Behavior Problems in Children With Specific Language Impairment

Abstract

We studied behavior in a group of children with specific language impairment in its 2 subtypes (expressive and mixed receptive/expressive). After exclusion of other psychiatric conditions, we evaluated 114 children of ages 2 to 7 years using language developmental tests and behavioral screening scales. Behavior problems appeared in 54% of the children. Withdrawn was the most frequently found syndrome in preschool children, whereas anxious/depressed and social problems were the most frequent in older children. The high frequency of behavioral syndromes in children with specific language impairment is remarkable and requires the awareness of primary attendants and specialists. Anxiety, depression, social isolation, and aggressive and rule-breaking behavior can obscure identification of the language impairment. Taking into account this relationship would improve the chances of a timely and appropriate intervention.

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Journal of Child Neurology
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DOI: 10.1177/0883073813509886
2014 29: 194 originally published online 21 November 2013J Child Neurol
Verónica Maggio, Nora E. Grañana, Alba Richaudeau, Silvio Torres, Adrián Giannotti and Angela M. Suburo
Behavior Problems in Children With Specific Language Impairment
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Original Article
Behavior Problems in Children With
Specific Language Impairment
Vero
´nica Maggio, SLP, PhD
1
, Nora E. Gran
˜ana, MD, PhD
1,2
,
Alba Richaudeau, MD, PhD
1
, Silvio Torres, MD
1
,
Adria
´n Giannotti, MD
1
, and Angela M. Suburo, MD, PhD
3
Abstract
We studied behavior in a group of children with specific language impairment in its 2 subtypes (expressive and mixed receptive/
expressive). After exclusion of other psychiatric conditions, we evaluated 114 children of ages 2 to 7 years using language
developmental tests and behavioral screening scales. Behavior problems appeared in 54% of the children. Withdrawn was the
most frequently found syndrome in preschool children, whereas anxious/depressed and social problems were the most frequent
in older children. The high frequency of behavioral syndromes in children with specific language impairment is remarkable and
requires the awareness of primary attendants and specialists. Anxiety, depression, social isolation, and aggressive and rule-
breaking behavior can obscure identification of the language impairment. Taking into account this relationship would improve the
chances of a timely and appropriate intervention.
Keywords
language impairment, behavior problems, social behavior, communication, Child Behavior Checklist, Illinois Test of Psycholinguis-
tic Abilities
Received May 12, 2013. Received revised August 28, 2013; September 27, 2013. Accepted for publication September 30, 2013.
Specific language impairment is one of the most important com-
munication problems affecting young children.
1
Children having
this condition show ‘‘inadequate language acquisition at the
expected age with otherwise ostensibly normal development.’’
2
Thus, diagnosis is based on a mismatch between language and
nonverbal abilities, which disturbs academic achievement or
social communication.
3,4
A similar definition is given by the
National Institute on Deafness and Other Communication Disor-
ders,
5
which acknowledges developmental language disorder,
language delay, and developmental dysphasia as alternative
names. Specific language impairment is clearly separated from
the secondary language impairment that accompanies various
conditions displaying frank sensory, cognitive, or neurologic
deficits.
Although exact numbers are lacking, specific language
impairment seems to be one of the most common childhood learn-
ing disabilities.
5
In the 1990s, a prevalence of 7%was shown in
preschoolers,
6
but a more recent review found a median for
prevalence of 5.95%.
7
A similar figure has been described in
Sweden.
8
By contrast, a prevalence smaller than 1%for children
younger than 6 years has been recently reported in Finland.
9
Clin-
ical populations of children with specific language impairment
show high levels of comorbidity with literacy and behavior disor-
ders.
10
The coexistence of language impairment and emotional
and behaviorproblems has been recognized by several authors, its
rate being estimated at 50%-70%.
11
Behavior problems can alert
about the magnitude of the communication impairment, but they
can also confound the diagnosis with other conditions such as dis-
orders of theautistic spectrum, pragmatic language impairment or
attention-deficit hyperactivity disorder (ADHD). As clearly
stated more than a decade ago, not every child with language
impairment is a misdiagnosed case of autistic disorder.
12
Because knowledge about the burden of behavior problems
could improve attention by primary care physicians, we evalu-
ated these difficulties in a population of consecutive pediatric
patients with confirmed specific language impairment. We
applied the Child Behavior CheckList
13,14
after careful exclu-
sion of any other neurologic, psychological, or social deprivation
condition. This well-known norm-referenced test assesses
1
Clı
´nica CLASE de Neuropsicologı
´a, Hospital Universitario Austral, Pilar,
Argentina
2
Neurologı
´a Infantil, Servicio de Pediatrı
´a, Hospital Carlos Durand, Buenos
Aires, Argentina
3
MedicinaCelular y Molecular, Facultad de Ciencias Biome
´dicas, Universidad
Austral, Pilar, Argentina
Corresponding Author:
Nora E. Gran
˜ana, MD, PhD, Juncal 2354-PB 3-(1125) Buenos Aires, Argentina.
Email: ngranana@gmail.com
Journal of Child Neurology
2014, Vol. 29(2) 194–202
ªThe Author(s) 2013
Reprints and permission:
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DOI: 10.1177/0883073813509886
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emotional (internalizing) and behavioral (externalizing) disor-
ders.
15
We also assessed sex ratios for each group, because a pre-
ponderance of boys or girls in any of the groups under study
might suggest a difference in the etiopathogenesis of the differ-
ent conditions.
16
Hand preference, which might be underdeve-
loped in children with specific language impairment,
17
was
also examined.
Methods and Materials
We analyzed the clinical histories of children consulting the Clı´nica de
trastornos de Atencio´n, Lenguaje y del Seguimiento Escolar at Hospi-
tal Universitario Austral, and a speech pathologist private practice
during the period 2008 to 2011. Both centers work with referrals of
children with problems of attention, language, or school performance
from the same community, a suburban area of medium-high socioeco-
nomic status. Tests used in this study form part of an established
routine for children attending these clinics. Our work was carried out
under a protocol approved by the Comite´ de Investigaciones de la
Facultad de Ciencias Biome´dicas, Universidad Austral, 2009. Only
native Spanish-speaking children with a confirmed specific language
impairment were included.
Specific language impairment was diagnosed according to the
tenets of the International Classification of Diseases–10 (ICD-10).
This standard uses a statistical definition and requires an intelligence
quotient within normal values, with at least a language test, either
expressive or receptive, scoring 2 standard deviations or more below
the population mean, that is, below the third percentile. In addition, it
stipulates that language skills should be at least 1 standard deviation
below that measured for nonverbal skills.
18
For evaluation of nonverbal intelligence quotient, we used the
Wechsler tests for Preschool and Primary Scale of Intelligence
(version III, WPPSI III), and the Intelligence Scale for Children (Ver-
sion IV),
19,20
the Leiter-R Brief nonverbal intelligence quotient,
21
the
Beery Developmental Test of Visual-Motor Integration,
22
the
McCarthy Scales of Children’s Abilities,
23
and the Visual Construction
and Draw-a-Person.
24
The diagnosis of a specific language impairment
requires an intelligence quotient within normal values 100 +15 (þ1
and – 1 standard deviation). Children showing a developmental delay,
that is, nonverbal intelligence quotient below the third percentile, did
not receive this diagnosis. The presence of any other concomitant
medical, genetic, or neurologic disorder, such as sensory deafness,
blindness, a definite diagnosis of autism or any autism spectrum disor-
der, pragmatic language impairment, or any other neurodevelopmental
delay excluded the diagnosis of specific language impairment.
Language evaluation was based on the Gardner’s Receptive One
Word Picture Vocabulary Test, including 2 subtests: Gardner’s
Comprehensive Vocabulary and Gardner’s Test for Expressive Vocabu-
lary.
25,26
In addition, we used several subtests of the Illinois Test of
Psycholinguistic Abilities, 3rd Ed (ITPA-3),
27
to clarify the aspects of
language that were difficult for a particular child. Examples of these subt-
ests—visual comprehension, visual association, auditive association,
and grammatical closure—are shown in Table 1. Impairments were
classified as expressive or mixed expressive-receptive.
28
An expres-
sive specific language impairment was diagnosed when children dis-
played Gardner’s and/or Illinois expressive subtest scores 2 standard
deviations or more below the population mean, that is, below the third
percentile. By contrast, a mixed expressive-receptive specific lan-
guage impairment was identified when children displayed receptive
subtest scores of 2 standard deviations or more below the population
mean.
Behavioral/Emotional problems and competencies were assessed
with the Child Behavior Checklist for preschoolers and for children
(CBCL/1½-5, CBCL/6-18), with a questionnaire validated for Latin
American populations.
29
The Preschool Age test for 1½-5-year-old chil-
dren uses the 7-syndrome model, including I, emotionally reactive; II,
anxious/depressed; III, somatic complaints; IV, withdrawn; V, sleep
problems; VI, attention problems; VII, aggressive behavior and other
problems. Syndromes I to IV make up the internalizing syndromes,
whereas VI and VII add to externalizing syndromes. The test for
school-age children (6-18 years) includes I, anxious/depressed; II, with-
drawn/depressed; III, somatic complaints; IV, social problems; V,
thought problems; VI, attention problems; VII, rule-breaking behavior;
VIII, aggressive behavior and other problems. Internalizing syndromes
comprise groups I, II, and III, whereas VII and VIII represent the exter-
nalizing syndromes. For each problem class, children above the 93th
percentile were scored as positive.
Statistics
The hypothesis under evaluation was that a significant proportion of
children with specific language impairment presented behavior prob-
lems. Therefore, we used simple descriptive statistics to evaluate their
frequency. As a secondary hypothesis, we tested whether different
types of language impairment correlated with different frequencies
or types of behavioral problem. Results were expressed as mean +
standard error, or median (lower and upper 95%confidence interval).
We used 2-tailed tests, and a 95%confidence interval was considered
acceptable. Calculations were made with GraphPad Prism (GraphPad
Software, San Diego, CA, www.graphpad.com).
Results
Language Impairment Diagnosis
Low scores in any one of the language tests would suffice to
diagnose language impairment. However, most children
showed 2 positive expressive tests. The agreement between the
Gardner’s test for expressive vocabulary and the Illinois Gram-
matical Closure was 84%in the expressive group and 92%in
the mixed (expressive-receptive) Group (Table 2). In the mixed
Table 1. Illinois Test of Psycholinguistic Abilities (ITPA): Subtests
Included in This Study.
Visual reception (VR): Measures ability to gain meaning from familiar
pictures.
Example: Match picture stimulus with picture from same category.
Auditory association (AA): Measures ability to relate concepts
presented orally.
Example: Verbal-analogies test (eg, ‘‘Grass is green, sugar is ...").
Visual association (VA): Measures ability to relate concepts presented
visually.
Example: Relate a pictorial stimulus to its conceptual counterpart (eg,
bone goes with dog).
Grammatical closure (GC): Measures ability to complete a phrase
grammatically correct in an automatic way.
Example; the examiner shows 2 pictures and say: ‘‘There’s one bed here,
there ... here,’’ to which the child might respond, ‘‘There’re are two
beds here.’’
Maggio et al 195
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group, most reception difficulties were identified by the Illinois
Auditive Association test, which was positive in 94%of the
affected children. There was high agreement between the var-
ious tests (Table 3), and most children scored positive in 2 to 3
tests (42%), or in all 4 of them (46%).
Characterization of the Population
We identified 114 children with a specific language impairment.
Their ages ranged from 2.1 to 7.9 years (4.7 +0.1 years). Girls
and Boys showed similar age distributions, 5.2 +0.3 and
4.5 +0.1 years,respectively. Taking into account developmental
milestones and the behavior checklists, we considered 3 age
groups: infant (2-3 years), Kindergarten (4-5 years), and school
(6-7 years) (Table 4). Affected children of school age were less
numerous than preschool children. This was to be expected,
because language impairment is usually diagnosed at an early age.
The sex ratio indicated a predominance of affected boys over
affected girls (Table 4). Infant children showed a much higher sex
ratio than Kindergarten and school-age children (w
2
for trend,
P< .05). Right lateralization was absent in 47%of the children
included in this study. Differences of dexterity between age
groups were not statistically significant (Table 4).
About 17%of the children had an expressive specific lan-
guage impairment. No significant differences in age or sex ratio
of children were detected between these children and those
having a mixed impairment (Table 4). Most children with an
expressive specific language impairment diagnosis appeared
in the infant group, whereas the mixed cases clustered in the
Kindergarten group. This difference of proportions was statis-
tically significant (w
2
,P< .02).
Behavior Problems
About half of the children displayed behavior problems (Tables
5 and 6). This proportion was found in all age groups and could
not be correlated with the presence of an expressive or a mixed
impairment. No demographic differences could be detected
between children with and without problems (Table 6).
Moreover, both groups showed the same predominance of boys
over girls and similar proportions of nondexterity. Affected
boys and girls displayed the same burden of problems: 2.25
problems per girl and 2.48 for boys.
As shown in Table 7, 80%of the preschoolers with behavior
problems showed internalizing syndromes. Withdrawn was the
most frequently found syndrome, appearing in 65%of children
with problems. Syndromes of the externalizing domain only
occurred in 57%of children with behavior problems. Children
displaying more than 3 syndromes were often found. These
highly troubled children usually displayed withdrawn in
various combinations with emotionally reactive, attention
problems, or aggressive behavior.
Internalizing problems were also the most frequently found
problem in children of school age (Table 7). In this group,
anxious/depressed syndrome showed in 50%of the affected
children. Social issues, withdrawn/depressed, and rule-
breaking behavior were also present.
Complexity of the behavioral difficulties, as reflected by the
number of syndromes detected in each affected child, was
higher in the mixed (2.67 +0.28 syndromes/child) than in the
expressive group (1.50 +0.38 syndromes/child, Mann-
Whitney test, P< .05).
Behavior problems could be a consequence of communica-
tion difficulties. If this were the case, more behavior problems
should be found in those children that failed in a larger number
of language subtests. To test this hypothesis, we looked for
associations between the number of behavior problems per
child and the number of failed receptive Illinois subtests in
preschool children with a mixed language impairment. We did
not observe any correlation between the number of failed Illi-
nois subtests and the number of behavioral syndromes. Many
children with difficulties in the 3 receptive subtests remained
free of behavior problems, whereas about 70%of the children
showed deficits in 3 receptive tests, irrespective of their
behavioral burden (Figure 1).
Discussion
We have evaluated a sample of children with specific language
impairment who attended our clinic for diagnostic purposes.
Because disruptive or withdrawn manners frequently appeared
as an important or even the main reason for consultation, we
evaluated the importance of behavior problems in this selected
sample. In addition, we investigated possible associations
between the characteristics of the language impairment and the
quality and load of these behavior problems. Our study, based
on the Child Behavior Checklist (Achenbach’s test), showed
that these problems appeared in about half of the children with
specific language impairment.
Prevalence of Behavioral Difficulties in Children With
Specific Language Impairment
It must be stressed that the importance of social withdrawal and
other behavior problems has been well established for children
with language impairment associated to neurodevelopmental
delay, such as low intelligence quotient or neurologic insult
Table 2. Children Failing the Different Expressive Tests.
Gardner’s
test for
expressive
vocabulary
Gramm-
atical
closure
Gardner’s
Test and
grammatical
closure
Expressive impairment
Infant (n ¼11) 11 10 10
Kindergarten age (n ¼2) 2 2 2
School age (n ¼6) 5 5 4
Mixed impairment
Infant (n ¼32) 31 32 31
Kindergarten age (n ¼43) 39 42 38
School age (n ¼20) 19 18 17
196 Journal of Child Neurology 29(2)
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(reviewed by Rescorla et al
30
). However, the association of spe-
cific language impairment with behavior difficulties has not yet
been established, because available studies have diverse results.
An early study of children with specific language impairment
showed that their behavior scores (Total Behavior Problems)
were not in the clinical range of the Achenbach’s test; however,
they were significantly greater than those from age peers with
typical language development.
31
Authors suggested that these
behavior problems would most likely represent an emotional
response. Behavior and social difficulties, though not necessarily
within the clinical range, might be more evident in language-
impaired children from low-income families.
32
On the other hand, several studies carried out in children
attending schools for the language and hearing impaired
showed clinically significant behavior problems in children
with specific language impairment: 23%of a sample (n ¼
56) of school-age children,
33
30%of a large sample (n ¼71)
of 5-year-old children,
34
and 18%of a smaller sample (n ¼
38) of children between 2.5 and 5.5 years.
35
Studies in toddlers
(up to 30-35 months of age) did not show a strong relationship
between language delays and behavioral/emotional problems,
leading to the suggestion that these difficulties only affected
older children.
30
Remarkably, some of these studies concluded
that behavior problems were associated with the inclusion of
children with neurodevelopmental delay or autism spectrum
disorders.
30,31
Other recent studies have used the Strengths and
Difficulties Questionnaire, which evaluates behavioral, emo-
tional and social difficulties. In the conduct subscale, fewer
problems occurred at age 16 than at ages 7-8, whereas problems
in the peers subscale increased over time.
36
As in the previous
studies, however, the mean scores did not reach clinical levels
of difficulty. Nevertheless, substantial peer problems have been
found in a group of 16-year-old youngsters with specific
language impairment.
37
Our figures for the coexistence of behavioral difficulties and
specific language impairment were, in average, larger than
those in previous reports. Moreover, we found almost the same
proportion of children with and without problems in the differ-
ent age groups—infant, Kindergarten, and school—suggesting
that these problems would be intrinsic to the language impair-
ment and not a reactive effect. Remarkably, the largest propor-
tion of behavior problems appeared in the infant group.
Although these figures might not represent the prevalence of
behavior problems in the general population of children with
specific language impairment, they certainly demonstrate the
existence of this association and its relevance for diagnosis and
treatment.
Table 4. Characteristics of Children With Specific Language
Impairment.
Age
Infant Kindergarten School Total
N 434526114
Age
Range 2.1-3.9 4.0-5.8 6.0-7.9 2.1-7.9
Median 3.1 4.9 7.0 4.6
Mean 3.2 4.9 6.8 4.7
Standard error 0.1 0.1 0.1 0.1
Dexterity
Yes 18 26 16 60
No 25 19 10 54
Sex ratio 6.7 3.8 1.9 3.8
Boys 37 36 17 90
Girls 6 9 9 24
Specific language
impairment
Expressive 11 2 6 19
Mixed 32 43 20 95
Table 5. Behavioral Problems in Children With Specific Language
Impairment.
Age
Infant Kindergarten School All ages
Expressive impairment 11 2 6 19
With problems 5 0 3 42%
Without problems 6 2 3 58%
Mixed impairment 32 43 20 94
With problems 19 23 11 55%
Without problems 13 20 9 45%
Table 6. Characteristics of Language Impaired Children With and
Without Behavioral Problems.
Age
Group Problems n Range Median Mean Standard error
Infant
With 24 2.1-3.9 3.1 3.2 0.1
Without 19 2.6-3.9 3.2 3.3 0.1
Kindergarten
With 23 4.0-5.7 5.0 4.9 0.1
Without 22 4.0-5.8 4.9 4.8 0.1
With 14 6.2-7.1 6.9 6.8 0.1
Without 12 6.0-7.9 6.9 6.8 0.2
Table 3. Number of Children Failing the Different Receptive Tests.
Gardner’s Comprehensive Vocabulary Visual comprehension Visual association Auditive association All tests
Infant (n ¼32) 27 28 30 31 23
Kindergarten age (n ¼43) 30 23 29 41 18
School age (n ¼20) 12 4 6 17 3
Maggio et al 197
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The Nature of Behavior Problems Associated to Specific
Language Impairment
Internalizing problems almost duplicated externalizing prob-
lems in children of preschool age as well as in older children.
The most frequently found syndromes in preschool children
were withdrawn and aggressive behavior. In children of school
age, the highest frequency corresponded to anxious/depressed
and social problems together with rule-breaking behavior. In
general, the behavior problems of children with specific
language impairment resembled those expected in autism spec-
trum disorders
38
or attention-deficit hyperactivity disorder.
39
Further studies are required to evaluate the stability of these
syndromes over time and their possible association to biologi-
cal markers that could indicate their etiology.
There is no consensus about the predominance of internaliz-
ing or externalizing syndromes in children with specific lan-
guage impairment. Some studies have found internalizing
syndromes as the most frequent problems,
11,33
whereas others
have reported that the highest frequency corresponded to exter-
nalizing syndromes.
40
At least one study reported that interna-
lizing syndromes had the same frequency as externalizing
ones.
34
Internalizing syndromes (Teacher Behavior Rating
Scale; reticence and solitary-passive withdrawal) have also
been recorded as the most frequent problems in a school sample
(n ¼41). Comparison with studies based on other behavioral
scales
41
is more difficult.
Behavior Problems and Neurodevelopmental Domains
As previously acknowledged,
33
not all children had behavioral
difficulties, suggesting that the relationship of these problems
with language impairment is not linear and that behavior could
be influenced by other—still unknown—variables. Conceiva-
bly, specific language impairment with behavior problems
might represent a different condition from the impairment
without such problems. At the present time, however, there are
no clues about the underlying neurobiological mechanisms.
Hand preference was carefully evaluated because it might
be related to the asymmetric development of the brain
Table 8. Behavioral Syndromes
a
Found in Children of School Age.
Children with
behavior
Problems
Number of syndromes in the population
Number of children with
syndromes
Syndromes/
child
Anxious/
depressed
Withdrawn/
depressed
Somatic
complaints
Social
problems
Thought
problems
Attention
problems
Rule-
breaking
behavior
Aggressive
behavior Internalizing Externalizing
Expressive (n ¼3) 1 0 1 0 0 0 1 0 2 1 1.0
Mixed (n ¼11) 6 3 2 5 1 2 3 2 8 4 2.2
All (n ¼13) 7 4 2 5 1 2 4 2 10 5 1.9
a
Columns showing internalizing and externalizing problems are painted in dark and pale gray, respectively.
Figure 1. Bars correspond to preschool children with a mixed
specific language impairment. Children were subdivided into 3 sub-
groups according to the number of behavior problems, 0, 1-3, and >3.
Stacks refer to the number of failed Illinois subtests per child. The
graph illustrates the lack of correlation between the burden of beha-
vior problems and the extension of the language impairment.
Table 7. Behavioral Syndromes
a
Found in Children of Preschool Age.
Children with
behavior problems
Number of syndromes in the expressive
and mixed subpopulations
Number of children with
syndromes
Syndromes/
child
Emotionally
reactive
Anxious/
depressed
Somatic
complaints Withdrawn
Sleep
problems
Attention
problems
Aggressive
behavior Internalizing Externalizing
Expressive (n ¼6) 0 3 1 2 1 2 2 5 2 1.8
Mixed (n ¼41) 15 9 9 28 7 15 17 35 25 2.4
All (n ¼47) 15 12 10 30 8 17 19 40 27 2.4
a
Columns showing internalizing and externalizing problems are painted in dark and pale gray, respectively.
198 Journal of Child Neurology 29(2)
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hemispheres underlying language maturation.
42-44
Moreover,
functional MRI has recently shown that children with specific
language impairment exhibit a significant lack of left laterali-
zation in all core language regions.
45
Handedness has been
associated to intellectual, motor, temperament, and behavioral
status, and moreover, evidence supports the existence of intrau-
terine and neonatal pathological mechanisms, other than brain
damage, leading to left hand preference.
46
Likewise, several
studies have reported higher rates of specific language impair-
ment among males than among females.
7,16
Recent measure-
ments of testosterone in cord blood show a correlation of
hormonal levels with increased risk of specific language
impairment in boys and decreased risk in girls.
47
On the other
hand, studies recruiting cases from the general population
reported similar proportions of boys and girls,
6
and it has been
suggested that the increased male prevalence could reflect the
fact that boys attract the attention of parents and teachers more
than girls.
48
In the children included in our study, hand preference and
sex ratios were different from the standard patterns. Almost
half of our population lacked right hand preference. A large
proportion of nondexterity (58%) appeared in infants, but it
was also found in 38%of the school-age children. Thus, it
cannot be attributed to lack of maturation. Remarkably, the sex
ratio was 6.7 in infants and 1.9 in children of school age (boys
to girls). The higher sex ratio of infants compared to that of
older children probably implies that language impairment
became evident earlier in boys than in girls.
We found the same burden of behavior problems in boys and
girls, suggesting that the male prevalence would not depend on
the different attention elicited by boys and girls.
48
Because hand
preference and sex ratios were similar in children with and with-
out behavior problems, the causes of these difficulties must be
sought in other, still unidentified developmental domains.
Behavior Problems in Expressive and Receptive/
Expressive (Mixed) Specific Language Impairment
Only 17%of the children in our population displayed an
expressive language impairment. A similar proportion (20%)
was also found in a sample of ages 3.5-9.5 years (n ¼86).
49
A larger proportion (30%) was described in a school sample
(n ¼41, ages 6-13 years).
41
Probably, much larger samples
would be required to evaluate the prevalence in the general
population. In our study, most children with an expressive
impairment belonged to the infant age group. About 34%of the
children in the infant group had an expressive impairment, as in
another large sample (n ¼103) of children aged 18-35
months.
30
In all these groups, the predominance of children
with a mixed impairment contrasts with the predominance of
expressive impairment described in the Diagnostic and Statis-
tical Manual of Mental Disorders, Fourth Edition. To our
knowledge, there is no justification for this phenomenon. How-
ever, comparison of the available evidence and our own results
allows speculating that higher mixed/expressive ratios might
be found in the clinical setting than in the general population.
A similar explanation has been given to account for the herit-
ability of specific language impairment in different scenarios.
50
Behavior problems were found in 42%of children with an
expressive impairment and in 55%of children with a mixed
impairment, a not statistically significant difference. However,
children with a mixed impairment displayed more clinical
syndromes, indicating a higher complexity of their behavioral
disorder. Several studies have indicated that children with
receptive difficulties are more likely to have social and
behavioral difficulties than those with only expressive prob-
lems.
51,52
Within the receptive group, however, we could not
find any correlation between behavior problems and specific
language deficits. These associations, however, have been
identified by other investigators. Girls with more severe recep-
tive problems appear with higher levels of solitary-passive
withdrawal than girls with less severe language problems.
41
By contrast, children with less severe receptive language
impairment exhibit more sociable behavior than their peers
with more severe impairment.
41
Communication Problems as the Basis for
Behavioral difficulties
Association of specific language impairment with behavior
problems has been explained in several ways. Classical
descriptions include limited information processing as a cause
of difficulties in language learning and social communication;
rejection from others, including their peers, that might result in
limited opportunities for social learning; and primary deficits in
the social cognition domain that would translate into oral
language.
53
Two frameworks (or models) have been proposed to under-
stand the relationship between the language impairment and the
behavioral comorbidities: the Social Adaptation Model consid-
ers that behavior problems of language-impaired children
reflect social adaptations to their language limitations. The
second model, the Social Deviance Model, considers that
differences between children with language impairment and
nonaffected children reflect differences in the underlying traits
that guide children’s socioemotional development.
11
These
authors studied a small sample (n ¼17) and found a large pro-
portion of children showing behavior problems at a clinical
level. Because parents and teachers gave different behavioral
ratings, they favored the Social Adaptation Model.
11
In our
study, the lack of association between behavior and biological
markers such as handedness and sex supports this hypothesis.
Adolescents with an earlier story of specific language
impairment display receptive language problems together with
emotional health difficulties.
54
Moreover, those with emotional
problems at 7 years of age also have increased anxiety at 16
years. Authors suggested, however, that behavior problems
would not be a direct result of impoverished communicative
experiences.
54
In consonance with these findings, our observa-
tion of the same frequency of behavior problems in the infant
age as in children of Kindergarten and school age suggests the
involvement of developmental factors unrelated to social
Maggio et al 199
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environment. Because we can assume that rejection and
intolerance would increase in the Kindergarten and school
years, and without denying the importance of the social envi-
ronment, our data suggest that rejection would not be the sole
explanation of behavior problems.
Association and Differential Diagnosis With Other
Nosological Entities
A diagnosis of specific language impairment can be hindered
by other possibly related impairments. One of them is late lan-
guage emergence, a condition of significant delay in language
development that is observed in about 19%of 2-year-olds.
55
Many ‘‘late talkers’’ will normalize their language skills by
3-4 years, although some might still show some language
impairment during adolescence.
56
Language impairment seems to be a key feature of autism
and, vice versa, autism has some remarkable similarities to lan-
guage problems in specific language impairment. Previous
studies have evidenced that autism-like symptoms, such as
poor social relations, aloofness, affectless behavior, and
unusual responses to stimuli, appear in about half of the
children with persistent language difficulties.
57-60
Moreover,
some studies suggest that children who present with autism
spectrum disorders and attention-deficit hyperkinetic disorder
have a similar neuropsychological and early language develop-
ment profile as children who present with a suspicion of early
preschool language delay and are shown at school age to have
autism spectrum disorders or attention-deficit hyperactivity
disorder.
61
Although similarities might suggest a common
pathogenesis, these are different clinical entities. Children with
an autistic spectrum disorder with language impairment display
weaker functional communication and more severe receptive
language difficulties than children with specific language
impairment.
12,62
However, these conditions might recognize
a common neural substrate.
63
Conclusions
Behavior problems were highly prevalent in specific language
impairment–affected children; they were equally frequent in
children of infant age as in older children. Moreover, children
with an expressive disorder displayed behavior problems as
often as those children with a mixed impairment. Withdrawn
was the most frequently found behavior problem in younger
children, whereas children of school age usually displayed anx-
ious/depressed and social problems.
Professionals and caregivers should be aware of these beha-
vior problems: first, because they further reduce the quality of
life of more than half of children with specific language impair-
ment and their families; second, because in some children they
might serve as an alert for an early diagnosis; and third, because
they might induce an autism spectrum disorders misdiagnosis,
as they often include isolation, social problems, and even
rule-breaking behavior.
The need for screening of speech and language delay in pri-
mary care practice has already been emphasized.
64
Our findings
further stress that language impairments should be methodically
explored to discriminate specific language impairment from
other pathologies, particularly when they are accompanied by
behavior problems. It is important for caregivers and others to
be aware of this relationship in order to consider appropriate
assessment of children referred for language impairment and
to advocate for appropriate early intervention.
Author Contributions
VM assessed the language and wrote the manuscript. NEG developed
the hypotheses, led the clinical team, and wrote the manuscript. AR
performed neuropsychological assessment of patients. ST analyzed
the data. AG performed clinical and behavioral assessment of patients.
AMS analyzed data and wrote the manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
Ethical Approval
This work was approved by Comite´ de Investigaciones de la Facultad
de Ciencias Biome´dicas, Universidad Austral.
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