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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 Withdrawn was the most frequently found syndrome in preschool children, whereas anxious/depressed and social problems were the most frequent in older children.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
The online version of this article can be found at:
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
´nica Maggio, SLP, PhD
, Nora E. Gran
˜ana, MD, PhD
Alba Richaudeau, MD, PhD
, Silvio Torres, MD
´n Giannotti, MD
, and Angela M. Suburo, MD, PhD
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 Withdrawn was the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.
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.
Children having
this condition show ‘inadequate language acquisition at the
expected age with otherwise ostensibly normal development.’
Thus, diagnosis is based on a mismatch between language and
nonverbal abilities, which disturbs academic achievement or
social communication.
A similar definition is given by the
National Institute on Deafness and Other Communication Disor-
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
Although exact numbers are lacking, specific language
impairment seems to be one of the most common childhood learn-
ing disabilities.
In the 1990s, a prevalence of 7%was shown in
but a more recent review found a median for
prevalence of 5.95%.
A similar figure has been described in
By contrast, a prevalence smaller than 1%for children
younger than 6 years has been recently reported in Finland.
ical populations of children with specific language impairment
show high levels of comorbidity with literacy and behavior disor-
The coexistence of language impairment and emotional
and behaviorproblems has been recognized by several authors, its
rate being estimated at 50%-70%.
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.
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
after careful exclu-
sion of any other neurologic, psychological, or social deprivation
condition. This well-known norm-referenced test assesses
´nica CLASE de Neuropsicologı
´a, Hospital Universitario Austral, Pilar,
´a Infantil, Servicio de Pediatrı
´a, Hospital Carlos Durand, Buenos
Aires, Argentina
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.
Journal of Child Neurology
2014, Vol. 29(2) 194–202
ªThe Author(s) 2013
Reprints and permission:
DOI: 10.1177/0883073813509886
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emotional (internalizing) and behavioral (externalizing) disor-
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.
Hand preference, which might be underdeve-
loped in children with specific language impairment,
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.
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),
the Leiter-R Brief nonverbal intelligence quotient,
Beery Developmental Test of Visual-Motor Integration,
McCarthy Scales of Children’s Abilities,
and the Visual Construction
and Draw-a-Person.
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-
In addition, we used several subtests of the Illinois Test of
Psycholinguistic Abilities, 3rd Ed (ITPA-3),
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.
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
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.
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.
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,
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
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
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.’
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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
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
,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).
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.
test for
Test and
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
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(reviewed by Rescorla et al
). 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.
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.
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,
30%of a large sample (n ¼71)
of 5-year-old children,
and 18%of a smaller sample (n ¼
38) of children between 2.5 and 5.5 years.
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.
Remarkably, some of these studies concluded
that behavior problems were associated with the inclusion of
children with neurodevelopmental delay or autism spectrum
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.
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.
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
Table 4. Characteristics of Children With Specific Language
Infant Kindergarten School Total
N 434526114
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
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
Expressive 11 2 6 19
Mixed 32 43 20 95
Table 5. Behavioral Problems in Children With Specific Language
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.
Group Problems n Range Median Mean Standard error
With 24 2.1-3.9 3.1 3.2 0.1
Without 19 2.6-3.9 3.2 3.3 0.1
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
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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
or attention-deficit hyperactivity disorder.
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,
whereas others
have reported that the highest frequency corresponded to exter-
nalizing syndromes.
At least one study reported that interna-
lizing syndromes had the same frequency as externalizing
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
is more difficult.
Behavior Problems and Neurodevelopmental Domains
As previously acknowledged,
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
Found in Children of School Age.
Children with
Number of syndromes in the population
Number of children with
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
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
Found in Children of Preschool Age.
Children with
behavior problems
Number of syndromes in the expressive
and mixed subpopulations
Number of children with
complaints Withdrawn
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
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.
functional MRI has recently shown that children with specific
language impairment exhibit a significant lack of left laterali-
zation in all core language regions.
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.
Likewise, several
studies have reported higher rates of specific language impair-
ment among males than among females.
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.
On the other
hand, studies recruiting cases from the general population
reported similar proportions of boys and girls,
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.
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.
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).
A larger proportion (30%) was described in a school sample
(n ¼41, ages 6-13 years).
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
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.
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-
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.
By contrast, children with less severe receptive language
impairment exhibit more sociable behavior than their peers
with more severe impairment.
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
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.
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.
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.
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
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
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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.
Many ‘late talkers’’ will normalize their language skills by
3-4 years, although some might still show some language
impairment during adolescence.
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.
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
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
However, these conditions might recognize
a common neural substrate.
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.
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.
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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... Children with DLD more often display behavior problems compared with their typically developing peers. They are at greater risk for developing internalizing behavior problems such as withdrawn, anxious, or depressed behavior (St Clair et al., 2011;Maggio et al., 2014;Yew and O'kearney, 2015a;Vermeij et al., 2021), as well as externalizing behavior problems such as aggression or attention deficits (Snowling et al., 2006;Maggio et al., 2014;O'kearney, 2015b, 2017;Vermeij et al., 2021). Several studies indicate that language problems may lead to behavior problems in children (Petersen et al., 2013;Morgan et al., 2015;Salmon et al., 2016). ...
... Children with DLD more often display behavior problems compared with their typically developing peers. They are at greater risk for developing internalizing behavior problems such as withdrawn, anxious, or depressed behavior (St Clair et al., 2011;Maggio et al., 2014;Yew and O'kearney, 2015a;Vermeij et al., 2021), as well as externalizing behavior problems such as aggression or attention deficits (Snowling et al., 2006;Maggio et al., 2014;O'kearney, 2015b, 2017;Vermeij et al., 2021). Several studies indicate that language problems may lead to behavior problems in children (Petersen et al., 2013;Morgan et al., 2015;Salmon et al., 2016). ...
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IntroductionIn the Netherlands, early language intervention is offered to children with presumed Developmental Language Disorder (DLD). The intervention is a combination of group language intervention, individual speech and language therapy and parent-implemented language intervention. During the intervention, some children show more language progress than others. It is unclear what might explain this variation. In this study, we therefore explored to what extent child, parental, and treatment factors were predictive for receptive and expressive language outcomes of young children with presumed DLD during early language intervention.Methods Four multiple regression analyses were conducted with four child factors [pre-test receptive syntax, behavior (internalizing and externalizing), non-verbal cognitive ability and gender], one parental factor (parental stress) and one treatment factor (treatment duration) as predictors and receptive and expressive language post-test scores as outcomes. For each language post-test, the corresponding pre-test language measure was also added. Data of 183 children with presumed DLD were included.ResultsReceptive syntax problems were an important predictor of expressive language outcomes. Findings also showed a longer treatment duration to be a predictor of progress in expressive vocabulary. Internalizing behavior, externalizing behavior, non-verbal cognitive ability, gender and parental stress did not contribute to predicting language outcomes. Lower pre-intervention language scores led to lower corresponding post-intervention language scores.Conclusions Professionals may need to be aware that children with receptive problems may be indicative of more pervasive impairment and that it can be more difficult to improve their language problems. In fact, children with receptive language problems may need both more and different approaches. The finding that the level of the pre-intervention score has an essential influence on language outcomes underlines the importance of early diagnosis and early intervention, to prevent language problems increasing.
... Specific problem behaviors include withdrawal, anxiety, depression, social isolation, aggression, rule violations, etc. These behaviors can obscure the recognition of language barriers, so parents, teachers, or scholars should increase timely and appropriate intervention opportunities (Maggio, Granana, et al., 2014). Flapper et al. evaluated the prevalence of Developmental Coordination Disorder in 65 SLI children aged 5-8. ...
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Compared with ordinary children, children with specific language impairment (SLI) have delayed language development, poor reading comprehension, and greater difficulties in learning. As a widely used teaching intervention method, picture books can promote the development of reading comprehension, oral narrative, emotion, and social communication in the study of language intervention for children with special language impairment. However, the specific mechanism of picture books for children with SLI is still unclear. Therefore, this article sorts out and reviews the language barrier symptoms of specific language impairment, the form of picture book intervention, and the potential mechanism of picture book intervention, and puts forward the current role of picture books in SLI. The challenges faced in the intervention, and a positive outlook on the teaching intervention of picture books in SLI, this research will provide reference and help for the study of picture book intervention in related professional fields and has important guiding significance and reference value for the language correction of SLI children in various countries.
... Previous studies demonstrated that childhood history of language delay and persistent language di culties were recognized to have higher incidences of subsequent psychiatric morbidities or problem behaviors than those whose language problems resolved earlier (10,11). These problem behaviors associated with speech delay might include internalizing behaviors, such as e anxiety, depression, or social isolation; as well as externalizing behaviors, including aggressiveness, convictions, or arrests (12,13). For children with ADHD and language problems, more negative social and attention di culties in the future were noticed as we compared to ADHD children without language problems (10,11). ...
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Background Speech therapy (ST) might moderate the prognosis in children with attention deficit hyperactivity disorder (ADHD) comorbid with speech delay. This study investigated whether ST in children with ADHD was associated with a decreased risk of subsequent psychiatric disorders. Methods The population-based National Health Insurance Research Database in Taiwan was used. Hazards of subsequent psychiatric disorders were compared between those that received ST and a propensity-score matched comparison group by Cox regression analyses. Results Of 11,987 children with ADHD identified from the dataset, 2911 (24%) had received ST. The adjusted hazard ratio for any subsequent recorded psychiatric disorder was 0.72 (95% confidence interval 0.63~0.82) in children that received ST compared to the matched counterparts. This protective association was only statistically significant in the subgroup that received both medication and behavioral interventions. Conclusions Speech therapy can moderate the effects of integrated early interventions in ADHD children with speech delay.
... Children with language disorders, on the other hand, demonstrated deficits in using language to fulfil these functional needs. It has been well-documented that language disorders may lead to negative impact on the individuals' social, psychological, and academic development (e.g., Fujiki et al., 1999;Maggio et al., 2014;Tomblin et al., 2000). This has created the strong need for effective language intervention that can promote language learning among children with language disorders, so as to reduce the listed negative impacts. ...
It has been well-documented that language input designed according to the principles of statistical learning can promote language acquisition among children with or without language disorder. Cantonese-speaking children with language disorder were reported to have difficulties using expanded verb phrases and prepositional phrases, but the corresponding intervention is relatively unexplored. The current study evaluated the efficacy of an intervention designed using the statistical learning principles to promote the acquisition of these two structures. A retrospective study of existing data collected from a total of 16 Cantonese-speaking children (four female; mean age = 6.70 years) with suspected language disorder was conducted. The participants were initially divided into the ‘Treatment’ and the ‘Control’ groups. A total of eight sessions of language treatment, which focused on giving systematic language input of expanded verb phrases and prepositional phrases, were conducted on each child. Results showed that the Treatment group produced significantly more expanded verb phrases in the post-treatment language samples, while the Control group did not. The final pre- and post-comparison conducted after the Control group also received treatment indicated overall significant increased number of expanded verb phrases produced across time. On the contrary, improvement in the production of prepositional phrases was not significant. It is suggested that the unique thematic roles coded by individual prepositions possibly restricted the generalisation effect of treatment, which explains the non-significant improvement across time. Theoretical and clinical implications were discussed.
... Entre ellos, el Trastorno por Déficit de Atención e Hiperactividad (TDAH, Mueller y Tomblin, 2012;Sánchez-Azanza et al., 2018), la dislexia (Alvarado y Pérez-Castelló, 2018;Archibald et al., 2013;Buil Legaz, 2016;Buil-Legaz et al., 2015, la disortografia y disgrafía (Alvarado y Pérez-Castelló, 2018;Archibald et al., 2013), el coeficiente intelectual limitado , los problemas de conducta (Maggio et al., 2014), los problemas con relaciones sociales el déficit de procesamiento auditivo (Rocha-Muniz et al., 2015), las dificultades sensomotoras (Hill, 1998;Hill et al., 1998), los trastornos del habla (Archibald y Gathercole, 2006;Lindsay y Strand, 2016), la prematuridad (Bosch-Galcerán et al., 2018 Por lo tanto, teniendo en cuenta las incongruencias en la definición del trastorno y también en su uso por diferentes profesionales del ámbito del lenguaje, se creó el proyecto CATALISE (Bishop et al., 2016(Bishop et al., , 2017. Este proyecto tuvo por objetivo lograr un consenso terminológico entre los profesionales de diferentes ámbitos implicados en las dificultades del desarrollo del lenguaje (logopedas, educadores, psiquiatras, pediatras, etc.). ...
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... Σύμφωνα με πρόσφατες έρευνες, οι παραπάνω δυσκολίες επηρεάζουν εκτός από την ακαδημαϊκή επίδοση και την ψυχολογία των μαθητών με αποτέλεσμα μεγάλο ποσοστό των παιδιών να εμφανίζουν συναισθηματικές δυσκολίες και προβλήματα συμπεριφοράς (Maggio et al., 2014). Οι δυσκολίες των παιδιών με ΕΜΔ υπογραμμίζονται και στην πρόσφατη έρευνα των Rusiewicz et al., (2017), οι οποίοι ανακάλυψαν ότι παιδιά ηλικίας 3-16 ετών με προβλήματα λόγου παρουσίαζαν δυσκολία στις κοινωνικές αλληλεπιδράσεις με τους συνομηλίκους τους, δυσκολίες στις καθημερινές δραστηριότητες και έντονη απογοήτευση και ματαίωση. ...
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... Communication difficulties during childhood and adolescence can significantly impact on an individual's psychosocial outcomes, educational attainment and wider social experience. Research has shown the links between communication abilities and education outcomes (Conti-Ramsden et al., 2009), self-esteem (Jerome et al., 2002), peer relationships (Durkin & Conti-Ramsden, 2007) and externalising behaviours (James et al., 2020;Maggio et al., 2014). Those with a communication disorder in early life are at greater risk of particular mental health conditions (Arkkila et al., 2008;Charman et al., 2015). ...
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The book was inadvertently published with an error: There is a misplaced reference to image 11.5 in PDF and book version of Chapter 11, which needed to be corrected.
Developmental language disorder (DLD) is a heterogenous neurodevelopmental disorder that affects a child’s ability to comprehend and/or produce spoken and/or written language, yet it cannot be attributed to hearing loss or overt neurological damage. It is widely believed that some combination of genetic, biological, and environmental factors influences brain and language development in this population, but it has been difficult to bridge theoretical accounts of DLD with neuroimaging findings, due to heterogeneity in language impairment profiles across individuals and inconsistent neuroimaging findings. Therefore, the purpose of this overview is two-fold: (1) to summarize the neuroimaging literature (while drawing on findings from other language-impaired populations, where appropriate); and (2) to briefly review the theoretical accounts of language impairment patterns in DLD, with the goal of bridging the disparate findings. As will be demonstrated with this overview, the current state of the field suggests that children with DLD have atypical brain volume, laterality, and activation/connectivity patterns in key language regions that likely contribute to language difficulties. However, the precise nature of these differences and the underlying neural mechanisms contributing to them remain an open area of investigation.
Background and aims: Epidemiological studies have provided invaluable insight into the origin and impact of low language skills in childhood and adolescence. However, changing terminology and diagnostic guidelines have contributed to variable estimations of the prevalence of developmental language difficulties. The aim of this review was to profile the extent and variability of low language prevalence estimates through a systematic review of epidemiological literature. Methods: A systematic review of the empirical research (August 2022) was undertaken to identify studies that aimed to estimate the prevalence of low language skills in children (<18 years). A total of 19 studies published between 1980-2022 met inclusion criteria for review. Results: Studies reported prevalence estimates of low language skills in children between 1 and 16 years. Estimated rates varied from 0.4% to 25.2%. More stable estimations were observed in studies of children aged 5 years and older and those that applied updated diagnostic criteria to performance on standardised assessments of receptive and expressive language. Conclusions and implications: The estimated prevalence of low language skills in childhood varies considerably in the literature. Application of updated diagnostic criteria, including the assessment of functional impact, is critical to inform advocacy efforts and govern social, health and educational policies. What this paper adds: What is already known on the subject Epidemiological research has informed our understanding of the origin and impact of low language capacity in childhood. Childhood language disorder is met with a rich history of evolving terminology and diagnostic guidelines to identify children with low language skills. Inconsistent definitions of and methods to identify low language in children have resulted in variable prevalence estimates in population-based studies. Variability in prevalence estimates impacts advocacy efforts to inform social, health and educational policy for child language disorder. What this study adds A total of 19 studies published at the time of this review aimed to provide estimates of the proportion of children who experience low language skills. Prevalence estimates varied between 0.4% and 25.2%, with more stable estimates reported in studies of older school-age children and those which utilised standardised assessments of both expressive and receptive language. Few studies utilised assessments of functional impact of language difficulties, which is misaligned with updated diagnostic criteria for child language disorder. What are the clinical implications of this work? This review reports substantial variability in estimates of the proportion of children and adolescents who live with low language skills. This variability underscores the importance of applying updated diagnostic criteria to identify the prevalence low language in childhood. Efforts to estimate the prevalence of low language must include measures of functional impact of low language skills. This aligns with clinical recommendations, which call for routine assessment of functional outcomes. To this end, we require a unified understanding of the term 'functional impact' in the context of low language, including the development and evaluation of measures that assess impact across emotional, social and academic domains.
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Around ten percent of all children could have a disorder where language does not develop as expected. This often effects vocabulary skills, i.e., finding the words to express wants, needs and ideas, which can influence behaviours linked to wellbeing and daily functioning, such as concentration, independence, social interactions and managing emotions. Without specialist support, needs can increase in severity and continue to adulthood. The type of support, known as interventions showing strongest evidence for improving vocabulary with some signs of improved behaviour and wellbeing are ones that use word-webs. These are diagrams consisting of lines that connect sound and meaning information about a word to strengthen the child's word knowledge and use. The diagrams resemble what is commonly known as mind-maps and are widely used by Speech and Language Therapists in partnership with schools to help children with language difficulties. In addition, interventions delivered through mobile-devices has led in some cases to increased vocabulary gains with positive influence on wellbeing and academic attainment. With advances in technology and the availability of user-friendly mobile devices to capture, combine and replay multimedia content, new opportunities for designing bespoke vocabulary instruction have emerged that are without timing and location constraints. This brings the potential to engage and motivate users and harbour independence through functional strategies that support each child's unique language needs. To achieve this, children with language disorder, their parents/carers, support professionals and software development team members must work jointly to create an intervention that is fit for purpose. This is the first research planned to explore the collaborative development and acceptability of a digitally enhanced vocabulary intervention for child language disorder.
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Two models of the relationship between socioemotional behavior and verbal abilities are compared: Social Adaptation and Social Deviance. The socioemotional integrity of 17 children with specific language impairment (SLI) and 20 unaffected children who were age-matched (AM) was examined using the Child Behavior Checklist (CBCL) and the Teacher's Report Form (TRF) at kindergarten and first grade. All CBCL and TRF syndrome scale means for both groups werewithin normal limits. Significant group x respondent interaction effects were observed; teachers, and not parents, rated the children with SLI as having more social and internalizing behavioral problems than their AM peers. Significant differences between groups were restricted to internalizing, social, and attention problems. Very little congruence or stability over time was observed in the clinical ratings. The outcomes support a Social Adaptation Model of socioemotional behavior and language impairment. Implications for the clinical management of children with SLI are discussed.
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Hand preference has been associated with psychological and physical well-being, risk of injury, pathological irregularities, longevity, and cognitive function. To determine hand preference, individuals are often asked what hand they use to write with, or what hand is used more frequently in activities of daily living. However, relying only on one source of information may be misleading, given the strong evidence to support a disassociation between self-reported hand preference and outcomes of hand performance assessments. This brief communication is intended to highlight the various methods used to determine hand preference, to discuss the relationship between hand preference inventories and performance measures and to present some recent findings associated with hand preference and musculoskeletal disorders.
The prevalence and the natural history of primary speech and language delays were two of four domains covered in a systematic review of the literature related to screening for speech and language delay carried out for the NHS in the UK. The structure and process of the full literature review is introduced and criteria for inclusion in the two domains are specié ed. The resulting data set gave 16 prevalence estimates generated from 21 publications and 12 natural history studies generated from 18 publications. Results are summarized for six subdivisions of primary speech and language delays: (1) speech and/or language, (2) language only, (3) speech only, (4) expression with comprehension, (5) expression only and (6) comprehension only. Combination of the data suggests that both concurrent and predictive case deé nition can be problematic. Prediction improves if language is taken independently of speech and if express- ive and receptive language are taken together. The results are discussed in terms of the need to develop a model of prevalence based on risk of subsequent diYculties.
The behavioural functioning of 56 children with a specific language impairment (SLI), aged 8, 10, and 12 years, was examined by using the Child Behaviour Checklist. Parents as well as teachers filled in the questionnaire. The data shows that 48&percnt; of the children with SLI were considered to have behavioural problems either at home or in school. The problems differ significantly from the norm group on internalizing behaviour and total behaviour. The children do not demonstrate more externalizing behaviour than children in the norm group. It is hypothesized that the absence of aggressive behaviour might be a characteristic of children with SLI.
This study explored the prevalence and stability of behavioral difficulties and self-concepts between the ages of 8 and 17 years in a sample of children with a history of specific language impairment (SLI). We investigated whether earlier behavioral, emotional, and social difficulties (BESD); self-concepts; and language and literacy abilities predicted behavioral difficulties and self-concepts at 16/17 years. In this prospective longitudinal study, 65 students were followed up with teacher behavior ratings and individual assessments of language, literacy, and self-concepts at 8, 10, 12, 16, and 17 years. The students had consistently higher levels than norms of 5 domains of BESD, which had different trajectories over time, and poorer scholastic competence, whose trajectory also varied over time. Earlier language ability did not predict later behavioral difficulties or self-concepts, but the prediction of academic self-concept at 16 by literacy at 10 years approached significance. The importance of distinguishing domains of behavioral difficulties and self-concept is demonstrated. Language, when measured at 8 or 10 years of age, was not a predictor of behavior or self-concepts at 16 years, or of self-concepts at 17 years. The study stresses the importance of practitioners addressing academic abilities and different social-behavioral domains in delivering support for adolescents with SLI.
Children with specific speech and language difficulties (SSLD) may have associated difficulties that impair their access to the curriculum, and their social relationships at home and in school. (i) To identify the range of additional problems experienced by children with SSLD in different educational contexts; (ii) to consider the relationship between these problems and the child's current language status and (iii) to consider the child's self-esteem and the extent to which self-esteem is associated with the primary language problem or other associated difficulties. Sixty-nine children (17 girls, 52 boys) aged 7-8 years (Year 3) who had been identified as having SSLD, 59 from two local education authorities and 10 from regional special schools for children with severe speech and language difficulties. The children were assessed on a range of cognitive, language and educational measures; children and teachers completed a measure of the children's self-esteem (Pictorial Scale of Perceived Competence and Social Acceptance); teachers and parents completed a behavioural questionnaire (Strengths and Difficulties Questionnaire (SDQ); teachers also completed a further rating scale which included a behaviour subscale (Junior Rating Scale: JRS). The children's behaviour was rated as significantly different from the norm on both the SDQ and JRS, with the parents more likely to rate the child as having problems, but also as having prosocial behaviour. Both teachers and parents tended to rate the boys as having more problems than girls on the SDQ, with significant differences for the parents' ratings occurring on the total score and the hyperactivity and conduct problems scales. The children had positive self perceptions, which were comparable to the standardisation sample, and generally significantly higher than those of the teachers. The language and educational attainment scores of the children in special and mainstream schools were generally not significantly different, but parents rated the latter group as having more behaviour difficulties. Multiple regression analyses identified language comprehension and reading comprehension as the only predictors of the parents' rating of behaviour (on the SDQ). No relationship was found with the teachers' ratings. Behavioural difficulties, but not low self-esteem, are common in children of 7-8 years with SSLD, but the differences in patterns of relationship between parents and teachers, and with respect to children attending mainstream and special schools, challenge simple interpretations of comorbidity.