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PEDIATRICS FOR THE CLINICIAN

Cues

for Screening

Language

Disorders

in Preschool

Children

Arthur H. Schwartz, Ph.D., and Michael W. Murphy, Ph.D.

From the University of Kentucky, Lexington

Parents frequently ask the pediatrician to make

judgments about the communication skills of their

preschool children. While the pediatrician is

attuned to listening to how a child talks (i.e., his speech patterns), less attention is typically given

to what the child talks about and the way he

forms his sentences

(i.e.,

his language patterns). A

1970 NINDS report estimated that not less than

1.5 million children evidenced some

develop-mental failure in language acquisition.’ The

purpose of this article is to identify and describe a

set of informal screening observations which are indicative of developmental language disabilities.

The observations can be made by the pediatrician

during an office examination.

NEED FOR RECOGNIZING LANGUAGE DISABILITIES

Detection of language disabilities in the

pre-school years is important for at least four reasons.

First, the primary means by which social and

interpersonal relationships are established and

maintained is through the use of language.

Disruptions in the ability to understand and express language may, if not corrected, interfere

with the development of social relationships and

emotional interactions. Second, language

consti-tutes the major mode of instruction during the

early school years. The child with problems in understanding or expressing himself will undoubt-edly have difficulty in developing academic skills.

A third and very important reason for early

detection concerns the optimal period for

language development. Although the age limits of

the critical period are disputed, most experts23

agree that the preschool years are the optimal

time for acquiring language. The older a child

gets, the greater the effort required to correct

deficit skills. Fourth, while the preschool years

are normally the prime period for children to

acquire language on their own, many children

with language disabilities tend to fixate at an

early developmental level.4#{176} Thus, the gap

between the language-disordered child and his

peers widens, rather than closes, with age. Early

detection of developmental language disabilities may be expected to maximize the effectiveness of

remedial programs and minimize residual effects

on communication.

DEFINITION OF DEVELOPMENTAL

LANGUAGE DISABILITIES

Detection of language disabilities in children is

predicated on a distinction between disorders of

language and disorders of articulation. The latter

involve difficulty in pronouncing speech sounds.

For example, the child may say “wabbit” for

“rabbit,” “thix” for “six,” or “yewo” for “yellow.”

(

Received June 7; revision accepted for publication September 23, 1974.)

ADDRESS FOR REPRINTS: (A.H.S.) Department of Biocommunication, University of Alabama in Birmingham,

(2)

Developmental language disabilities, however, usually involve difficulty in the comprehension or use of words and larger language units. Articula-tion and language disorders are separate clinical

entities that can, and frequently do, occur simul-taneously.

CHARACTERISTICS OF DEVELOPMENTAL LANGUAGE DISABILITIES

The pediatrician should suspect a

develop-mental language disability if the child shows

inaccuracies or inconsistencies in the ability to

understand spoken language (i.e., comprehension)

and/or the ability to produce spoken language

(

i.e., expression). Disruptions in language compre-hension and expression may be characterized by

an inability to: (1) assign meaning to words; (2)

organize words into sentences; (3) alter word

forms to indicate tense, possession, or number;

and (4) produce the speech sounds comprising the

words of language. The information in Table I

provides a more detailed description of the char-acteristics of these four facets of developmental language disabilities.

Inability To Assign Meaning To Words (Vocabulary)

Basic to the development of language is the

acquisition of words, or symbols representing

objects, feelings, and concepts. This is commonly regarded as “vocabulary,” although it is apparent

that much more is involved than the learning of

words and symbols. Comprehension and

expres-sion of the meaning of a word is contingent upon

the child’s proficiency at conceptualizing its

char-acteristics such as “size,’ “shape,” “color,”

“function,” or “composition.” Children with

de-velopmental language disabilities typically have reductions in both vocabulary comprehension and expression. Morehead and Ingram7 have indicated

that these children take nearly three times as long

to develop vocabulary as do normal children.

Thus, one of the cues indicative of a

develop-mental language disability is a reduction in

voca-bulary.

When preschool children who are acquiring

language normally are asked to describe a

common object they typically volunteer not only

its name but also give information about the object and its characteristics, function, how you

use it, etc. Preschool children with a

develop-mental language disability may also give the

object’s name; however, they are typically unable

to elaborate and provide the additional

informa-tion. Recognizing and expressing the characteris-tics of abstract symbols is more difficult than for

tangible objects for both normally developing

children and for those with language disabilities.

Consequently, vocabulary development for

sym-bols representing concepts and feelings may lag

behind that for objects. This lag seems to be more

pronounced in the case of children with language

disabilities. The clinical impression of some

language specialists is that the symbols repre-senting objects in the vocabulary of the children

with language disabilities may be only slightly

smaller than that for their normal peers.

However, they are likely to have markedly

inferior vocabularies for symbols representing

concepts and feelings. Thus, impoverishment of

abstract vocabulary is another cue indicative of

language disability in preschool children.

Another characteristic, and one which seems to

be related to impoverishment of abstract

vocabu-lary, is the reported tendency of

language-disor-dered children to overuse some classes of words

while underusing other classes. When the

utter-ances and sentences of language-disordered

chil-dren are compared with those of normal children

they contain proportionately more concrete words such as nouns and verbs, while containing

proportionately fewer abstract words such as

adjectives, adverbs (modifiers), and prepositions,

articles, and conjunctions (relational words). Inability To Organize Symbols Into

Patterns

One of the major signs of a language disorder is

an inability to comprehend or express sentences

accurately. Children following a normal course of

development typically begin to use two-word

sentences by 24 months of age. On the average,

children with developmental language disabilities

do not begin using two-word sentences until 42

months of age.7 Once they have begun using

sentences, these children are reported to have many of the same grammatical structures as do normal children.’ However, they tend to use

questions, compound, and complex sentences far

less frequently than normal children at the same

stage of linguistic development.6.s

When children with language problems do

produce sentences, they tend to omit parts of a

sentence. In many instances, these children will

omit either the subject or the predicate when

producing a sentence. Frequently, they will omit

smaller words such as prepositions, articles, and

conjunctions. This may result in language that is

“telegraphic” in nature. Verbs present particular

(3)

Spe-cifically, the “to be” verb forms (is, am, are, was, and were) are used inappropriately. As a group, these children seem also to use forms of the verbs

“do” and “can” inaccurately.

Most of the sentences of the language-disorderd

child are statements rather than questions or

negations. Although the child may produce some

negative sentences (i.e., sentences containing

“no” or “not”), it has been reported that they

have difficulty understanding and producing questions requiring a yes-no answer.8 Further-more, questions beginning with “who,” “what,” “when,” “where,” “why,” or “how” (known as wh-questions) are seldom comprehended accur-ately, and are even less frequently produced by

children with language disabilities. When these

children do use wh-questions, they are most apt to

use “who” or “what.” Those wh-questions seem

to involve concepts which are less abstract and

more easily mastered than is the case for the

“when,” “where,” “why,” and “how”

wh-ques-tions.

Children with language disabilities take much

longer to progress from one developmental level

to another. It has been reported that these

chil-dren take, on the average, three times longer to

initiate and acquire basic sentence patterns than

do normal children.7 That is, many

language-disordered children will not begin to combine

words into sentences until sometime between

their third and fourth birthdays. This

character-istic operates to preclude “self-recovery” as a function of increasing age. In her studies with

language disordered children, Menyuk45 com-pared normally speaking 3-year-olds with lan-guage-disordered 6-year-olds. She found few significant differences between the two groups, suggesting that after the language-disordered child reaches a certain stage of linguistic

develop-ment, language skills become fixated and further

development without remedial assistance is

extremely slowed. The tendency to fixate is a major disruption in the development of the ability

to organize symbols into patterns and it is a major

screening characteristic of language disability in

preschool children.

Inability To Alter Symbol Forms

Although each symbol has a specific meaning,

many words can have their meaning changed by alterations in their form. The form of a noun can

be changed to indicate pluralization (i.e., one

shoe-two shoes); verbs can be changed to

mdi-cate tense (i.e., he walks-he walked); pronouns can be altered to indicate possession

(i.e.,

he-his).

Children with developmental language

disabili-ties have difficulty making changes in word

forms. This difficulty may manifest itself in two

fashions: (1) the child may fail entirely to make

such alterations; or (2) the child may use them

inappropriately. As an example, the child who

said, “Yesterday I walk,” is regarded as having

omitted the tense marker on the verb “walk.”

This kind of failure to alter word forms when seen

consistently in the 4- to 6-year-old preschool child

is regarded as an unfavorable sign and one

sugges-tive of a language disability. Altering word forms

is usually a regular and unconscious procedure such as adding “ed”to verbs to indicate past tense,

or “s” or “z” to nouns to indicate plurals. Many

words, however, have irregular rules for altering

their form (run-ran, foot-feet). It is not

uncommon for children to overuse the regular

rules for altering word forms, resulting in such

forms as “runned” for “ran,” “seed” for “saw,”

“doed” for “did,” or “comed” for “came.” The

preschool child who says “Yesterday I sleeped”

instead of “Yesterday I slept,” is showing an

inappropriate alteration of word form. However,

this is not regarded as an unfavorable sign,

because it indicates that the child is beginning to

develop skills at altering word forms. Most chil-dren normally tend to overapply these uncon-scious rules occasionally up through ages 7 or 8.

In contrast, language-disordered children tend to

omit word endings entirely because they

appar-ently do not have the basic rules for altering word forms.

Inability To Produce Speech Sounds

Many children with developmental language

disabilities also have articulation problems. Their

misarticulations, however, seem to differ from those seen in children who are developing

language normally. The spontaneous speech of

language-disordered children is frequently

unin-telligible to all but his parents and other familiar

listeners. Normal preschool children with

articu-lation problems tend to substitute or distort a low

number of consonants rather than omitting them. Their articulation errors generally occur on

sounds which normally are among the last to be

learned (s, 1, r, and the th sound as in think and

that).

Consequently the overall intelligibiliity of

their conversational speech is not typically

impaired to a serious degree. Children with

developmental language disabilities, on the other

hand, tend to omit a higher number of

conso-nants, particularly at the end of words (The

sentence “Bill can eat the cake” may be spoken as

(4)

.,

TABLE I

SYNoPsIs OF DISRUPTIONS IN DIFFERENT FACETS OF LANGUAGE COMPREHENSION AND/OR EXPRESSION

Area ofDisruption Specific Characteristics

1. Assigning meaning to words

a. First words not uttered before second birthday.

b. Vocabulary size reduced for age.

c. Difficulty describing characteristics of objects

although may be able to name them.

d. Infrequent use of modifier words (adjectives or ad-verbs).

. . .

2. Organizing woros into sentences

a. First sentences not uttered before third birthday.

b. Short and incomplete sentences

C. Tendency to omit words (articles, prepositions).

. .,,..,, ,

a. Misuse ot tne De, ao ana can vero torms.

e. Difficulty understanding and producing questions.

f. Plateaus at an early developmental level.

3. Altering word forms

a. Omission of endings for plurals and tense.

b. Inappropriate use of plurals and tense endings. C. Inaccurate use of possession words.

. .

4. Articuiation patterns

a. Intelligibility of conversational speech reduced for age. b. Omission of consonants at end of words.

c. Substitution of t, d, k, and g for most other

consonants.

d. Slowed or plateaued progress in the acquisition of new sounds.

or two simple, early developing consonants, (t, d,

k, or g) for many others. For example, words such

as “nose,” “dog,” “foot,” “fork,” and “spoon,”

may be articulated as “doe,” “gog,” “toot,” “tok,”

and “koon.” As with other facets of their

language, these children seem to fixate in their

patterns of misarticulation; consequently, they do

not show the maturational changes in articulation

skill development over time that is typically seen

in children who are developing normally. Thus,

preschool children who present unintelligible

speech, who seem either to omit many consonants

or substitute one or two consonants for most

others, and who have shown little or no change in

their articulation skill during the preceding six

months should be suspected of having a language

disability.

Evaluating the Child’s Language

The central premise of this article has been that

if the pediatrician knows what to look for in the

language behavior of children, it may be possible

for him to recognize suspect children and to refer

them for a full language assessemnt and treatment

during their preschool years. The screening cues

discussed above can best be used by directly observing the child’s language behavior. Direct

observation, however, is sometimes complicated by still another characteristic of language disabil-ity, a reduction in spontaneous language.

Chil-dren with language disabilities usually use short

verbal utterances, and they must be coaxed to

talk. They are frequently overly dependent on parents and siblings to talk for them or to act as an

“interpreter.” Possibly because of embarrassment

and shyness some language-disordered children

refuse altogether to talk around strangers and

when they are apprehensive. Even though a child

may be reluctant to talk, it is possible to obtain

either directly or indirectly sufficient information

to make a screening judgment regarding referral

for a formal language assessment.

Direct Procedures for Obtaining Language

Observations of language based on first-hand

interactions between the child and the

pediatri-cian are regarded as direct procedures. The goal

of such procedures is to get the child to verbalize

spontaneously about topics of interest. While the

child is talking, the pediatrician can be listening

to vocabulary, sentence organization, word form

usage, and articulation patterns. Frequently,

common objects such as a pocket flashlight, a pen,

or a set of keys can be used to evoke some

spontaneous language from the child. When

attempting to elicit language from young children

there is a tendency to show them an object and to

ask them to name it. Such a format will result in

(5)

24 months or older 36 months or older Yes Yes Yes Yes Yes Yes No No No Yes Yes Yes Yes

the opportunity for listening to other facets of

language. One technique that has been found

helpful is to show the child an object and ask him

to describe how it works or what it does. Another

procedure which seems effective for evoking

spontaneous language is to ask the child what he

wants for his birthday. This type of question can

be followed with a “Why?” which usually results

in additional language from the child. Normal

preschool children, when confronted with the

question “If you had three wishes in the whole

world, what would you wish for?” often produce

long and complex language samples. They seem

willing to further explain what they would do with each object they have wished for, and why they chose it, etc. It is proposed that this entire interaction can be accomplished while the pedia-trician is examining the child and such informa-tion about language is obtained in a subtle manner.

Another procedure for obtaining language from

the child is to have him imitate sentences

produced by the pediatrician. It is currently

believed by language specialists that children are

not able to repeat statements containing

gram-matical structures they are not able to use

them-selves. Children with developmental language

disabilities will also have difficulty accurately

repeating sentences of more than three or four

words. If the sentence contains forms of the verbs

“to be,” “do,” or “can,” such children tend to

omit the crucial parts of the sentence or reduce

the sentence to a simpler form as they repeat it.

If time permits and the equipment is available,

it may be helpful to make a tape-recording of the

speech and language of children suspected of

having a developmental language disability. First,

children are often intrigued by tape recorders and

they like to hear themselves on the tape. This can frequently be of assistance in eliciting a language sample from children who are reluctant to talk for

the examiner. Second, with tape-recordings

obtained over a succession of office visits it is

much easier to identify the child who is

progressing slowly or who has plateaued in

language development and who therefore should

be considered suspect relative to a language

disability.

Indirect Procedures for Sampling Language

Occasionally, because of shyness,

apprehen-sion, or inability, some children will not produce

sufficient language for the pediatrician to make

judgment concerning the normality of their

language development. In such instances, some of

1.

TABLE II

PERTINENT QUESTIONS To ASK PARENTS OF PRESCHOOL CHILDREN WITH SUSPECTED

LANGUAGE DISORDERS

Suspect

Parent

Key Questions Responses

How old was your child when he

began to speak his first words9

2. How old was your child when he

began to put words into sentences? 3. Does your child have difficulty

learning new vocabulary words? 4. Does your child omit words from

sentences (i.e., do his sentences

sound telegraphic)

5. Does your child speak in short or

incomplete sentences?

6. Does your child have trouble with verbs such as “is, am, are, was,

were”?

7. Does your child have difficulty

following directions?

8. Does your child seem to have difficulty in understanding you if you use long sentences?

9. Does your child respond

appro-priately to questions?

10. Does your child ask questions

beginning with “who,” “what,”

“where,” and “why”?

1 1. Does your child use present and past

tense verbs correctly?

12. Does it seem that your child has

made little or no progress in speech and language in the last 6 to 12 months?

13. Does your child omit sounds from his words?

14. Do you feel your child’s speech is more difficult to understand than

it should be in view of his age?

15. Does it seem like your child uses t,

d, k, or g in place of most other

consonants when he speaks?

the pertinent information may be obtained by

asking the child’s parents key questions regarding

his language. These questions are based on the

characteristics of language disorders which have

been described in this article. A set of key

questions is given in Table II along with suspect

answers which are indicative of language

disabil-ity. However, information obtained by ques-tioning the child’s parents needs to be used

cautiously. Because of poor memory, lack of

understanding, or desire to convey a positive

(6)

objective and accurate. Unfortunately yes-no

questions seem to be particularly subject to such

criticism. If the pediatrician suspects a problem,

it is a good idea to ask for examples or clarifying information. If five or more “suspect” responses

are obtained to the 15 questions in Table II the

child should be regarded as presenting

character-istics associated with language disability.

FOLLOW-UP PROCEDURES

If, after listening to the child’s language, or

judging from parental reports, the pediatrician

believes the child has some of the screening

characteristics of developmental language

disabil-ities described in this article, referral to a speech and hearing clinic for a diagnostic evaluation is in

order. Diagnostic assessment by a speech and

language specialist together with consideration of

the child’s medical, developmental, social, and

emotional history can establish whether a

language disability does exist and if so what course of remedial action is most appropriate.

Such decisions should not be made on the basis of

the screening observations described in this

arti-cle. Early referral when a problem is suspected

can result in early diagnosis and implementation

of remedial programs for those children needing

language therapy, thereby maximizing the

possi-bility of improvement and minimizing the

resid-ual effects of a language disability.

When a child is referred to a speech and

hearing clinic for an evaluation, the pediatrician

should expect to receive a diagnostic report from

the clinic. It is also common practice following

the evaluation for the speech and language

clini-cian to describe the child’s status to the parents

and to make disposition recommendations. In the

case of children subsequently enrolled in a

treat-ment program, therapy and progress reports are routinely sent to the referring pediatrician only if

he or the parents have specifically requested it.

SUMMARY

This article has described procedures and

criteria a pediatrician may employ during office

evaluation to identify children suspected of

having a developmental language disability.

Disruptions in vocabulary comprehension,

vocab-ulary production, sentence organization, use of

word forms, and articulation patterns are

impor-tant cues signaling the need for referral for a

speech and language evaluation. The 1970

NINDS1 estimate that no less than one out of every 170 children has a developmental disability

affecting the development of language suggests

that one or more such children with such a

disability enter the pediatrician’s office each

week. Many of the negative consequences of this

problem may be prevented or greatly reduced by

early detection and appropriate referral based

upon the information described in this article.

REFERENCES

1. NINDS; Human Communication and Its Disorders: An

Overview, monograph No. 10. Bethesda, Md.:

National Institute of Neurological Diseases and

Strokes, Department of Health, Education, and

WeLfare, 1972.

2. Lenneberg, E. H.: Biological Foundations of Language. New York: John Wiley & Sons, 1967.

3. McNeil, D.: The Acquisition of Language: The Study of Developmental Psycholinguistics. New York:

Harp-er & Row, 1970.

4. Menyuk, P.: Comparison of the grammar of children

with functionally deviant and normal speech. J.

Speech Hearing Res., 7:109, 1964.

5. Menyuk, P: Sentences Children Use. Cambridge: MIT

Press, 1969.

6. Menyuk, P.: Linguistics and evaluating the language

disorders of children. Read before the Annual

Convention of the American Speech and Hearing Association, Chicago, 1971.

7. Morehead, D. M., and Ingram, D.: The development of

base syntax in normal and linguistically deviant

children. J. Speech Hearing Res., 16:330, 1973. 8. Leonard, L.: What is deviant language? J. Speech

Hearing Dis., 37:427, 1972.

9. Miller, J. F., and Yoder, D. L.: A syntax teaching

program. In, McLean, J. L., Yoder, D. L., and

Schiefelbush, R. (eds.): Intervention Strategies for the Retarded. Baltimore: University Park Press,

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1975;55;717

Pediatrics

Arthur H. Schwartz and Michael W. Murphy

Cues for Screening Language Disorders in Preschool Children

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1975;55;717

Pediatrics

Arthur H. Schwartz and Michael W. Murphy

Cues for Screening Language Disorders in Preschool Children

http://pediatrics.aappublications.org/content/55/5/717

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