For some children, the difficulties disappear during the first year of school, while for others the difficulties persist and some develop reading and writing difficulties.
What are language difficulties?
Language difficulties include problems with comprehension, oral expression and pronunciation. Some may have language difficulties related to other developmental difficulties such as autism spectrum disorder or Down’s syndrome, while others have no problems that can explain their language difficulties.
There are several ways of defining language difficulties, with great variation in severity. In Norway, language difficulties are divided into three main diagnostic groups:
- Difficulties speaking and expressing language, but with good language comprehension, (expressive language disorders).
- Difficulties with both understanding and expressing language, (mixed expressive and receptive language disorders).
- Difficulties with pronunciation, (phonological disorders).
In addition, language difficulties can include problems with fluency of speech (stuttering) or voice problems.
New classifications of language difficulties
Research from the last decade has shown that there is a strong association between expressive language abilities and the ability to understand spoken language. Internationally, new classifications of language difficulties are being developed to replace the ones described above. Rather than dividing the difficulties into expressive and receptive abilities, a more general classification of communication disorders, with several subgroups, has been suggested.
The 2013 revision of the American diagnostic system, DSM, suggests seven subcategories of communication disorders. It is expected that the next update of the diagnostic system of the World Health Organization, ICD, will adopt similar classifications:
1. Language impairment
Language abilities are below-age expectations, for example regarding vocabulary, grammar or the ability to tell stories. This classification only applies if the child’s difficulties do not fit any of the other criteria below. Language impairment is either the main difficulty or is present together with other developmental disorders, such as autism spectrum disorder or learning difficulties.
2. Late language emergence
The child starts speaking later than expected for his or her age, but has no other diagnosed disabilities or developmental delays. This subgroup is only applicable for preschool children and can be used up to four-five years of age.
Many children with late language emergence catch up with peers in their language development. However, for some children, late language emergence is the first sign of a developmental disorder which can later be diagnosed as a specific language impairment (see criteria 3), autism spectrum disorder, learning difficulty, ADHD, developmental disorder or other developmental difficulty. It is often difficult to predict which children with late language emergence will subsequently develop specific language impairment (Tage-Flusberg & Cooper, 1999).
3. Specific language impairment
The child has weaker language skills than expected for his or her age, but otherwise seems to develop normally with regard to non-verbal learning skills and understanding (Bishop & Leonard, 2000). Children with disabilities like hearing difficulties, autism spectrum disorders, or developmental disorders are not included in this group (Tomblin et al., 1996).
4. Social communication disorder
The child has difficulties using language in social settings, also called pragmatic difficulties. The child has problems with conversations in daily situations and struggles with both verbal and non-verbal communication. This subgroup refers to children who have difficulties with both using and understanding the social codes in conversations, but does not include children with autism spectrum disorder (Bishop & Norbury, 2001). Studies have shown that pragmatic difficulties are not related to problems in use of sounds in language, understanding of meaning or grammar skills (Tomblin et al., 2004).
5. Speech sound disorder
The child has difficulties creating speech sounds expected for his or her age. Structural or neurological damage does not explain the difficulties. This difficulty was previously known as phonological disorder or articulation disorder. The new description is more neutral regarding causality. Children with speech sound disorder may have difficulties both with pronunciation and sorting the sounds in language that give meaning (e.g. hat/cat). Speech sound disorder can occur together with other difficulties, such as language impairment or cerebral palsy.
6. Childhood-onset fluency disorder
Childhood-onset fluency disorder, also known as stuttering, means that the child has problems speaking with normal fluency. In some cases the child develops avoidance strategies to avoid speaking because of the stuttering. Stuttering with onset during adulthood is commonly associated with neurological damage.
Voice disorder means that the child speaks with deviating tone, volume or rhythm, inappropriate for the child’s age or sex. The difficulty usually persists over time. Voice disorder may be the main difficulty or can occur together with other difficulties. The difficulties are so severe that communication with other people, social participation and ability to function in school are reduced. Symptoms must have started in early childhood, even though the difficulty may not be detected before the demands on language, speech and communication reach a certain level.
Children with language difficulties often have additional problems, particularly if the language difficulties persist over time. These children more often develop behavioural, social, educational and psychological problems than children with normal language development (Ottem & Lian, 2008). Some children with language difficulties become shy and withdrawn, or develop difficulties with controlling aggression (Snowling et al., 2006). It is estimated that around 15-30 per cent of preschool children with language difficulties also have behaviour problems (Beitchman et al., 2001). Children with language difficulties may be rejected by peers in play, thus not gaining the same social experience (Liiva & Cleave, 2005).
One of the most common co-occurring problems for children with language problems is motor difficulties (Hill, 2001). Children may have poor fine motor skills or be clumsy. There is no obvious reason why language difficulties should lead to motor difficulties, and this association has been used as an argument that specific language impairments are not so specific after all, but rather part of a bigger picture. Problems with reading and writing are also common for children with current or previous language difficulties (Bishop & Snowling, 2004). When children with language difficulties grow up, they are at increased risk of developing mental health problems, such as behaviour difficulties, social anxiety or depression (Beitchman et al., 2001).
In children with co-occurring problems, the language difficulty may be difficult to detect because the focus is on the other problem. Children with additional problems may have other intervention needs than children who only have language difficulties.
Applies to many children
Language difficulties are a common developmental difficulty in young children (Heim & Benaich, 2006). A Norwegian study found that 10 per cent of children between six and ten years have language difficulties (Hollung-Møllerhaug, 2010). The study was based on parental questionnaires (Children’s Communication Checklist-2, CCC-2). They divided the children into subgroups and when they excluded the children with predominantly social communication difficulties, they found that 7.5 per cent of the children had difficulties with language expression and comprehension.
The results from the Norwegian study correspond to international literature showing that between 10 and 20 per cent of two to three year olds have delayed or abnormal language development (Rescorla & Achenbach, 2002), and between 5 and 10 per cent of all preschool children have a language difficulty (Bishop & Leonard, 2000).
Language difficulties are more common for boys than girls. Studies from the US show that there is a tripled risk of boys having delayed language development than for girls (Zubrik et al., 2007). In Norway it has been found that twice as many boys as girls have language difficulties, based on parental reports (Hollun-Møllerhaug, 2010).
Delayed language development is caused by the influence of a combination of environmental and genetic factors over time. The fact that boys more often are affected than girls, together with results from family and twin studies, suggest that heritability of language difficulties is substantial (Heim & Benaisch, 2006; Bishop, 2000). One study found that in families where one parent has had a language difficulty, 40 per cent of the children also had such difficulties, whereas if both parents had a history of language difficulties, 70 per cent of the children also had them (Tallal et al., 2001).
If one identical twin has language difficulties, the other twin has the same difficulties in up to 80-86 per cent of the cases. In fraternal twins, this is found in only 40-50 per cent of the cases (Bishop et al., 1996). These numbers vary with the type of language difficulty studied.
For each individual child one cannot assume that there is only one underlying cause. Language difficulties can be a result of several underlying difficulties related to different learning and environmental conditions (Bishop, 2006).
The risk of developing language difficulties is greater for boys, children with low birth weight, premature children and twins/triplets (Rutter et al., 2003; Schjølberg et al, 2011). Children weighing less than 85 per cent of their optimal birth weight have twice the risk of delayed language development compared to children of optimal weight (Zubick, 2007).
Language difficulties have not been found to be related to the parents’ educational level, socioeconomic status, mental health, parenting style or the family’s general functioning (Dale et al., 2003; Paul, 1996).
At the same time, studies have shown that socioeconomic status and parent’s educational level do affect children’s general language development, such as vocabulary, storytelling skills and use of language (Hart & Risley, 1995). Thus environmental factors may contribute either by reducing or increasing the effect of innate difficulties with language learning (Sameroff & MacKenzie, 2003).
Can be identified at public health clinic, child care centre or school
Most child care centres can carry out systematic observations to identify emerging language difficulties, for example TRAS, Språk4 or others methods. At the two and four year check-up at the public health clinic, the public health nurse will assess the child’s hearing and language abilities. The child is referred for further assessment if needed. The schools also have assessment materials that teachers can use to identify language difficulties.
Early identification, assessment and implementation of appropriate interventions increase the chances that a child with language difficulties will cope with the common demands they encounter as a child, adolescent and adult. Early intervention is often of critical importance for a positive development trajectory and to prevent the child from developing additional problems, which can inhibit the child as much as the primary language difficulty. Public health clinics can give advice about preventative measures, for example, how to stimulate and play with language, read, sing, rhyme and classify words as part of everyday activities.
What parents can do
If parents suspect that their child has language difficulties, they should first raise their concern with a professional at the child care centre, school or public health clinic if the child does not attend a child care centre. It is important that parents do not wait, but that they discuss the child’s difficulties and their concerns with a professional. In many cases, language stimulation can be sufficient to support the child’s language development.
The child care centre or school can carry out a systematic observation and assess more specifically the child’s language abilities. The child can then be referred to educational services (PPT) if necessary. The parents may also contact the PPT directly.
Research and registries at the Norwegian Institute of Public Health
Language and learning – language difficulties and learning outcome (SOL) is a collaboration between the Norwegian Institute of Public Health and the Ministry of Education that began in 2007. Even though language difficulties are common during the preschool years, the causes and developmental pathways are not well understood. The aim of the SOL study is to provide the best possible knowledge base for understanding causes and developmental trajectories of language difficulties, to enable early preventative measures.
The SOL study will also contribute to increased knowledge about factors at home, in child care centres and in school, which contribute to good language development, and which minimise the difficulties in children with a particular vulnerability. The study recruits children from the Norwegian Mother and Child Cohort Study (MoBa).
Norwegian Institute of Public Health, PO Box 4404 Nydalen, N-0403 Oslo