Expressive and/or Receptive Language Disorder​

Spoken language disorders can be either expressive language disorder, receptive language disorder, or mixed expressive receptive language disorder. 
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Definitions: 
  • Expressive language: a child’s verbal output
  • Receptive language: a child’s understanding of other’s language
  • Expressive language disorder is when a child has a difficult time expressing their wants, needs, thoughts and desires at an age appropriate level; however, their receptive language is normal.
  • Receptive language disorder is when a child has a difficult time understanding language; however, their language output is normal.

Mixed expressive receptive language delay is when a child has a delay in both expressive and receptive language.

Toddlers who exhibit a language disorder may also be referred to as "late talkers" or "late language learners."
Children with language disorders may be at risk for developing language and/or literacy difficulties. (See ASHA’s Practice Portal pages on Spoken Language Disorders and Written Language Disorders.) Children with language disorders who have receptive and expressive delays are at greater risk for poor outcomes than children with language disorders whose comprehension skills are in the normal range (Marchman & Fernald, 2013).

Late language development may evolve into other disabilities, such as
  • social communication disorder,
  • autism spectrum disorder,
  • intellectual disability,
  • learning disability, or
  • attention-deficit/hyperactivity disorder.
In order to make a differential diagnosis, consider hearing loss and monitor the child’s global development as well as cognitive, communication, sensory, and motor skill development.


Children With Late Language Development Versus Late Bloomers
Some researchers distinguish a subset of children with Late Language Development as late bloomers. Late bloomers are children with Late Language Development who catch up to their peers. At the onset, it is difficult to distinguish children with Late Language Development from late bloomers because this distinction can be made only after the fact.

Some research suggests that there may be some early differences. For example, late bloomers used more communicative gestures than age-matched children with Late Language Development who remained delayed (Thal & Tobias, 1992; Thal et al., 1991), thereby compensating for limited oral expressive vocabularies (Thal & Tobias, 1992). Late bloomers also were less likely to demonstrate concomitant language comprehension delays when compared with children who remain delayed (Thal et al., 1991).


Fast Facts: 
Prevalence estimates are higher for children with a positive family history of LLE (23%) compared with those with no reported history (12%; Zubrick et al., 2007).

Males are 3 times more likely than females to exhibit LLE (Zubrick et al., 2007).


Signs and Symptoms
An extensively used set of criteria for Late Language Development is an expressive vocabulary of fewer than 50 words and no two-word combinations by 24 months of age (Paul, 1991; Rescorla, 1989).
It is essential to review these criteria at regular intervals (e.g., every 6 months) to assess language growth and to determine if language skills fall outside of developmental trajectories and whether the child demonstrates LLE.

It is also important to consider other language development factors, including rate of vocabulary growth, speech sound development, emerging grammar, language comprehension, social language skills, use of gestures, and symbolic play behaviors (Olswang et al., 1998; Wetherby et al., 2002).
For example, when compared with toddlers of the same age with typical language development, late talkers may demonstrate phonological differences once they do produce their first words, including less complex/mature syllable structures, lower percentage of consonants correct, and smaller consonant and vowel inventories (Mirak & Rescorla, 1998; Paul & Jennings, 1992; Rescorla & Ratner, 1996); delayed comprehension and use of symbolic gestures for communication (Thal et al., 2013); use of shorter and less grammatically complex utterances—particularly for toddlers with expressive and receptive delays (Thal et al., 2013); and comprehension of fewer words (Thal et al., 2013, 1991).

Research also suggests that delays and differences in babbling before the age of 2 years can predict later delays in expressive vocabulary, limited phonetic repertoire, and use of simpler syllable shapes (Fasolo et al., 2008; Oller et al., 1999; Stoel-Gammon, 1989).

Approximately 50%–70% of children with LLE are reported to catch up to peers and demonstrate normal language development by late preschool and school age (Dale et al., 2003; Paul et al., 1996). The prevalence of language impairment at the age of 7 years was 20% for children with a history of LLE compared with 11% for controls (Rice et al., 2008). That is, only one in five children with LLE had language impairment at the age of 7 years.

Although many children with LLE go on to perform within the normal range on expressive and receptive language measures by kindergarten age (Ellis Weismer, 2007; Rescorla, 2000, 2002), their scores on such measures continue to be lower than those of children with a history of typical language development, matched for socioeconomic status (Paul, 1996; Rescorla, 2000, 2002).

For example, school-age children who had been identified as demonstrating LLE also demonstrated
lower scores at the age of 5 years on language measures that tap complex language skills, such as narrating a story; poorer performance on measures of general language ability, speech, syntax, and morphosyntax at the age of 7 years; poorer performance on reading and spelling measures at ages 8 and 9 years; lower scores on aggregate measures of vocabulary, grammar, verbal memory, and reading comprehension at the age of 13 years; and lower scores on vocabulary/grammar and verbal memory factors at the age of 17 years (Girolametto et al., 2001; Rescorla, 2002, 2005, 2009; Rice et al., 2008).

For some children, LLE may be an early indicator of language impairment.

The causes of late language emergence (LLE) in otherwise healthy children are not known. However, several variables are thought to play a role.


Risk Factors
Based on research comparing children with late language emergence with typically developing peers on variables linked to language development, a number of risk factors for LLE have been proposed, including child and family factors, elaborated as follows.


Child Factors
Gender—Boys are at higher risk for LLE than girls (Collison et al., 2016; Horowitz et al., 2003; Klee et al., 1998; Rescorla, 1989; Rescorla & Achenbach, 2002; Rescorla & Alley, 2001).

Motor development—Children with LLE were found to have delayed motor development (in the absence of disorders or syndromes associated with motor delays) when compared with typically developing children (Klee et al., 1998; Rescorla & Alley, 2001).

Birth status—Children born at less than 85% of their optimum birth weight or earlier than 37 weeks gestation were found to be at higher risk for LLE (Zubrick et al., 2007).

early language development—language abilities at 12 months appear to be one of the better predictors of communication skills at 2 years (Reilly et al., 2007).


Family Factors
Family history—Children with LLE are more likely to have a parent with a history of LLE (Collison et al., 2016; Ellis Weismer et al., 1994; Paul, 1991; Rescorla & Schwartz, 1990).

Presence of siblings—Children with LLE are less likely than children without LLE to be an only child; these findings may reflect decreased maternal resources available to the child (Zubrick et al., 2007).

Mother's education and socioeconomic status (SES) of the family—Lower maternal education and lower SES of the family are associated with higher risk for LLE (Fisher, 2017; Zubrick et al., 2007); maternal education and family SES are thought to be related to the amount of support (resources) available to the child for language learning (Hoff-Ginsberg, 1994; Wells, 1985).

For children younger than 18 months, screen media use (other than video chatting) is discouraged (American Academy of Pediatrics, 2016).  Infant exposure to certain types of media was associated with lower language scores, although the relationship between media and language development is not fully understood (Zimmerman et al., 2007).

Early identification and intervention can mitigate the impact of risk factors (Guralnick, 1997, 1998; National Research Council, 2001; Thelin & Fussner, 2005). Therefore, it is important for speech-language pathologists to recognize these risk factors when identifying LLE and considering service delivery options.


Evaluation
The first step in treatment is to receive a comprehensive evaluation by a speech language pathologist (SLP).  During a comprehensive evaluation the SLP completes a case history, oral mechanism exam, completes a standardized assessment and determines a plan of care based off of the results of the assessment. 
After the evaluation is completed, the SLP analyzes the results of the standardized assessment and determines a plan of care and recommends therapy if needed. 

Depending on the insurance requirements, a prior approval may need to be obtained prior to therapy sessions beginning. This process requires the SLP to submit the results of the evaluation to the insurance company and getting approval from them before therapy may begin. This process may take up to 2 weeks. 


Treatment
Typically, therapy is 30 minutes 1-2 times per week depending on the severity of the disorder, child’s age, child’s attention span and family needs. It is typically better to complete therapy sessions in short frequent bursts each week, rather than longer sessions only once a week. 

The therapist will determine the treatment approach that would best serve the child and their specific speech sound disorder based off of the results from the evaluation. The therapist will develop a treatment plan based off of the evaluation results.

The therapist will provide the family activities to complete at home during the days that the child does not have therapy. Completing activities at home is very important to the child’s retention of the strategies taught during therapy and offers that child to practice these strategies at home. It is similar to practicing a musical instrument or learning a new sport. A child must practice daily in order to improve. 
Approximately every 6 months, the SLP will complete a reassessment to determine therapy progress and areas that are needed to be further addressed during therapy intervention. 


Treatment Approaches
Treatment approaches for children with language delay or disorder can vary along a continuum of naturalness (Fey, 1986). They include clinician-directed—drill-based activities in a therapy room, child-centered—play-based activities that include everyday activities in natural settings, and hybrid—activities and settings that combine both approaches.

One example of a hybrid approach is dialogic reading, an interactive technique in which adults prompt children with questions and engage them in discussions while reading together (Zevenbergen & Whitehurst, 2003).
Other strategies may include involving extended family, siblings, or other children and engaging in structured didactic learning tasks led by the care provider (Guiberson & Ferris, 2018, 2019).

A hybrid treatment that is child-centered and naturalistic play that is rich in language using strategies to improve speech and language are preferred over clinician directed drill based activities.  Although a therapist may use drill based activities throughout the session; a drill based approach for late language learners leads to poor carryover to a naturalistic environment. Drill based learning for language acquisition will often times teach a child to only respond when asked questions. This is called a prompt-dependent communicator. 


Information taken from ASHA.org