Co-occurrence of Disorders

Numerous investigators have reported a high level of co-occurrence between communicative disorders and socioemotional problems. This high level of co-occurrence has been observed in various groups of children, including both those with a primary diagnosis of speech and language impairment and those with a primary diagnosis of psychiatric impairment or behavior disorder. Illustrative of these findings is the work of Baker and Cantwell (1987). These researchers performed psychiatric evaluations on 600 consecutive patients seen at a community speech, language, and hearing clinic. Children were divided into three subgroups of communication problems: speech (children with disorders of articulation, voice, and fluency), language (children with problems in language expression, comprehension, and pragmatics), and a speech and language group (children with a mixture of problems). Of these children, approximately 50% were diagnosed as having a psychiatric disorder. These problems were categorized into two general groups of behavior disorder and emotional disorder.

Several researchers have speculated on the basis for this high level of co-occurrence between communication and socioemotional disorders. For example, Beitchman, Brownlie, and Wilson (1996) proposed several potential relationships, including the following: (1) impaired communicative skills lead to socioemotional impairment, (2) impaired communicative skills result in academic problems, which in turn lead to behavioral problems, (3) other variables (e.g., socioeconomic status) explain, in part or in whole, the relationship between communicative problems and socioemotional difficulties, and (4) an underlying factor (e.g., neurodevelopmental status) accounts for both types of problems.

Further research is needed to clarify the relationship between speech and language ability and socioemotional status. One approach to this problem has been to investigate various child factors that may contribute to developmental risk. For example, Tomblin et al. (2000) reported that reading disability is a key mediating factor predicting whether children with language impairment demonstrate behavioral difficulties.

Of particular interest is the relationship between social competence, communicative competence, and socioemotional functioning. It is clear that speech and language skills play a critical role in social interaction and that children who have difficulty communicating are likely to have difficulty interacting with others. The way in which various components of behavior interact, however, is not as straightforward as might initially be thought. For example, Fujiki et al. (1999) found that children with language impairment were more withdrawn and less sociable than their typical peers, consistent with much of the existing literature. More specific evaluation revealed that these differences were based on particular types of withdrawal (reticence, solitary active withdrawal). Further, severity of language impairment, at least as measured by a formal test of language, was not related to severity of withdrawal. Further clarification is needed to determine how these areas of development interact to produce social outcomes, and what factors may exacerbate or moderate socioemotional status.

Long-Term Consequences

A related line of work has focused on the long-term psychosocial and sociobehavioral consequences of speech and language impairment. In summarizing numerous studies looking at the outcomes of communication disorders, Aram and Hall (1989) stated that children with language impairment have frequently been found to have high rates of persistent social and behavioral problems. Children with speech impairment tend to have more favorable long-term outcomes.

The work of Beitchman and colleagues provides one example of a research program examining long-term psychosocial outcomes of individuals with communicative impairment. These researchers followed children with speech impairment and language impairment and their typical controls longitudinally over a 14-year period (Beitchman et al., 2001). At age 5, the children in the group with speech impairment and the group with language impairment had a higher rate of behavioral problems than the control group. At age 12, socioemotional status was closely linked to status at age 5. At age 14 years and at age 19 years, individuals in the group with language impairment had significantly higher rates of psychiatric involvement than the control group. Children in the group with speech impairment did not differ from the controls.

A few studies have examined the long-term psychosocial outcomes of individuals with speech and/or language impairment as they enter adulthood. For example, Records, Tomblin, and Freese (1992) examined quality of life in a group of 29 young adults (mean age, 21.6 years) with specific language impairment and 29 controls. The groups did not significantly differ on reported personal happiness or life satisfaction. Additionally, differences were not observed with respect to satisfaction in relation to specific aspects of life, such as employment or social relationships.

Howlin, Mawhood, and Rutter (2000) reported a bleaker picture. They reexamined two groups of young men, 23–24 years of age, who had first been evaluated at 7–8 years of age. One group was identified with autism and the other with language impairment. At follow-up, the group with language impairment showed fewer social and behavioral problems than the group with autism. The two groups had converged over the years, however, and differences between the two were not qualitative. The young men with language impairment showed a high incidence of social difficulties, including problems with social interaction, limited social contacts, and difficulty establishing friendships. Most still lived with their parents and had unstable employment histories in manual or unskilled jobs. Neither childhood language ability nor current language ability predicted social functioning in adulthood. Howlin et al. (2000) concluded that in language impairment, “as in autism, a broader deficit underlies both the language delay and the social impairments” (p. 573).

Given some of the data cited above, it would appear that children with speech difficulties achieve better psychosocial outcomes than children with language difficulties (see also Toppelberg and Shapiro, 2000). Although this may generally be the case, generalizations across individuals with different types of speech impairment must be made with caution. Some types of speech problems, such as stuttering, are likely to have important psychosocial implications, but also have relatively low incidence rates. Thus, in large group design studies where individuals are categorized together under the general heading of “speech,” the unique psychosocial difficulties associated with such disorders may be masked by the psychosocial profiles associated with more commonly occurring communication problems.

It should also be noted that speech impairments may vary from having no outward manifestations aside from those involved in talking to relatively severe physical or cognitive deficits. The impact of associated problems on the psychosocial development of children with differing types of communicative impairment is difficult to summarize briefly. Illustrative of the complexity even within a specific category of speech impairment are children with cleft lip and palate. These children may have articulation problems and hypernasality secondary to specific physical anomalies. These physical anomalies may be resolved, to various degrees, with surgery. Speech may also vary considerably. No specific personality type has been associated with children with cleft palate (Richman and Eliason, 1992). Individual studies, however, have found these children to exhibit higher than expected rates of both internalizing and externalizing behavior (Richman and Millard, 1997). It appears that factors such as family support, degree of disfigurement, and self-appraisal interact in complex ways to produce psychosocial outcomes in children with cleft lip and palate.

In summary, it is clear that individuals with communicative disorders often have difficulty with aspects of psychosocial behavior and that these problems can have long-term implications. There is also evidence that children with language impairment have more psychosocial difficulties than children with speech impairment. It must be remembered, however, that speech problems differ by type of impairment, severity, and other variables. Thus, generalizations must be made with caution. Given the accumulated evidence, there is good reason to believe that parents, educators, and clinicians working with children with speech and language impairment should give serious consideration to psychosocial status in planning a comprehensive intervention program.

See also poverty: effects on language; social development and language impairment.