreover, the majority of children have the manifestations of phonological disorders: the speech is not understandable to strangers (12%), the speech is not clear to the family members (6%) (McLeod & Harrison, 2009, p. 1220). Teachers have been concerned about 22.3% of the children (McLeod & Harrison, 2009, p. 1222).

According to the study conducted in the United Kingdom by Broomfield and Dodd (2004), the prevalence of speech disabilities is approximately 14.6% with the majority of diagnosed aged from 2 to 6 (p. 303).

All of the results are presented in the table below.

Additionally, it is interesting how speech disorders and phonological skills depend on the number of languages a child learns. Many people believe that bilingual children are more likely to have speech disorders since they can confuse two languages. However, Goldstein, Fabiano, and Washington (2005) prove the opposite. With 5 English-speaking, 5 Spanish-speaking and 5 bilingual participants, the authors show that there is no significant difference between children’s phonological skills, such as consonant and syllable accuracy, the number of substitutions, and so on (Goldstein et al., 2005, p. 214).

Speech disorders in general and phonological disorders in particular have many long-term consequences that make it imperative to address this problem at its early stages.

First of all, there is a threat to the education of a child. Since children with phonological disorders substitute and miss some sounds, as well as change and simplify the words greatly, they can face difficulties with spelling, reading, and writing in the future. As Ruscello (2008) states, some of them can even get diagnosed with learning disabilities (p. 3). That, in its turn, affects their performance in school and then in college or university. The study by Garcia de Goulart and Chiari (2014) reveals direct proportionality between the presence of the speech disorder and the school failure (p. 813). According to their words, pupils with disorders are nearly three times more likely to fail in school (Garcia de Goulart & Chiari, 2014, p. 813). McLaughlin (2011) confirms the same: speech disorders can result in impaired spelling and punctuation and an increased difficulty in reading (p. 1184).

However, that is not the only concern of phonological and other speech disorders. Even the mildest disorders can result in communication and social problems. Those can arise because the child’s speech is not understandable to others, and he or she can feel embarrassed about it. Such children usually passively participate in conversations with peers, do not initiate topics or invite others to conversations, rarely provide any new information, poorly and briefly reply to questions, etc. (Heward, 2010). All of this may result in the lack of communication and friends, excessive shyness, low self-esteem, self-doubt and so on. As Sices, Taylor, Freebairn, Hansen, and Lewis (2007) claim, speech disorders may contribute to various social and communication problems, as well as psychological ones, up to anxiety or depressions (p. 2). On the other hand, when children are not able to express themselves verbally, they may start doing it with their acts, which usually results in unpredictable and even inappropriate behavior. Additionally, disorders can also become the reason for bullying, especially if a particular problem with the speech is not overcome until relatively adult years.

Firstly, the child should be examined for additional health-related conditions since phonological disorder can be caused by other disorders, such as various neurological or cognitive problems, problems with hearing and physical disorders (Kaneshiro, 2014a, par. 4). If one of those is revealed, firstly, the treatment should address it. When dealing with phonological disorders only, speech sessions should be conducted. Admittedly, slight and mild forms of a disorder may disappear without any interventions, but those are still recommended. Therapy can be provided either in a group or individually with every patient, but according to Ruscello (2008), individual sessions and in-home treatment work much better than group interventions (p. 6).

Before starting the treatment, a speech-language pathologist has to determine the details of the disorder, or in other words, how a child puts the sounds together. The SLT analyzes if a child misses the first word’s sound or the last one, if he or she has difficulties in pronouncing many syllables or many consonant, if it is hard for him or her to pronounce continuing sounds or those that should be produced at the back of the mouth, etc. (Spivey, 2012, p. 1). Considering all of this, the methods of therapy are chosen.

Phonological methods of intervention include many approaches. One of the most efficient and famous is the Modified Cycles Model. Each week the SLT trains a patient to pronounce only one or two sounds with the help of particular target words, and by the end of each week, the assessment of results is made. If a child can pronounce at least 20% of the target words correctly, then another sound or other sounds will be taught during the next week; otherwise, the same sounds and words will be worked on (CeronI, PagliarinII, & Keske-Soares, 2013, p. 191). Another method, called the Maximal Oppositions Approach, has also proven its efficiency. It helps a child to develop their speech skills using pairs of words that differ in only one phoneme, for example, sad-mad, sat-mat, and so on (CeronI et al., 2013, p. 191). These differences should be understood by the child. To get to the next level, he or she has to understand at least the half of the pairs selected for a section (CeronI et al., 2013, p. 191). The ABAB-Withdrawal and Multiple Probes Model is based on learning a complicated sound using a simpler one (CeronI et al., 2013, p. 191). In their study, CeronI et al. (2013) have proved the efficiency of these models and showed that those can address the phonological disorder regardless of its severity level or the age group of the participants. The only thing that has its effect on the result is the number of sessions: the more of them, the more sounds are learned, and the better results are observed.

To conclude, although speech disorders, including phonological ones, are very common among the children of pre-school and school age, and in many cases, they disappear without any interventions, these conditions should not be ignored. Regardless of the level of severity or the age at which a child faces this problem, if he or she feels embarrassed because of the disorder or if it has a negative influence on the communication process and the internal state of a child, it should be addressed as a matter of urgency. Speech disorders are fraught with many long-term consequences that can have an adverse impact on the rest of the child’s life.

Broomfield, J., & Dodd, B. (2004). Children with speech and language disability: caseload characteristics. International Journal of Language and Communication Disorders, 39 (3), 303-324.

Cavalheiro, L. G., Brancalioni, A. R., & Keske-Soares, M. (2012). Prevalence of phonological disorders in children from Salvador, Bahia, Brazil. Revista da Sociedade Brasileira de Fonoaudiologia, 17 (4), 441-446.

CeronI, M. I., PagliarinII, K. C., & Keske-Soares, M. (2013). Advances in the treatment of children with phonological disorders. International Archives of Otorhinolaryngology, 17 (2), 189-195.

Eadie, P., Morgan, A., Ukoumunne, O. C., Eecen, T. K., Wake, M., & Reilly, S. (2015). Speech sound disorder at 4 years: prevalence, comorbidities, and predictors in a community cohort of children. Developmental Medicine & Child Neurology, 57 (6), 578-584.

Garcia de Goulart, B. N., & Chiari, B. M. (2014). Speech disorders and grade retention in elementary. Revista CEFAC, 16 (3), 810-815.

Goldstein, B. A., Fabiano, L., & Washington, P. S. (2005). Phonological Skills in Predominantly English-Speaking, Predominantly Spanish-Speaking, and Spanish-English Bilingual Children. Language, Speech, and Health Services in Schools, 36 , 201-218.

Heward, W.L. (2010). Characteristics of Children with Communication Disorders . Web.

Kaneshiro, N. K. (2014a). Phonological disorder . Web.

Kaneshiro, N. K. (2014b). Speech disorders – children . Web.

McLaughlin, M. R. (2011). Speech and Language Delay in Children. American Family Physician, 83 (10), 1183-1188.

McLeod, S., & Harrison, L. J. (2009). Epidemiology of Speech and Language Impairment in a Nationally Representative Sample of 4-to 5-Year-Old Children. Journal of Speech Language and Health Research, 52 (5), 1213-1229.

Oliveira, C., Lousada, M., & Jesus, L. M. T. (2015). The clinical practice of speech and language therapists with children with phonologically based speech sound disorders. Child Language Teaching and Therapy, 31 (2), 173-194.

Ruscello, D. M. (2008). Treating Articulation and Phonological Disorders in Children . St. Louis, MO: Mosby Elsevier.

Sices, L., Taylor, G., Freebairn, L., Hansen, A., & Lewis, B. (2007). Relationship Between Speech-Sound Disorders and Early Literacy Skills in Preschool-Age Children: Impact of Comorbid Language Impairment. Journal of Developmental & Behavioral Pediatrics, 28 (6), 438-447.

Spivey, B. L. (2012). What are Phonological Disorders? Web.

• Debates Concerning the Phoneme and Phonological Matters
• Phonological and Phonemic Awareness Activities
• Effect of Mandarin on spoken English
• Multilingualism and Children Language Behaviour
• Developmental Pragmatics: The Speech Act of Apology
• Pragmatics Application
• Delivering Effective Oral Presentations: How to Succeed in Public Speaking
• Critique of a speech by Tristram Stuart
• Chicago (A-D)
• Chicago (N-B)

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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

6 Overall Conclusions

This report has two ultimate goals: (1) to synthesize what is known about trends in speech and language disorders in children in the general population and in the Supplemental Security Income (SSI) child disability population, and (2) to document the current state of knowledge regarding identification and treatment of speech and language disorders in children and levels of impairment associated with these conditions. As noted in each of the preceding chapters, the committee drew upon the existing literature and other relevant sources of information to formulate its findings and conclusions. The committee was not tasked with providing recommendations to the Social Security Administration (SSA). At the same time, the committee's findings and conclusions underscore potential directions and opportunities—for policy makers, and professionals in relevant fields of research and practice—related to the identification and treatment of speech and language disorders in children. In addition, the committee's findings and conclusions could be used to inform eligibility criteria and ongoing monitoring of children with speech and language disorders within the SSI program. Finally, the committee's review of the literature and multiple sources of data provides insight into current data collection efforts related to children with speech and language disorders. The committee's findings and conclusions in this area, in particular, offer significant opportunities for the SSA, for researchers, and for individuals who provide care for children with these disorders.

• OVERALL CONCLUSIONS

Chapters 2 through 5 of this report each end with a list of findings and conclusions related to the topics examined within the respective chapters. Collectively, these findings and conclusions address the objectives, goals, and activities specified in the committee's statement of task (see Box 1-1 in Chapter 1 ). The findings are statements of the evidence; the conclusions are inferences, interpretations, or generalizations drawn from the evidence and supported by the committee's findings. (A complete list of the committee's findings and conclusions, by chapter, is presented later in this chapter.) From this more extensive set of findings and conclusions, the committee drew seven overall conclusions. This final chapter highlights supporting evidence and examples included in the report for each of these overall conclusions. The chapter ends with the committee's reflections on how its work can contribute to advancing understanding of and improving outcomes for children with severe speech and language disorders.

Impact of Severe Speech and Language Disorders

As noted in Chapter 2 , severe speech and language disorders in children are associated with significant impairment in functioning. Children with severe speech and language disorders—those whose functioning is considered two to three standard deviations from the norm—may lack the ability to communicate effectively. The committee found that these disorders can have a lasting and profound impact on the children and families they affect. Specifically, the committee concluded that

1. Severe speech and language disorders in children are conditions that interfere with communication and learning and represent serious lifelong threats to social, emotional, educational, and employment outcomes.

Severe disruptions in speech or language acquisition 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. In a 15-year follow-up study of children with speech and language disorders, for example, more than half (52 percent) of the children initially identified with speech and language disorders had residual learning disabilities and poor academic achievement later in life ( King, 1982 ). Research has shown that the consequences of speech and language disorders extend beyond communication and learning. For example, a longitudinal study of children with severe language disorders found that in their mid-30s, these individuals experienced poor social adaptation, prolonged unemployment, and few close social relationships ( Clegg et al., 2005 ).

Finally, as noted in Chapter 3 , the functional requirements for language and communication increase continually throughout childhood. For children with moderate to severe speech and language disorders, these requirements often outpace their development. Thus, even if children with such disorders make some progress from growth and with treatment, the gap between their abilities and functional expectations widens.

Prevalence and Comorbidity

The committee was asked to identify past and current trends in the prevalence of speech and language disorders in the general U.S. population under age 18. As a first step to this end, the committee sought to arrive at a current estimate of the overall prevalence of speech and language disorders among children in the United States. In addition, the committee was asked to identify common comorbidities (or co-occurring conditions) of childhood speech and language disorders. To do so, the committee consulted numerous sources of data, including clinical data from small treatment studies, population-based data from large national surveys, and administrative data from large federal programs. (See Chapter 5 and Appendix B for detailed descriptions of these data sources.) From this review, the committee concluded that

2. Speech and language disorders affect between 3 and 16 percent of U.S. children. Approximately 40 percent of children with speech and language disorders in nationally representative studies have serious comorbidities such as intellectual disabilities, autism spectrum disorder, and other neurodevelopmental and behavioral disorders.

This range is based on prevalence estimates of speech and language disorders from peer-reviewed studies of U.S. children (between 3.8 and 15.6 percent) and from three national surveys (between 3.2 percent and 7.7 percent). As noted in Chapter 5 , the data available regarding the prevalence of childhood speech and language disorders within the general population are limited in several ways. In particular, the sources of data considered by the committee vary markedly in how speech and language impairments are identified, the level of severity documented, the reporting sources, and the populations within the dataset. For example, many of the sources of data include information reported by a parent or caregiver but include no corroborating information from clinical assessment.

The few but varied data collection strategies used to estimate the prevalence of speech and language disorders in children leave room for both undercounts and overcounts. For example, conditions that commonly co-occur with speech and language disorders, such as autism spectrum disorder and attention deficit hyperactivity disorder, may initially be identified as speech and language disorders, thereby inflating the number of speech and language disorders reported. Conversely, speech and language disorders may be included in other reported categories, such as “development delays” or “multiple disabilities,” or reported as secondary impairments, thereby effectively deflating the number of speech and language disorders reported.

Although the committee encountered challenges, it found sufficient evidence to estimate that 3 to 16 percent of the general population of children from birth to through age 21 experience problems with speech or language. 1 Specifically, studies on childhood speech sound disorders show overall prevalence rates ranging from 2 to 13 percent ( Campbell et al., 2003 ; Eadie et al., 2015 ; Shriberg et al., 1999 ). Research on childhood language disorders shows overall prevalence rates between 6 and 15 percent, depending on age ( Law et al., 2000 ; McLeod and Harrison, 2009 ). And one population-based study of specific language impairment found a prevalence rate of 7.4 percent among children in kindergarten ( Tomblin et al., 1997 ).

Given the complex, multidimensional nature of language acquisition and the integral role of speech and language across multiple domains of child development, speech and language disorders occur at relatively high rates ( Kena et al., 2014 ) and, as noted in Chapter 2 , are frequently identified in association with (i.e., comorbid with) a wide range of other neurodevelopmental disorders. For example,

• in clinical practice, when children present with significant delays in the development of communication skills, autism spectrum disorder is one of the primary diagnostic considerations ( Myers and Johnson, 2007 );
• all children and adolescents with intellectual disability have varying degrees of impairment in communication skills ( American Psychiatric Association, 2013 ); and
• multiple studies have demonstrated a strong association between attention deficit hyperactivity disorder and speech and language disorders ( Pennington and Bishop, 2009 ; Tomblin and Nippold, 2014 ).

National Health Interview Survey data from 2000 to 2012 indicate that more than 40 percent of children with speech and language problems experienced comorbidities such as developmental delay (estimated at 32 percent), autism (estimated at 12 percent), and intellectual disability (estimated at 10 percent) ( Bainbridge, 2015 ). Finally, young children with language impairments are at high risk for later manifestation of learning and mental health disorders.

Thus, it is important both to carefully examine the speech and language skills of children with other developmental disorders and to identify other neurodevelopmental disorders among children presenting with speech and language impairments. Among populations of children with conditions as diverse as autism spectrum disorder, attention deficit hyperactivity disorder, traumatic brain injury, and genetic disorders, speech and language disorders may be the most easily identified area of impairment because of the central role of language and communication in the functional capacity of children and adolescents.

Supplemental Security Income

Research shows that children living in poverty are at greater risk for a disability relative to those not living in poverty ( Emerson and Hatton, 2005 ; Farran, 2000 ; Fujiura and Yamaki, 2000 ; Msall et al., 2006 ; Parish and Cloud, 2006 ), as well as that childhood disability increases the risk of a family's living in poverty ( Lustig and Strauser, 2007 ; NASEM, 2015 ). 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. Research has established that childhood poverty can exacerbate disabilities and their effects and lead to deleterious outcomes across a range of indicators, including emotional, social, and mental development; academic achievement; and employment during adulthood ( Fujiura and Yamaki, 2000 ; Kuhlthau and Perrin, 2001 ; Kuhlthau et al., 2005 ; Parish et al., 2008 ). The converse is true as well: the consequences of poverty are likely to be especially serious for children with disabilities because of their heightened vulnerabilities, elevated needs for health care, and overall poor health ( Kuhlthau et al., 2005 ; Newacheck and Kim, 2005 ).

As described in Chapter 4 , the SSI program for children was established to address the needs of children with disabilities living in low-income households because they were determined to be “among the most disadvantaged of all Americans and are deserving of special assistance” ( U.S. House of Representatives, 1971 ). SSI recipients include children whose health conditions or disabilities are severe enough to meet the program's disability eligibility criteria and whose family income and assets are within limits specified by the Social Security Administration. The committee concluded that

3. Children of families with low incomes are more likely than the general population to have disabilities, including speech and language disorders. The Supplemental Security Income (SSI) program is designed to award benefits to the most severely impaired children from low-income, resource-limited families. Currently, 0.31 percent of U.S. children receive SSI benefits for speech and language disorders.

An analysis of the impact of SSI revealed that the receipt of children's SSI benefits reduced the percentage of families with incomes below the federal poverty level from 58 percent to 32 percent. Still, economic vulnerability remains notable for these families. Bailey and Hemmeter (2014) found that approximately 58 percent of families receiving children's SSI benefits continued to have incomes below 150 percent of the federal poverty level, 2 even after accounting for receipt of the benefit.

To qualify for SSI benefits, children must meet a complex and detailed set of eligibility criteria that are income- and asset-related, work-related, and disability-related. The evidence required to document severity of disability is extensive and includes both medical evidence—such as formal testing to provide developmental and functional information, signs, symptoms, and laboratory findings—and parental and teacher reports. Under the SSA's standards, observations and information from a single source—such as a parent or caregiver—are an insufficient basis for a finding of disability.

Assessment, Evaluation, and Standards of Care

In accordance with its charge, the committee reviewed standards of care, including diagnostic evaluation and assessment, treatments and protocols, and educational interventions for children with speech and language disorders. The committee reviewed the literature and invited speech, language, and special education experts to provide additional insights into current standards of care and practices for children with these disorders. Chapters 2 and 3 provide an overview of this review and, when available, include evidence on the efficacy of treatments and interventions.

In addition, the committee was asked to identify the kinds of care documented or reported to be received by children in the SSI disability program. As described in Chapter 4 , the committee requested a review of a random sample of case files of children who receive SSI benefits for speech and language disorders. The results of this review helped demonstrate the kinds of evidence the SSA considers when making a disability determination for a child. Based on its review of professional standards of care and the documentation included in a random sample of case files, the committee concluded that

4. To determine the severity of speech and language disorders in children, the Social Security Administration employs the results of professionally administered assessments and also takes into account other clinical evidence that would be consistent with severe speech and language disorders.

As described in Chapter 4 , the evidence in the sample of case files reviewed by the committee was derived overwhelmingly from diagnostic, evaluation, and treatment information. This evidence helped the committee understand the types of treatment the children in the sample were documented or reported to have received and the extent to which such diagnostic and evaluation services reflect the professional standards described in Chapters 2 and 3 . For example, Chapter 2 describes the standardized tests typically used to diagnose speech and language disorders in children. Of the 152 cases included in the committee's review, 143 included evidence of standardized testing. Three case files that lacked information regarding standardized testing included diagnostic evidence derived from nonstandardized ratings and measurements as well as spontaneous language samples, evidence that is often used to make diagnoses of speech and language disorders in children. Finally, nearly all of the case files in the sample included information from speech-language pathologists regarding the child's speech and language status, and more than half contained developmental screening reports from a pediatrician. In all, only two of all of the cases reviewed lacked the type of specialized, objective clinical and evaluative data one would expect to find in a case based on functional equivalency. As noted in Chapter 4 , while these findings cannot be considered representative of the entire SSI child population with speech and language disorders, the committee's review yielded valuable information that is consistent with other sources of evidence considered for this study.

In addition, as noted in Chapter 4 , the process for identifying children with speech and language disorders who are eligible for SSI benefits is consistent with the multidimensional, multimethod, and multisource perspective that is evident in current professional practice. This process includes the assessment of children across multiple domains to determine the presence and severity of impairments in any individual areas, as well as their combined and interacting effects on day-to-day functioning. Likewise, children's case records include multiple forms of evidence concerning impairment and functioning (e.g., test scores, classroom records, progress in intervention), with no single piece of evidence being considered in isolation. Finally, information from parents, caregivers, and others with direct knowledge of children's daily functioning in age-appropriate environments and activities (e.g., Child Function Report Forms [SSA 3375-3379], Teacher Questionnaire Form [SSA 5565]) also is used to ensure that formal and criterion-referenced scores in the case record are consistent with levels of functioning in typical settings.

The descriptions of “marked” and “extreme” limitations that are used to identify impairments sufficiently severe to functionally equal the SSA's Listing of Impairments (“Listings”) also are consistent with professional practice in interpreting norm- and criterion-referenced tests of speech and language. For example, meeting the functional equivalence standard requires marked limitations in at least two of the six domains of function or an extreme limitation in one domain (C.F.R. 416.926a). Marked and extreme limitations are defined, respectively, as levels of impairment that “seriously” or “very seriously” interfere with the ability “to independently initiate, sustain or complete activities” in a domain. On norm-referenced tests, marked limitations correspond to the level of functioning that would be expected of children whose scores are at least two but less than three standard deviations below the mean. As noted in Chapter 2 , in a sample of 100 children, only 2 would be expected to have scores sufficiently low to meet this standard. Even fewer children—only about 1 of every 1,000—would be expected to have scores more than three standard deviations below the mean, the standard for extreme limitation.

In children younger than 3 years of age, for whom norm-referenced testing is generally infeasible, chronological age is used as the reference standard for defining limitations sufficiently severe to functionally equal the Listings. Such children have a marked limitation if their functioning in a domain is comparable to that of children who are more than one-half but less than two-thirds of their chronological age; they have an extreme limitation if their functioning is typical of children one-half their chronological age or younger. This means that a 24-month-old child functioning at a level consistent with that of typical children between 13 and 18 months of age would have a marked limitation; a 24-month-old functioning at the level of a typical child 12 months of age or younger would have an extreme limitation. These definitions of marked and extreme limitations are comparable to and in some cases more stringent than standards for identifying children (aged birth to 3 years) eligible for early intervention under the Individuals with Disabilities Education Act (IDEA) Part C based on developmental delays ( U.S. Department of Education, 2011 ; see also Rosenberg et al., 2013 ).

Trends in Prevalence of the General U.S. Population Compared with Trends in the Supplemental Security Income Population

One of the committee's primary objectives was to consider past and current trends in the prevalence of speech and language disorders among the general U.S. population under age 18 and to compare those trends with trends observed among participants in the SSI childhood disability program. To do so, the committee analyzed clinical studies, nationally representative survey data, and administrative or service data from a range of sources. These data, however, are primarily serial cross-sections as opposed to longitudinal—that is, they do not follow individual children over time. Instead, these data reflect changes in the prevalence of speech and language disorders observed within populations of respondents (in the case of survey data) or beneficiaries (in the case of SSI data) over successive years. Because children observed in one year may not be the same as children observed in another, the composition of these populations will change over time; consequently, these data cannot be used to describe the natural history of speech and language disorders over time. Not only may changes in population composition over time affect rates of observed occurrence; changes in programs for children with severe disabilities also will affect the size and characteristics of the population of children who receive benefits based on a severe disability in any given year. Thus, over time, SSI eligibility standards and the eligibility determination process itself, along with broader economic factors such as the Great Recession (from December 2007 to June 2009), also may influence the rate at which speech and language disorders are observed among any given population of children at any given point in time.

Despite these data limitations, the committee was able to draw certain conclusions from the evidence regarding the extent to which speech and language disorders are documented in specific populations of children over time.

Trends in the General U.S. Population

The committee used the best available evidence to assess trends in the prevalence of speech and language disorders in the general U.S. child population. Several sources that collect data on these disorders in children suggest that over the past decade their prevalence has increased. The two nationally representative surveys that include measures of speech and language disorders in children at multiple points in time are the National Survey of Children's Health and the National Survey of Children with Special Health Care Needs. The National Survey of Children's Health showed an increase in prevalence of speech and language disorders from 3.8 percent (n = 2,697) in 2007 to 4.8 percent (n = 3,916) in 2011, a 26 percent increase. The National Survey of Children with Special Health Care Needs showed an increase in prevalence from 3.2 percent (n = 8,435) in 2005-2006 to 5.0 percent (n = 11,936) in 2009-2010, an increase of 56 percent. Although not directly comparable, the committee reviewed SSI data on initial allowances for speech and language disorders for two points in time to determine the percent increase in those initial allowances. The number of initial allowances for speech and language disorders in 2007 (n = 21,135) and the number in 2011 (n = 29,309) show a 40 percent increase. Therefore, the committee concluded that

5. The best available evidence shows an increase in the prevalence of speech and language disorders over the past decade in the U.S. child population. Trends in annual Supplemental Security Income initial allowances parallel this overall increase.

Causes, Treatment, and Persistence

The committee was asked to identify causes of speech and language disorders and to determine how often these impairments are the result of known causes. Chapter 2 notes that a variety of congenital and acquired conditions may result in abnormal speech and/or language development. These conditions include primary disorders of hearing, as well as specific genetic diseases, brain malformation syndromes, toxic exposures, nutritional deficiencies, injuries, and epilepsy. ( Box 2-3 in Chapter 2 includes examples of speech and language disorders with known causes.) In some cases, the cause of speech and language disorders in children may not be known. In these cases, research points to an array of possible risk factors for these disorders in children. To date, the evidence best supports a cumulative risk model in which increases in risk are greater for combinations of risk factors than for individual factors ( Harrison and McLeod, 2010 ; Lewis et al., 2015 ; Pennington and Bishop, 2009 ; Reilly et al., 2010 ; Whitehouse et al., 2014 ). For example, one study of speech sound disorders found that three variables—male sex, low maternal education, and positive family history of developmental communication disorders—were individually associated with increased odds of speech sound disorder, but the odds of such a disorder were nearly eight times greater in a child with all three risk factors than in a child with none of them ( Campbell et al., 2003 ).

As detailed in Chapter 3 , a range of different strategies are used to treat mild, moderate, and severe speech and language disorders in children. These strategies vary based on the particular needs and circumstances of the child. Several important factors shape the intervention program for any given child. These factors include treatment objectives (e.g., conventional or compensatory communication goals), the nature of the disorder, the developmental level of the child, the individuals involved in the intervention (or “agents of change”), and the settings in which treatment is provided (e.g., school-based, home-based, or clinic-based). In reviewing the evidence, the committee found that, with treatment, mild speech and language disorders may completely resolve or be limited to relatively minor impairments; moderate speech and language disorders may substantially diminish, with residual impairments in an associated domain, such as reading and literacy. In the most severe cases, however, even with treatment, core speech and language deficits will likely continue into adolescence and may be lifelong. Therefore, committee concluded that

6. Children with mild to moderate speech and language disorders will benefit from a variety of treatments. For children with severe speech and language disorders, treatment improves function; with few exceptions, however, substantial functional limitations will persist.

An implication of this conclusion is that a severe disorder will persist over time, thereby necessitating ongoing educational, social, and health supports and, in the case of children from low-income families, continuing eligibility for financial assistance through the SSI program.

Trends Among Supplemental Security Income Program Participants

To identify trends among participants in the SSI program, the committee reviewed administrative data collected by the SSA on initial allowances and recipients based on primary speech and language impairments. Between 2004 and 2014, the number of children receiving SSI benefits for speech and language disorders increased from 90,281 to 315,523, a 249 percent increase. Given the substantial increase in the total number of recipients, the committee reviewed older data to help explain this growth. At the committee's request, the SSA provided supplemental data for review beginning in 1994, the year in which the impairment code for speech and language impairment (3153) was introduced. From its review of the data, the committee concluded that

7. The total number of children receiving Supplemental Security Income for speech and language disorders more than tripled in the past decade. In addition to an increase in prevalence of these disorders in the general U.S. child population, this growth is explained primarily by two factors: the introduction of a new impairment code for speech and language disorders in 1994, and the continuing eligibility of children whose severe speech and language disorders persist throughout childhood.

Prior to 1994, there were zero initial allowances for the impairment code for speech and language impairment in children (3153). The current total number of recipients reflects both the accumulation over time of new individuals in this impairment category and the very low attrition from the program due to the above-noted persistence of severe speech and language disorders throughout childhood and adolescence.

As described in Chapter 5, in 1994, the first year that the new impairment code existed, only 1,585 children met the eligibility criteria under this new code. In 1995, an additional 4,109 children began receiving benefits under this new code; in 1996, an additional 4,119 children were allowed benefits, and so forth for each subsequent year. Given that children with severe speech and language impairments are likely to continue to have those severe impairments throughout adolescence and into adulthood, the total number of SSI recipients who received benefits under this new code in any given year approaches the total number of children who became eligible in each of the preceding 18 years. As a result, the total number of children receiving SSI benefits for speech and language impairments in 2013 will include almost all of the children who became eligible in the years from 1996 through 2013.

Several additional factors contribute to the changes observed in the number of children who receive SSI benefits for speech and language disorders. For example, the total number of child SSI recipients fluctuates depending on the number of initial allowances, terminations, suspensions, and suspension reentries. When the number of allowances exceeds the number of terminations and suspensions in a year, the total number of recipients increases for that year. Overall growth in the population of children would be expected to contribute some growth to the program as well. Consequently, the number of children who are allowed (found eligible for the program) in a given year can be expected to exceed the number who exit the program. Finally, allowances are affected by macroeconomic conditions. During a period of economic expansion, as family income increases and joblessness decreases, fewer children are likely to meet the SSA's financial eligibility criteria. By contrast, during periods of economic downturn, such as the Great Recession (from December 2007 to June 2009), more children will meet the program's financial eligibility criteria as a result of relatively higher unemployment.

Supporting Evidence for the Committee's Overall Conclusions

Box 6-1 shows the connections between each of the committee's overall conclusions and its chapter-specific findings and conclusions. Box 6-2 collects all of the committee's chapter-specific findings and conclusions organized by chapter.

Overall Conclusions and Supporting Evidence.

Chapter-Specific Findings and Conclusions.

• FINAL THOUGHTS

This report represents the National Academies of Sciences, Engineering, and Medicine's first comprehensive study of speech and language disorders in children. Using available data drawn from various sources, the committee carried out the study called for in its statement of task. First, this report presents an overview of the current status of diagnosis and treatment of speech and language disorders and the level of impairment these disorders cause among children. Second, the report identifies past and current trends in the prevalence and persistence of speech and language disorders among the general population of U.S. children and compares these trends with those found in the SSI childhood disability population. The evidence presented in this report underscores the long-term and profound impact of severe speech and language disorders on children and their families, as well as the degree to which children with such disorders can be expected to be a significant presence in a program such as SSI, whose purpose is to provide basic financial assistance to families of children with the severest disabilities. It is the committee's hope that this report will make a substantial contribution to understanding the nature of severe speech and language disorders in children and will provide a strong foundation for future efforts in policy, practice, and research.

The committee's findings and conclusions characterize the current state of knowledge. Its findings also highlight the challenges that arise in undertaking a close examination of children's health status in the area of speech and language because of deficiencies in the evidence across both the general population and, in this case, the specific population of children enrolled in the SSI program. In particular, the committee notes that its ability to address salient questions more thoroughly was limited by the absence of two basic types of information: (1) longitudinal data on children who receive SSI benefits on the basis of speech and language disorders, and (2) comprehensive information on the prevalence of these disorders among the general U.S. child population that captures a range of health, demographic, and socioeconomic characteristics such as gender, income, race/ethnicity, and condition severity. Longitudinal data on children who receive SSI benefits on the basis of speech and language disorders would provide insight into these children's status over time, as well as the types and range of treatments and their impact on health and functioning. This information would be useful in assessing the impact of treatment on continuing eligibility and would significantly enhance the SSA's ability to shape its continuing disability review process for children. More complete information on the prevalence of speech and language disorders in the general U.S. child population would enable the SSA to better determine the extent to which its initial SSI eligibility determination rates align with the prevalence of these disorders within both the general child population and the population of low-income children. It is this latter group of children who are most likely to qualify for SSI benefits if they experience speech and language disorders that reach the degree of severity required to satisfy the SSI program's rigorous eligibility standard.

Despite its limitations, the evidence presented in this report offers valuable insight into the relationship between the general population of children with speech and language disorders on the one hand and the presence of children with these disorders in the SSI program on the other. Furthermore, the evidence presented here can assist policy makers, health and education professionals, and SSI program administrators in understanding the extent to which the program's basic design and administrative process operate together to connect the nation's most severely impaired and disadvantaged children with speech and language disorders to the benefits the program offers.

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• Reilly S, Wake M, Ukoumunne OC, Bavin E, Prior M, Cini E, Conway L, Eadie P, Bretherton L. Predicting language outcomes at 4 years of age: Findings from Early Language in Victoria study. Pediatrics. 2010; 126 :e1530–e1537. [ PubMed : 21059719 ]
• Rosenberg SA, Robinson CC, Shaw EF, Ellison MC. Part C early intervention for infants and toddlers: Percentage eligible versus served. Pediatrics. 2013; 131 (1):38–46. [ PubMed : 23266922 ]
• Shriberg LD, Tomblin JB, McSweeny JL. Prevalence of speech delay in 6-year-old children and comorbidity with language impairment. Journal of Speech, Language, and Hearing Research. 1999; 42 (6):1461–1481. [ PubMed : 10599627 ]
• Tomblin JB, Nippold MA. Understanding individual differences in language development across the school years. New York: Psychology Press; 2014.
• Tomblin JB, Records NL, Buckwalter P, Xhang X, Smith E, O'Brien M. Prevalence of specific language impairment in kindergarten children. Journal of Speech, Language, and Hearing Research. 1997; 40 (6):1245–1260. [ PMC free article : PMC5075245 ] [ PubMed : 9430746 ]
• U.S. Department of Education. Early intervention program for infants and toddlers with disabilities; assistance to states for the education of children with disabilities. Final Rule and Proposed Rule 34 CFR Part 303. Federal Register. 2011; 76 (188):60140–60283. [ PubMed : 21961195 ]
• U.S. House of Representatives. Social Security Amendments of 1971: Report of the Ways and Means Committee on H.R. 1. H. 1971. pp. 146–148. (Report No. 92-251).
• Wang Q. Disability and American families: 2000. Bulletin. 2005; 62 (4):21–30.
• Whitehouse AJO, Shelton WMR, Ing C, Newnham JP. Prenatal, perinatal, and neonatal risk factors for specific language impairment: A prospective pregnancy cohort study. Journal of Speech, Language, and Hearing Research. 2014; 57 (4):1418–1427. [ PubMed : 24686440 ]

While the primary population of focus for this study is children under age 18, the committee reviewed and has included here relevant Individuals with Disabilities Education Act (IDEA) data (which include children from birth to age 21).

Poverty researchers typically identify 200 percent of the federal poverty level as the income threshold for adequate subsistence ( Boushey et al., 2001 ).

• 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. 6, Overall Conclusions.
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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.

Related Links

• Brain and Behavior
• Developmental-Behavioral Pediatrics
• Speech Sound Disorders in Children
• Age-Appropriate Speech and Language Milestones
• Communication Disorders in Children

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Developmental Disorders

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Speech Disorders in English Language Learners

The development and acquisition of language skills and speech by children have always been of particular interest for linguists. The way children learn and produce language differs drastically among various age groups. Although there are possible violations of the norm, there are cases when children face difficulty in receiving and producing language. When these violations are not appropriate for the particular age group or when they hinder the successful learning, the child should be diagnosed with speech and language disorders. Speech and language disorders may become obstacles towards child’s academic success.

According to the Individuals with Disabilities Act, “speech or language impairment means a communication disorder, such as stuttering, impaired articulation, a language impairment, or a voice impairment, that adversely affects child’s educational performance” ( Building the Legacy: IDEA 2004 , n.d., para. 19). IDEA is a primary source for the protection of rights of learners with disabilities. Thus, IDEA guarantees that all students including those who have speech and language impairments have equal access to FAPE — free and appropriate public education.

The problem of speech and language impairment should be addressed adequately in every school environment. Difficulties with reception and production of language impede child’s academic performance. Most children who have some impairment cannot follow all requirements of the particular grade. It is the primary responsibility of schools and educators to provide all necessary conditions for the successful education of such pupils. In the field, the topic is investigated from several perspectives. Thus, some scholars focus on the evaluation of fundamental reasons for the development of impairments. The other area refers to the peculiarities of the identification of language disorders in English language learners. Also, there are controversies concerning appropriate ways of intervention.

Annotated Bibliography

Bishop, D., & Leonard, L. (Eds.). (2014). Speech and Language Impairments in  Children . New York, NY: Psychology Press.

The book under consideration is a collection of various researches concerning reasons and intervention of speech and language difficulties. Investigations of educational researchers are gathered in the source for the evaluation of causes (poverty, genetics, and cultural background), peculiarities of impairments (the connection with syntax, grammar, reading, and literacy), and interventions. The book is intended for researchers. Besides, educators may find useful information to consider while choosing the best techniques of teaching pupils with speech and language impairments.

Building the Legacy: IDEA 2004 . (n.d.). Web.

The source provides the text of the Individuals with Disabilities Act (2004). It is prepared by the U.S. Department of Education. The source is useful for both educators and parents. It is a legal text that provides all necessary information concerning rights of children with disabilities.

Fisher, S. (2009). Assessing English Language Learners for a Learning Disability or a Language Issue. Professional Development in Education, 7 (2), 13-19.

The author of the article addresses the issue of language learning disabilities in English language learners. According to the article, there is often a misinterpretation whether the student is a slow learner or has learning disabilities. The incorrect diagnosis may lead to the adverse effects on the student’s personality. The author provides information about possible reasons for misdiagnosis. Also, Fisher writes about the difference between language disability and language issue. Finally, the author dwells on the way of the identification of language disabilities in ELL. The author is an educational researcher who has written the paper from the combination of educational and behavioral perspectives. The article is a useful source for school educators and other researchers.

Handler, S., & Fierson, W. (2011). Learning Disabilities, Dyslexia, and Vision.  Pediatrics, 127 (3), 818-856.

Authors introduce information about dyslexia — a reading disability that belongs to receptive language-based disorders. Authors dwell on causes and remedial programs for reading difficulties. They also emphasize the importance of an early recognition of the problem for the most efficient result. The article refers to the connection between visual problems and reading disabilities. Authors of the source are medical doctors and researchers who rely on medical perspective. The topic addresses the controversy of causes of reading disabilities and appropriate interventions.

Lerner, J., & Johns, B. (2014). Learning Disabilities and Related Disabilities: Strategies  for Success. Stamford, CT: Cengage Learning.

The book is a knowledgeable source that provides relevant information concerning theoretical and practical aspects of the issue. Authors evaluate theories of learning and describe strategies. Thus, separate parts of the books are devoted to strategies for spoken language difficulties, reading, and writing difficulties. The book is written from the perspective of an education researcher and the combination of educational and behavioral theoretical frameworks. The information is useful for parents, educators, and students.

Murdoch, B. (2013). Acquired Speech and Language Disorders: a Neuroanatomical and  Functional Neurological Approach. New York, NY: Springer.

The book under consideration represents a valid source for the understanding of the connection between various neurological processes and speech and language impairments. The purpose of the source is to provide a detailed explanation of speech pathology from perspectives of neuroanatomy and functional neurology. The author has written this book due to the lack of sources that describe the issue from this particular viewpoint. The author of the book is an educator. The source is written from a purely medical theoretical framework. It provides information about different speech and language impairments and specific learning disabilities.

Smith-Lock, K., Leitao, S., Lambert, L., & Nickels. L. (2013). Effective intervention for expressive grammar in children with specific language impairment. International  Journal of Language & Communication Disorders, 48 (3), 265-282.

Pupils who have problems with productive areas of language often experience extreme difficulties when studying grammar. Expressive grammar is considered to be rather a challenge for both educators and students. The purpose of the article is to assess the efficiency of a school-based intervention program for pupils who are five years old. The article is written from the perspective of the researcher, and it is useful for the further evaluation of school educators. Authors have found out that individual intervention is the most effective for those children who do not have problems with articulation of particular grammatical forms. Techniques of direct intervention, imitation, and focused stimulation have been used for the study.

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Study reveals brain mechanisms behind speech impairment in Parkinson’s

Most Parkinson’s disease patients struggle with speech problems. New research by Stanford Medicine scientists uncovers the brain connections that could be essential to preserving speech.

May 28, 2024 - By Nina Bai

Research by Stanford Medicine scientists may explain why some treatments for Parkinson’s — developed mainly to target motor symptoms — can improve speech impairments while other treatments make them worse. Lightspring /Shutterstock.com

Parkinson’s disease is most well-known and well-studied for its motor impairments — tremors, stiffness and slowness of movement. But less visible symptoms such as trouble with memory, attention and language, which also can profoundly impact a person’s quality of life, are less understood. A new study by Stanford Medicine researchers reveals the brain mechanisms behind one of the most prevalent, yet often overlooked, symptoms of the disease — speech impairment.

Based on brain imaging from Parkinson’s patients, the researchers identified specific connections in the brain that may determine the extent of speech difficulties.

The findings , reported May 20 in the Proceedings of the National Academy of Sciences , could help explain why some treatments for Parkinson’s — developed mainly to target motor symptoms — can improve speech impairments while other treatments make them worse.

More than a motor disorder

“Parkinson’s disease is a very common neurological disorder, but it’s mostly considered a motor disorder,” said Weidong Cai , PhD, clinical associate professor of psychiatry and behavioral sciences and the lead author of the new study. “There’s been lots of research on how treatments such as medications and deep brain stimulation can help improve motor function in patients, but there was limited understanding about how these treatments affect cognitive function and speech.”

Over 90% of people with Parkinson’s experience difficulties with speech, an intricate neurological process that requires motor and cognitive control. Patients may struggle with a weak voice, slurring, mumbling and stuttering.

“Speech is a complex process that involves multiple cognitive functions, such as receiving auditory feedback, organizing thoughts and producing the final vocal output,” Cai said.

The senior author of the study is Vinod Menon , PhD, professor of psychiatry and behavioral sciences and director of the Stanford Cognitive and Systems Neuroscience Laboratory .

The researchers set out to study how levodopa, a common Parkinson’s drug that replaces the dopamine lost from the disease, affects overall cognitive function. They focused on the subthalamic nucleus, a small, pumpkin-seed-shaped region deep within the brain.

Weidong Cai

The subthalamic nucleus is known for its role in inhibiting motor activity, but there are clues to its involvement in other functions. For example, deep brain stimulation, which uses implanted electrodes to stimulate the subthalamic nucleus, has proven to be a powerful way to relieve motor symptoms for Parkinson’s patients — but a common side effect is worsened speech impairment.

Same test, different scores

In the new study, 27 participants with Parkinson’s disease and 43 healthy controls, all older than 60, took standard tests of motor and cognitive functioning. The participants with Parkinson’s took the tests while on and off their medication.

As expected, the medication improved motor functioning in the patients, with those having the most severe symptoms improving the most.

The test for cognitive functioning offered a surprise. The test, known as the Symbol Digit Modalities Test, is given in two forms — oral and written. Patients are provided with nine symbols, each matched with a number — a plus sign for the number 7, for example. They are then asked to translate a string of symbols into numbers, either speaking or writing down their answers, depending on the version of the test.

As a group, the patients’ performance on both versions of the cognitive test was little affected by medication. But taking a closer look, the researchers noticed that the subset of patients who performed particularly poorly on the spoken version of the test without medication improved their spoken performance on the medication. Their written test scores did not change significantly.

“It was quite interesting to find this dissociation between the written and oral version of the same test,” Cai said.

The dissociation suggested that the medication was not enhancing general cognitive functions such as attention and working memory, but it was selectively improving speech.

“Our research unveiled a previously unrecognized impact of dopaminergic drugs on the speech function of Parkinson’s patients,” Menon said.

Uncovering connections

Next, the researchers analyzed fMRI brain scans of the participants, looking at how the subthalamic nucleus interacted with brain networks dedicated to various functions, including hearing, vision, language and executive control.

Vinod Menon

They found that different parts of the subthalamic nucleus interacted with different networks.

In particular, they discovered that improvements on the oral version of the test correlated with better functional connectivity between the right side of the subthalamic nucleus and the brain’s language network.

Using a statistical model, they could even predict a patient’s improvement on the oral test based on changes in their brain’s functional connectivity.

“Here we’re not talking about an anatomical connection,” Cai explained. Rather, functional connectivity between brain regions means the activity in these regions is closely coordinated, as if they are talking to each other.

“We discovered that these medications influence speech by altering the functional connectivity between the subthalamic nucleus and crucial language networks,” Menon said. “This insight opens new avenues for therapeutic interventions tailored specifically to improve speech without deteriorating other cognitive abilities.”

This newly identified interaction between the subthalamic nucleus and the language network could serve as a biological indicator of speech behavior — in Parkinson’s as well as other speech disorders like stuttering.

Such a biomarker could be used to monitor treatment outcomes and inspire new therapies. “Of course, you can directly observe the outcome of a medication by observing behavior, but I think to have a biomarker in the brain will provide more useful information for the future development of drugs,” Cai said. 

The findings also provide a detailed map of the subthalamic nucleus, which could guide neurosurgeons performing deep brain stimulation in avoiding damage to an area critical to speech function. “By identifying key neural maps and connections that predict speech improvement, we can craft more effective treatment plans that are both precise and personalized for Parkinson’s disease patients,” Menon said.

The study received funding from the National Institutes of Health (grants P50 AG047366, P30 AG066515, RF1 NS086085, R21 DC017950-S1, R01 NS115114, R01 MH121069 and K99 AG071837) and the Alzheimer’s Association.

About Stanford Medicine

Stanford Medicine is an integrated academic health system comprising the Stanford School of Medicine and adult and pediatric health care delivery systems. Together, they harness the full potential of biomedicine through collaborative research, education and clinical care for patients. For more information, please visit med.stanford.edu .

Hope amid crisis

Psychiatry’s new frontiers

Researchers have located the brain network responsible for stuttering

An international research group led by researchers from the University of Turku and Turku University Hospital in Finland has succeeded in identifying the probable origin of stuttering in the brain.

Stuttering is a speech rhythm disorder characterised by involuntary repetitions, prolongations or pauses in speech that prevent typical speech production. Approximately 5-10% of young children stutter, and an estimated 1% continue to stutter into adulthood. A severe stutter can have a profound negative impact on the life of the individual affected.

"Stuttering was once considered a psychological disorder. However, with further research, it is now understood to be a brain disorder related to the regulation of speech production," says Professor of Neurology Juho Joutsa from the University of Turku.

Stuttering may also be acquired as a result of certain neurological diseases, such as Parkinson's disease or a stroke. However, the neurobiological mechanisms of stuttering are not yet fully understood, and where it originates in the brain remains uncertain. The findings from brain imaging studies are partly contradictory, and it is challenging to determine which changes are the root cause of stuttering and which are merely associated phenomena.

Stuttering localised in the same brain network regardless of its cause

Researchers from Finland, New Zealand, the United States and Canada developed a new research design that could provide a solution to this problem. The study included individuals who had suffered a stroke, some of whom developed a stutter immediately after it. The researchers discovered that although the strokes were located in different parts of the brain, they all localised to the same brain network, unlike the strokes that did not cause stuttering.

In addition to people who had suffered a stroke, the researchers used magnetic resonance imaging (MRI) to scan the brains of 20 individuals with developmental stuttering. In these individuals, the stuttering was associated with structural changes in the nodes of the brain network originally identified in relation to causal stroke lesions -- the greater the changes, the more severe the stuttering. This finding suggests that stuttering is caused by a common brain network, regardless of the aetiology (developmental or neurological).

The key nodes of the network identified by the researchers were putamen, amygdala and claustrum located deep within the brain, and the connections between them.

"These findings explain well-known features of stuttering, such as the motor difficulties in speech production and the significant variability in stuttering severity across emotional states. As major nuclei in the brain, the putamen regulates motor function and the amygdala regulates emotions. The claustrum, in turn, acts as a node for several brain networks and relays information between them," explains Joutsa.

The results of the study provide a unique insight into the neurobiological basis of stuttering. Locating stuttering in the brain opens up new possibilities for medical treatment. Researchers hope that in the future, stuttering could be effectively treated, for example, with brain stimulation that can be targeted specifically to the now identified brain network.

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Story Source:

Materials provided by University of Turku . Note: Content may be edited for style and length.

Journal References :

• Catherine Theys, Elina Jaakkola, Tracy R Melzer, Luc F De Nil, Frank H Guenther, Alexander L Cohen, Michael D Fox, Juho Joutsa. Localization of stuttering based on causal brain lesions . Brain , 2024; DOI: 10.1093/brain/awae059

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Study reveals brain mechanisms behind speech impairment in Parkinson's

by Nina Bai, Stanford University

Parkinson's disease is most well-known and well-studied for its motor impairments—tremors, stiffness and slowness of movement. But less visible symptoms such as trouble with memory, attention and language, which can also profoundly impact a person's quality of life, are less understood.

A new study by Stanford Medicine researchers reveals the brain mechanisms behind one of the most prevalent, yet often overlooked, symptoms of the disease— speech impairment. Based on brain imaging from Parkinson's patients, the researchers identified specific connections in the brain that may determine the extent of speech difficulties.

The findings , reported May 20 in the Proceedings of the National Academy of Sciences , could help explain why some treatments for Parkinson's—developed mainly to target motor symptoms—can improve speech impairments while other treatments make them worse.

More than a motor disorder

"Parkinson's disease is a very common neurological disorder, but it's mostly considered a motor disorder," said Weidong Cai, Ph.D., clinical associate professor of psychiatry and behavioral sciences and the lead author of the new study.

"There's been lots of research on how treatments such as medications and deep brain stimulation can help improve motor function in patients, but there was limited understanding about how these treatments affect cognitive function and speech."

More than 90% of people with Parkinson's experience difficulties with speech, an intricate neurological process that requires motor and cognitive control. Patients may struggle with a weak voice, slurring, mumbling and stuttering.

"Speech is a complex process that involves multiple cognitive functions, such as receiving auditory feedback, organizing thoughts and producing the final vocal output," Cai said.

The senior author of the study is Vinod Menon, Ph.D., professor of psychiatry and behavioral sciences and director of the Stanford Cognitive and Systems Neuroscience Laboratory.

The researchers set out to study how levodopa, a common Parkinson's drug that replaces the dopamine lost from the disease, affects overall cognitive function. They focused on the subthalamic nucleus, a small, pumpkin-seed-shaped region deep within the brain.

The subthalamic nucleus is known for its role in inhibiting motor activity, but there are clues to its involvement in other functions. For example, deep brain stimulation, which uses implanted electrodes to stimulate the subthalamic nucleus, has proven to be a powerful way to relieve motor symptoms for Parkinson's patients—but a common side effect is worsened speech impairment.

Same test, different scores

In the new study, 27 participants with Parkinson's disease and 43 healthy controls, all older than 60, took standard tests of motor and cognitive functioning. The participants with Parkinson's took the tests while on and off their medication.

As expected, the medication improved motor functioning in the patients, with those having the most severe symptoms improving the most.

The test for cognitive functioning offered a surprise. The test, known as the Symbol Digit Modalities Test, is given in two forms—oral and written. Patients are provided with nine symbols, each matched with a number—a plus sign for the number 7, for example. They are then asked to translate a string of symbols into numbers, either speaking or writing down their answers, depending on the version of the test.

As a group, the patients' performance on both versions of the cognitive test was little affected by medication. But taking a closer look, the researchers noticed that the subset of patients who performed particularly poorly on the spoken version of the test without medication improved their spoken performance on the medication. Their written test scores did not change significantly.

"It was quite interesting to find this dissociation between the written and oral version of the same test," Cai said.

The dissociation suggested that the medication was not enhancing general cognitive functions such as attention and working memory, but it was selectively improving speech.

"Our research unveiled a previously unrecognized impact of dopaminergic drugs on the speech function of Parkinson's patients," Menon said.

Uncovering connections

Next, the researchers analyzed fMRI brain scans of the participants, looking at how the subthalamic nucleus interacted with brain networks dedicated to various functions, including hearing, vision, language and executive control.

They found that different parts of the subthalamic nucleus interacted with different networks.

In particular, they discovered that improvements on the oral version of the test correlated with better functional connectivity between the right side of the subthalamic nucleus and the brain's language network.

Using a statistical model , they could even predict a patient's improvement on the oral test based on changes in their brain's functional connectivity.

"Here we're not talking about an anatomical connection," Cai explained. Rather, functional connectivity between brain regions means the activity in these regions is closely coordinated, as if they are talking to each other.

"We discovered that these medications influence speech by altering the functional connectivity between the subthalamic nucleus and crucial language networks," Menon said. "This insight opens new avenues for therapeutic interventions tailored specifically to improve speech without deteriorating other cognitive abilities."

This newly identified interaction between the subthalamic nucleus and the language network could serve as a biological indicator of speech behavior—in Parkinson's as well as other speech disorders like stuttering.

Such a biomarker could be used to monitor treatment outcomes and inspire new therapies. "Of course, you can directly observe the outcome of a medication by observing behavior, but I think to have a biomarker in the brain will provide more useful information for the future development of drugs," Cai said.

The findings also provide a detailed map of the subthalamic nucleus , which could guide neurosurgeons performing deep brain stimulation in avoiding damage to an area critical to speech function.

"By identifying key neural maps and connections that predict speech improvement, we can craft more effective treatment plans that are both precise and personalized for Parkinson's disease patients," Menon said.

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• Patient Care & Health Information
• Diseases & Conditions
• Frontotemporal dementia

Frontotemporal dementia (FTD) is an umbrella term for a group of brain diseases that mainly affect the frontal and temporal lobes of the brain. These areas of the brain are associated with personality, behavior and language.

In frontotemporal dementia, parts of these lobes shrink, known as atrophy. Symptoms depend on which part of the brain is affected. Some people with frontotemporal dementia have changes in their personalities. They become socially inappropriate and may be impulsive or emotionally indifferent. Others lose the ability to properly use language.

Frontotemporal dementia can be misdiagnosed as a mental health condition or as Alzheimer's disease. But FTD tends to occur at a younger age than does Alzheimer's disease. It often begins between the ages of 40 and 65, although it can occur later in life as well. FTD is the cause of dementia about 10% to 20% of the time.

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Symptoms of frontotemporal dementia differ from one person to the next. Symptoms get worse over time, usually over years.

People with frontotemporal dementia tend to have clusters of symptom types that occur together. They also may have more than one cluster of symptom types.

Behavioral changes

The most common symptoms of frontotemporal dementia involve extreme changes in behavior and personality. These include:

• Increasingly inappropriate social behavior.
• Loss of empathy and other interpersonal skills. For example, not being sensitive to another person's feelings.
• Lack of judgment.
• Loss of inhibition.
• Lack of interest, also known as apathy. Apathy can be mistaken for depression.
• Compulsive behaviors such as tapping, clapping, or smacking lips over and over.
• A decline in personal hygiene.
• Changes in eating habits. People with FTD typically overeat or prefer to eat sweets and carbohydrates.
• Eating objects.
• Compulsively wanting to put things in the mouth.

Speech and language symptoms

Some subtypes of frontotemporal dementia lead to changes in language ability or loss of speech. Subtypes include primary progressive aphasia, semantic dementia and progressive agrammatic aphasia, also known as progressive nonfluent aphasia.

These conditions can cause:

• Increasing trouble using and understanding written and spoken language. People with FTD may not be able to find the right word to use in speech.
• Trouble naming things. People with FTD may replace a specific word with a more general word, such as using "it" for pen.
• No longer knowing word meanings.
• Having hesitant speech that may sound telegraphic by using simple, two-word sentences.
• Making mistakes in sentence building.

Movement conditions

Rare subtypes of frontotemporal dementia cause movements similar to those seen in Parkinson's disease or amyotrophic lateral sclerosis (ALS).

Movement symptoms may include:

• Muscle spasms or twitches.
• Poor coordination.
• Trouble swallowing.
• Muscle weakness.
• Inappropriate laughing or crying.
• Falls or trouble walking.

In frontotemporal dementia, the frontal and temporal lobes of the brain shrink and certain substances build up in the brain. What causes these changes is usually not known.

Some genetic changes have been linked to frontotemporal dementia. But more than half of the people with FTD have no family history of dementia.

Researchers have confirmed that some frontotemporal dementia gene changes also are seen in amyotrophic lateral sclerosis (ALS). More research is being done to understand the connection between the conditions.

Risk factors

Your risk of getting frontotemporal dementia is higher if you have a family history of dementia. There are no other known risk factors.

Frontotemporal dementia care at Mayo Clinic

• Frontotemporal disorders. National Institute of Neurological Disorders and Stroke. https://www.ninds.nih.gov/disorders/all-disorders/frontotemporal-dementia-information-page. Accessed Aug. 30, 2023.
• Loscalzo J, et al., eds. Frontotemporal dementia. In: Harrison's Principles of Internal Medicine. 21st ed. McGraw Hill; 2022. https://accessmedicine.mhmedical.com. Accessed Aug. 30, 2023.
• Ulugut H, et al. Frontotemporal dementia: Past, present and future. Alzheimer's & Dementia. 2023; doi:10.1002/alz.13363.
• Grossman M, et al. Frontotemporal lobar degeneration. Nature Reviews: Disease Primers. 2023; doi:10.1038/s41572-023-00447-0.
• Antonioni A, et al. Frontotemporal dementia, where do we stand? A narrative review. International Journal of Molecular Sciences. 2023; doi:10.3390/ijms241411732.
• Diagnosing FTD. The Association for Frontotemporal Degeneration. https://www.theaftd.org/for-health-professionals/diagnosing-ftd/. Accessed Aug. 30, 2023.
• What are frontotemporal disorders? Causes, symptoms and treatment. National Institute on Aging. https://www.nia.nih.gov/health/what-causes-frontotemporal-disorders. Accessed Aug. 30, 2023.
• Lee SE, et al. Frontotemporal dementia: Treatment. https://www.uptodate.com/contents/search. Accessed Aug. 30, 2023.
• Ferri FF. Frontotemporal dementia. In: Ferri's Clinical Advisor 2024. Elsevier; 2024. https://www.clinicalkey.com. Accessed Aug. 30, 2023.
• The ALLFTD team. ARTFL LEFTDS Longitudinal Frontotemporal Lobar Degeneration. https://www.allftd.org/allftd-executive-team. Accessed Sept. 6, 2023.
• Providing care for a person with a frontotemporal disorder. National Institute on Aging. https://www.nia.nih.gov/health/providing-care-person-frontotemporal-disorder. Accessed Aug. 30, 2023.
• Ami TR. Allscripts EPSi. Mayo Clinic. Sept. 4, 2023.
• Alzheimer's disease research centers. National Institute on Aging. https://www.nia.nih.gov/health/alzheimers-disease-research-centers. Accessed Aug. 30, 2023.
• Participating institutions. Arizona Alzheimer's Consortium. http://azalz.org/about-us/participating-institutions/. Accessed Aug. 30, 2023.
• MRI comparison

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News from Mayo Clinic

• Global consortium to study Pick's disease, rare form of early-onset dementia April 24, 2024, 03:15 p.m. CDT
• Untangling the threads of early onset dementia March 29, 2024, 03:01 p.m. CDT
• What is frontotemporal dementia? Feb. 23, 2024, 04:15 p.m. CDT
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Understanding the Four Lobes of the Brain: Functions and Significance

This essay about the four cerebral lobes explores their specialized functions and significance in perception, cognition, and behavior. It describes the frontal lobe’s role in executive functions and personality, the parietal lobe’s sensory integration and spatial cognition, the temporal lobe’s auditory processing and memory formation, and the occipital lobe’s visual perception. The essay highlights the impact of injuries or diseases on these lobes and their associated conditions, emphasizing their crucial roles in maintaining cognitive and emotional stability.

How it works

In the vast expanse of the human brain, four distinct territories reign supreme, each wielding its own specialized functions and profound significance. These regions, commonly known as the four cerebral lobes—frontal, parietal, temporal, and occipital—serve as the epicenters of perception, cognition, and behavior, orchestrating the intricate dance of neural activity within our skulls.

At the helm of this cerebral command lies the frontal lobe, commanding attention from its perch behind the forehead. It stands as the maestro of executive functions, governing decision-making, problem-solving, and social behavior.

Nestled within its folds lies the prefrontal cortex, the esteemed “CEO” of cognition, regulating our impulses, emotions, and social interactions with the finesse of a seasoned diplomat.

Moreover, the frontal lobe serves as the stage for personality expression, shaping our identities and influencing our interpersonal relationships. When afflicted by injury or disease, it can plunge individuals into the depths of behavioral turmoil, manifesting as impulsivity, emotional volatility, or impaired social cognition. Indeed, the frontal lobe’s prominence in the neural landscape is reflected in its association with conditions ranging from attention deficit hyperactivity disorder (ADHD) to frontal lobe syndrome, underscoring its indispensable role in maintaining cognitive and emotional equilibrium.

Venturing deeper into the cerebral terrain, we encounter the parietal lobe, nestled snugly between its frontal and occipital counterparts. This cerebral stronghold serves as the nexus of sensory integration, melding tactile sensations, proprioceptive feedback, and spatial awareness into a cohesive tapestry of perception. Its domain extends beyond mere sensation, delving into the realms of mathematical ruminations, language comprehension, and spatial cognition.

Of particular note is the parietal lobe’s mastery of spatial cognition, guiding us through the labyrinthine corridors of our surroundings with unerring precision. Yet, when beset by injury or disease, this cerebral bastion can falter, leading to conditions like spatial neglect, where one side of space is forsaken in favor of the other. Such afflictions serve as stark reminders of the parietal lobe’s pivotal role in spatial awareness and attentional mechanisms, illuminating the intricacies of our cognitive architecture.

Adjacent to the temporal lobe, the parietal realm also wields influence over language processing, facilitating comprehension and semantic memory retrieval. Within its confines lie bastions of linguistic prowess, such as Wernicke’s area, where the symphonies of speech are deciphered, and the angular gyrus, where visual stimuli metamorphose into linguistic constructs. Alas, lesions within these hallowed halls can precipitate linguistic discord, heralding the advent of receptive aphasia and anomia, where words become elusive specters haunting the recesses of the mind.

Turning our gaze to the temporal lobe, ensconced within the temporal temples, we encounter a realm teeming with auditory marvels, mnemonic enchantments, and emotional reckonings. Here, amidst the convoluted folds of cortical tissue, the auditory cortex reigns supreme, orchestrating the symphony of sound that permeates our auditory landscape. Yet, its dominion extends beyond mere audition, delving into the depths of memory formation, emotional regulation, and spatial navigation.

Central to the temporal lobe’s narrative is the hippocampus, a seahorse-shaped sentinel guarding the gates of memory formation and spatial cognition. Its demise heralds the onset of profound amnesia, relegating cherished memories to the annals of oblivion and robbing individuals of their temporal bearings. Moreover, the temporal lobe’s association with emotional processing is epitomized by the amygdala, the sentinel of fear and the custodian of emotional memory. Dysfunction within these hallowed halls manifests as temporal lobe epilepsy, schizophrenia, and post-traumatic stress disorder (PTSD), casting shadows upon the shores of emotional stability.

Lastly, we arrive at the occipital lobe, nestled at the rearmost reaches of the cerebral expanse, where visions of grandeur unfold amidst the symphony of sight. Here lies the primary visual cortex, where photons transmute into perception, granting us the gift of sight and illuminating the canvas of our reality with hues of color and shades of light. Yet, its dominion extends beyond mere vision, encompassing higher-order functions such as object recognition, motion perception, and visual attention.

Within the occipital lobe, the ventral and dorsal streams converge, weaving a tapestry of visual perception that transcends the boundaries of the mundane. Alas, when afflicted by injury or disease, this cerebral bastion can falter, leading to afflictions such as cortical blindness and visual agnosia, where the world becomes a fragmented mosaic bereft of coherence. Such tribulations serve as poignant reminders of the occipital lobe’s pivotal role in shaping our visual reality, underscoring the profundity of its significance within the cerebral pantheon.

In summation, the four cerebral lobes—frontal, parietal, temporal, and occipital—stand as bastions of cognition, perception, and behavior within the vast expanse of the human brain. Their interplay orchestrates the symphony of neural activity that underlies our conscious experience, shaping the contours of our reality and sculpting the tapestry of our minds. To understand the intricacies of these cerebral domains is to unravel the mysteries of the human psyche, unlocking the secrets of our cognition and charting a course towards enlightenment within the labyrinthine corridors of the mind.

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Understanding the Four Lobes of the Brain: Functions and Significance. (2024, May 28). Retrieved from https://papersowl.com/examples/understanding-the-four-lobes-of-the-brain-functions-and-significance/

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PapersOwl.com. (2024). Understanding the Four Lobes of the Brain: Functions and Significance . [Online]. Available at: https://papersowl.com/examples/understanding-the-four-lobes-of-the-brain-functions-and-significance/ [Accessed: 31 May. 2024]

"Understanding the Four Lobes of the Brain: Functions and Significance." PapersOwl.com, May 28, 2024. Accessed May 31, 2024. https://papersowl.com/examples/understanding-the-four-lobes-of-the-brain-functions-and-significance/

"Understanding the Four Lobes of the Brain: Functions and Significance," PapersOwl.com , 28-May-2024. [Online]. Available: https://papersowl.com/examples/understanding-the-four-lobes-of-the-brain-functions-and-significance/. [Accessed: 31-May-2024]

PapersOwl.com. (2024). Understanding the Four Lobes of the Brain: Functions and Significance . [Online]. Available at: https://papersowl.com/examples/understanding-the-four-lobes-of-the-brain-functions-and-significance/ [Accessed: 31-May-2024]

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