We use our abilities to speak and write in an effort to inform and request; they are the skills we use most often to accomplish our daily tasks. This ability serves as the foundation for our day, our week, and our lives. Yet, as I begin this paper, and consider the process of organizing and presenting my thoughts, the information I have gathered, and determining what is worth sharing, I feel the challenge of communication, a frustration felt many times over by students with Expressive Language Disorder.
How often do we find ourselves struggling to communicate effectively? We can all think of occasions where we might have presented things more efficiently, written more clearly, or said something differently. For the majority of us this is more a condition of unpreparedness, spontaneity, or just being human. However, for children with Expressive Language Disorder, it is about an actual inability to compose or articulate their thoughts.
Imagine yourself immersed in an environment where you can understand what people are saying to you, and you can read all the signage around you. You can find your way around this environment by what you are told by others and by what you can read for yourself. What you hear, read and understand can even be complex.
However, when it becomes time for you to express your own thoughts, or to respond to others, your mind presents you with a limited selection of words to choose from. You struggle to put these words in order so that they will be understood. You may even have trouble remembering the words you have at your disposal each time you are expected to use them. Certain conversations and expressions are beyond your limits, and you learn to recognize these limits quickly. This invariably can cultivate a belief that it is easier simply not to engage in these interactions rather than struggle to communicate the things you want to say, or risk underscoring their meaning.
You eventually settle for choosing only occasional exchanges, rather than opening your mouth to speak, or putting a pencil to paper to write. It isn't difficult to understand how a child who experiences these things eventually becomes less interested, more frustrated, and can be perceived by those around him as inattentive or unintelligent.
As with virtually all learning disabilities, initial diagnosis can be difficult in that Expressive Language Disorder shares and emulates characteristics, both in its developmental onset and in its progressive manifestation, with other speech disorders. So which traits are distinct to this disability and what methods are preeminent in searching for and recognizing these subtle characteristics?
Expressive language disorder in children between the ages of five and thirteen is commonly defined as a learning disability that features disordered communication, characterized specifically by difficulties in written and verbal expression. At its onset, creating complex sentences poses considerable difficulty, as does remembering words within a limited vocabulary set. In some instances there may also be abnormalities in articulation. (1)
However, in every instance of expressive language disorder diagnosis, the preeminent characteristic in meeting an accurate diagnosis is a pronounced difference between a child's receptive functioning (understanding, listening and writing) and their expressive functioning. That is, they have more difficulty speaking and writing than the average person their age and general developmental level. While speech ability is specifically impaired by comparison to developmental expectations for their age group, language comprehension is within normal limits. (2)
This assessment can be a difficult one to make, especially in young children. Their perception and comprehension must be recognized as an unaffected cognitive process, while their capacity for expression of oneself and the given material around them must be determined as problematic. Parents and educators recognize that the pace and cadence at which children develop can differ significantly, especially in acquiring language skills. However, many experts, including those parents and educators, disagree on when exactly the appropriate time to initiate intervention for a child who shows signs of ELD. While some experts push for early intervention, some believe that once a child reaches age four or five intervention should be initiated, and that for younger children, waiting to see if they catch up in development is a better approach. (2)
The consensus among language specialists seems to recognize that in addition to tests that require spoken answers to gauge both comprehension and response, non-verbal tests must also be utilized. As a rule, a child's hearing is evaluated with the recognition that auditory limits, whether mild or severe, will affect the ability to construct sentences similarly to those children with expressive language disorder. Also, testing should take into account the primary spoken language in a child's household if it is something other than English, and tests should be administered in their primary language if possible. This obviously would have an effect on a child's vocabulary and sentence building in English. [e.g.(4)]
Beyond these initial and essential preliminary evaluations, further tests for speech and language delays in children can escalate to assessments more specifically targeting clinical diagnoses such as Mental Retardation, Autism, Dysarthria and other specific learning disabilities, including but not limited to cognitive or receptive language disorders. These considerations all reflect the importance of differential diagnosis relating to expressive language disorder. For our purposes we look to further examine the distinctions of ELD which clarify its definition.
In considering the attributes of ELD, it is important to recognize a few distinctions that aide in defining and distinguishing it from other communication disorders. Primarily, it is important to recognize that expressive language disorders differ from speech problems. Speech disorders involve a child's physiology, specifically the physical structures of the tongue, mouth and voice box and their subsequent functionality which directly affect the physical formation of words. Language disorders are affected by cognitive considerations, this being the area of the brain that controls the processing of language and the ability to use that language. There is also receptive language capabilities- interpretation of information the child receives. "Since different areas of the brain control receptive and expressive language processing, it is possible to have difficulties in just one of these areas, but still have normal or above normal intelligence and reasoning abilities in all other areas."[e.g.(5)]
It is also worth noting that despite these normal intelligence levels, children with ELD may appear more limited and less capable than they actually are because of their inability to express themselves. Very often a child with ELD may have a comprehension of language and subject matters in school that is as well developed as their classmates.[e.g.(6)] However, their ability to express the ideas they do comprehend to others around them is impaired, not their actual understanding. This essentially means that these children may understand words that they simply cannot use themselves when constructing sentences. Comprehension of sentences of a complex nature and intricate instructions may be very manageable for these children despite their inability to compose their own unique statements and responses. [e.g. (4)]
By definition, ELD can actually be categorized in two types. These variations can overlap characteristically and can be difficult to differentiate from one another. The first type is Delayed ELD and is characterized by a childï¿½s slow language development, but the usual sequence or pattern of other developmental milestones are normal. The second type is Disordered ELD which is characterized by slow language development with both the sequence of development and the pattern of grammatical errors being recognized more different than normally expected. [e.g.(8)] While delayed language development may commonly be corrected with early language intervention, it is also more likely to be overlooked and viewed as a matter of eventual self-regulation. There is a very fine line between 'delay' and the conventions around it and 'disability' and their subsequent treatments. As with all early intervention, therapy may be only as successful as its implementation allows for, and timing along with diagnostic accuracy are both of the utmost importance. [e.g.(9)]
In exploring what defines Expressive Language Disorder we have considered specifically what universal traits it displays in school aged children, which communicative properties it affects and which it doesn't, and the variations it can exist under. But how is ELD defined by the institutions from which the disorder expects recognition and treatments under- namely American school districts and the scientific community which in turn defines by its own diagnostic criteria?
From the perspective of Part 200 of the Regulations of the Commissioner of Education, school districts may categorize ELD as a Learning Disability, listed as the sixth of eleven categories used to identify "a handicapping condition which "requires special services and programs approved by the State Education Department.";
"Learning disability means a disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, which manifests itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations. The term includes such conditions as perceptual disabilities, brain injury, minimal brain dysfunction, dyslexia and developmental aphasia. The term does not include learning problems that are primarily the result of visual, hearing or motor disabilities, of mental retardation, of emotional disturbance, or of environmental, cultural or economic disadvantage." [e.g.(10)]
The Diagnostic and Statistical Manual of Mental Disorders or DSM is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders. Despite the sometimes controversial and perhaps negative connotations of necessarily referencing learning disabilities (which encompass mental, physical and emotional challenges) as mental disorders, the DSM serves as a guide for clinicians and researchers and is frequently used to determine and communicate classifications for disorders based on diagnostic information.[e.g.(11)] The DSM is currently in its fourth edition (DSM-IV-TR) having been revised several times and has the following assessment in regard to the diagnosis of ELD;
"There are four general criteria for diagnosing expressive language disorder. The first is that the child communicates using speech at a level that is less developed than expected for his or her intelligence and ability to understand spoken language. This problem with communication using speech must create difficulties for the child in everyday life or in achieving goals. The child must understand what is being said at a level that is age-appropriate, or at a developmental level consistent with the child's. Otherwise the diagnoses should be mixed receptive-expressive language disorder. If the child has mental retardation, poor hearing, or other problems, the difficulties with speech must be greater than is generally associated with the handicaps that the child has."
In addition to this assessment, the DSM also assigns numbers for each disorder and its diagnostic criteria. In this particular case, expressive language disorder is 315.31.
In order to meet the diagnostic criteria of the DSM, a child must exhibit the following or meet all of the following:
A. The scores obtained from standardized individually administered measures of expressive language development are substantially below those obtained from standardized measures of both nonverbal intellectual capacity and receptive language development. The disturbance may be manifest clinically by symptoms that include having a markedly limited vocabulary, making errors in tense, or having difficulty recalling words or producing sentences with developmentally appropriate length or complexity.
B. The difficulties with expressive language interfere with academic or occupational achievement or with social communication.
C. Criteria are not met for Mixed Receptive-Expressive Language Disorder or a Pervasive Developmental Disorder.
D. If Mental Retardation, a speech-motor or sensory deficit, or environmental deprivation is present, the language difficulties are in excess of those usually associated with these problems.[e.g.(12)]
The specific traits that both the Regulations of the Commissioner of Education standards and the Diagnostic and Statistical Manual of Mental Disorders provide set the classification for the purposes of recognition and assessment in academia and mental health. How a child's ELD (and the degree to which it creates limitations) is ultimately defined can directly influence both the type and degree of subsequent preventative intervention.
Many of us are familiar with situations in which a very young child might not speak as early or as often as their families would like. While many children do eventually develop their own preferences and frequencies for speech that are unique to their personalities, stimulatory levels, and surroundings, others may find themselves at a distinct disadvantage due to ELD long before school is even a possibility for them. Expressive language disorder itself is a relatively common childhood disorder. It is estimated that between three to five percent of all children in the United Kingdom have ELD. Estimates among the US population are not available. [e.g.(13)] In the United States it has been estimated that language delays occur in ten to fifteen percent of children under three years old, and in three to seven percent of school aged children. Not all these delays will be eventually contributed to ELD. For reasons that are unknown, boys are more commonly diagnosed with communication disorders overall than girls are. Studies suggest that developmental expressive language disorder occurs two to five times more frequently in boys than in their female peers.[e.g.(4)
As with the specific type of expressive language disorder that a child can develop, the actual causes for the disorder have also been categorized into two different distinctions. They are developmental expressive language disorder and acquired expressive language disorder.[e.g.(3)] These variations by their nature are similar to many other considerations for causes of disabilities in that they also can originate as a result of either genetic or environmental influences.
The developmental derivative of ELD typically appears when a child is first learning to formulate and imitate the sounds around them by speaking. Developmental expressive language disorder does not currently have a known cause.[e.g.(4)] Some studies have indicated through MRI analysis of structural brain differences that genetic roots in family clusters account for similarities in inherited language disorder. Sixteen researchers and clinicians specializing in this particular field are continually making efforts to understand what the causes of developmental ELD might be. [e.g.(3)]
The acquired variant of ELD is caused by damage to the brain. It can result suddenly after such events as a stroke, seizure or traumatic head injury and therefore can occur at any age. The developmental form of the disorder is far more common than the acquired type.[e.g.(4)]
The characteristics and symptoms of ELD differ from one child to the next and depend on the childï¿½s age and the severity of the disorder. [e.g.(3)] They do however share certain similarities in that they can manifest within a family of characteristics that typify the disorder. As previously touched upon earlier in this presentation, comprehension of what they are being told is not an issue for children with ELD. However, speaking itself and the requirements for crafting words into sentences is where the difficulty lies.
A child with ELD may face academic difficulty in not just the expected subjects of reading and writing, but also in any classwork that requires note taking, oral presentations, or spoken participation. The child with ELD may face challenges in making friends, as they have difficulty connecting with their limited vocabularies, and difficulties in engaging in complex imaginary and cooperative play due to the verbal interactions they require. For example, a child with ELD may not be able to describe a movie they have seen, limiting their shared experiences with peers.[e.g.(3)]
Specific symptoms are numerous and can include any one of the following:
ï¿½ Frequently having trouble finding the right word
ï¿½ Having a limited and basic vocabulary
ï¿½ Using non-specific vocabulary such as ï¿½thisï¿½ or ï¿½thingï¿½
ï¿½ Using the wrong words in sentences or confusing meaning in sentences
ï¿½ Making grammatical mistakes, leaving off words (such as helper verbs) and using poor sentence structure
ï¿½ Relying on short, simple sentence construction
ï¿½ Using noticeably less words and sentences than children of a similar age
ï¿½ Relying on stock standard phrases and limited content in speech
ï¿½ Repeating (or ï¿½echoingï¿½) a speakerï¿½s utterance
ï¿½ Inability to ï¿½come to the pointï¿½ or talking in circles
ï¿½ Problems with retelling a story or relaying information
ï¿½ Inability to start or hold a conversation
ï¿½ Difficulty with oral and written work and school assignments in older children. [e.g.(8)]
These symptoms are all signs that both educators and parents may recognize in the children they supervise and engage with. Depending on the environment and the circumstances, some of these indications of ELD can be extremely subtle ones to anyone not looking for them, especially if these children have ample opportunities to simply keep quiet and refuse spoken or written tasks and interactions.
A perfect example of different symptoms affecting speech can be found at the following YouTube location; [e.g.(18)]
Expressive language disorderï¿½ Sariah Age 10 ï¿½ http://www.youtube.com/watch?v=BnRNeDtme0g
A very brief conversation with this little girl might not necessarily sound any alarms on a given day, but repeated interactions might redefine any assumptions about her traits initially being labeled as tired, distracted, shy or self-conscious behavior.
In reference to behavioral considerations, those that can germinate due to expressive language disorder are numerous. To be unable to communicate adequately can effectively undermine both interpersonal relationships and sense of self to such a degree that children can struggle greatly to develop socially. Inability to participate in group activities can lead to purposeful isolation and avoidance on the part of these children. Problem behaviors in the form of aggression or distracting behaviors may become the method the child most uses to communicate and have their needs met. The anxiety, frustration, and feelings of distress the child feels can manifest in difficulty falling asleep and staying asleep and problem behavior surrounding bedtime and other normal family routines. Some parents report a great deal of conflict and non-compliance with their child with ELD, which may be a symptom of frustration with the childï¿½s inability for adequate self-expression on both sides of the parent-child relationship. Repeated school absences, poor self-image and failing grades can all occur as the situation escalates.[e.g.(3)]
It is important to also note that such unfortunate stresses on a child struggling with the effects of ELD can find themselves being dually diagnosed with other disorders and conditions; "Although the prognosis of the disorder is very good and most of the children overcome their language difficulties, some studies suggest that children with language disorders may be at risk for mood and behavior disorders. Some researchers report that half of children diagnosed with ELD and referred for speech therapy may also be diagnosed with Depression, Anxiety Disorder, Attention Deficit/Hyperactivity Disorder (ADHD), Conduct Disorder (CD), or Oppositional Defiant Disorder (ODD)." [e.g.(3)]
These consequences only serve to exemplify the importance of instructionally based intervention for children who have language difficulties. It is also of great benefit to acknowledge and recognize how successful teaching methodology and strategy can be for children contending with ELD.
Purposeful intervention that is designed to prevent, eliminate and/ or overcome obstacles that might otherwise keep a child from learning and from full active participation in school and society is as the goal of every special education program. As in every instance of program planning, coordination between special educators, general educators, parents and speech pathologists is integral to a child's success and improvement. For the purposes of specialized teaching methods, placement & inclusion provisions and Individual Education Plan customization, what strategies might most benefit a child with expressive language disorder?
In order to answer this question, parents and professionals must isolate which services might benefit the child, what learning environment will allow them the most success, and where exactly the typical deficiencies exist in the processes that allow for them to both construct sentences and utilize/remember vocabulary sets. [e.g.(6)]
If the child is referred for an intervention, a speech language pathologist is the specialist who can offer the most effective treatment for them. A speech pathologist should work directly with the child to increase the number of words and phrases that they can remember, draw from, and express. Simultaneously, it is important for parents to play a significant and active role in the child's treatment plan by requesting and following routines provided by the pathologist that can be incorporated into the child's daily routine at home. [e.g.(3)]
While diagnostic writing and speech/language testing can determine language difficulty levels for these students, observations, student work analysis, cognitive assessment and occupational therapy evaluations can further refine and bolster chances for a successful program plan.
In the past, children with communication disorders were routinely removed from the regular class for individual speech and language therapy. While this is still the case in severe instances, considerations for least restrictive environment by inclusion recommend keeping the child in the mainstream as much as possible. In order to accomplish this goal, teamwork among the teacher, speech and language therapist, audiologist, and parents is once again of the utmost and essential importance. [e.g.(24)]
Specific problems for children with ELD can be centered on word retrieval issues or the inability to use complex sentences in building paragraphs. Often, both aspects can present difficulty. Ironically, these children again may have a strong and intuitive understanding of the material, but cannot find the appropriate sentence structure or words to express this understanding along with any further insights, realizations, or contributions they may have. [e.g.(22)]
Here are few specific teaching strategies for expressive language disorder as outlined by the Chapin School;
"When appropriate, offer occasional alternative assessments that do not rely exclusively on language (e.g., drawings, paintings, music compositions, dance pieces).ï¿½
ï¿½ The child may be hesitant about participating in class discussions. Sometimes, it is helpful to prepare her beforehand. In other words, the day before tell her what specific question you will be asking so that she has a chance to prepare herself. Another strategy is to encourage partner and/or small group discussions.
ï¿½ With written assignments, try to focus on scaffolding a specific skill. For instance, if she has trouble with topic sentences, make that the focus of the assignment. Work one-on-one with her beforehand. Too much feedback in her writing can overwhelm her.
ï¿½ When posing an oral question or promoting discussion with a student, be concise and clear. Allow for ample wait time while the student is formulating her response." [e.g.(22)]
An impressive 50 to 80 percent of the referred cases involving language delays in young children achieve normal language skills during their preschool years and are defined as just late talkers. When expressive language disorder continues after preschool and into early childhood years, as discussed, it may cause serious problems both socially and in school. However, the developmental type of the disorder is most likely to disappear by high school, although some small problems with expressing complex ideas or thoughts may continue. [e.g.(3)]
The prognosis for the acquired type of expressive language disorder depends on the nature and location of the brain injury. Assisted by therapy, some people get their language skills back over days or months. For others it takes years, and some people never fully recover expressive language function.[e.g.(4)]
Even in the process of reading and researching material for the purposes of trying to accurately describe expressive language disorder, I felt certain that I could at least marginally imagine what it might be like to have to contend with an inability to efficiently communicate in my surroundings. I have had the good fortune to have found travelled abroad in locations where the written language did not resemble any alphabet or written convention I had ever known, and the spoken language around me was completely indecipherable. Through that experience, longing to speak with those around me, and not being able to do any such thing, I have experienced just a fraction of the frustration that must come with any communication disorder.
The reality of the situation is that I really have no idea about what dealing with such a disability like ELD would be like. In those times I found myself ignorant of what was going on around me, there were several significant differences. I couldn't understand the language, unlike children with ELD. I couldn't read the language, unlike children with ELD. I couldn't take what I heard and read around me, and come to some very definitive ideas, opinions, realizations or thoughts about the world around me. And perhaps most significantly, as a tourist, no one expected me to be able to respond, share, express, or direct any information of any kind back to them. So at no point did I necessarily feel as though the situation was a permanent or necessary one, because it simply wasn't.
For children with expressive language disorder those expectations are there waiting for them every day. Without the necessary interventions, the more they might learn as they grow, the less they can express this knowledge, and as a result, the less they can benefit from it. In order to allow children with ELD the fullest lives they can experience, proper diagnosis and recognition from the educational community is essential.