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Unidentified Language Deficits in Children With Emotional and Behavioral Disorders: A Meta-Analysis



Low language proficiency and problem behavior often co-occur, yet language deficits are likely to be overlooked in children with emotional and behavioral disorders (EBD). Random effects meta-analyses were conducted to determine prevalence and severity of the problem. Across 22 studies, participants included 1,171 children ages 5-13 with formally identified EBD and no history of developmental, neurological, or language disorders. Results indicated prevalence of belowaverage language performance was 81%, 95% CI [76, 84]. The mean comprehensive language score was 76.33 [71, 82], which was significantly below average. Implications include the need to (a) require language screening for all students with EBD, (b) clarify the relationship between language and behavior, and (c) develop interventions to ameliorate the effects of these dual deficits.
Children with emotional and
behavioral disorders (EBD)
exhibit maladaptive social and
behavioral responses charac-
terized as severe, chronic, and
pervasive (Gresham, 2005). Whether identified
and served through educational or mental health
channels, outcomes for children with EBD are
likely to include school failure, dropping out, un-
employment, substance abuse, and contact with
mental health or criminal justice systems
(Bradley, Doolittle, & Bartolotta, 2008). Diffi-
culty in academic, social, emotional, and behav-
ioral functioning contribute uniquely to the
negative outcomes experienced by children with
EBD; however, problems in each of these areas
interact in ways that are not yet well understood
(Tomblin, Zhang, Buckwalter, & Catts, 2000).
One variable that is strongly related to perfor-
mance in each of these areas is childrens language
proficiency (Beitchman, Cohen, Konstantareas,
& Tannock, 1996). Language development is the
Exceptional Children
Vol. 80, No. 2, pp. 169-186.
©2014 Council for Exceptional Children.
Unidentified Language
Deficits in Children With
Emotional and Behavioral
Disorders: A Meta-Analysis
Peabody College of Vanderbilt University
University of Nebraska-Lincoln
ABSTRACT: Low language proficiency and problem behavior often co-occur, yet language deficits
are likely to be overlooked in children with emotional and behavioral disorders (EBD). Random
effects meta-analyses were conducted to determine prevalence and severity of the problem. Across 22
studies, participants included 1,171 children ages 5-13 with formally identified EBD and no his-
tory of developmental, neurological, or language disorders. Results indicated prevalence of below-
average language performance was 81%, 95% CI [76, 84]. The mean comprehensive language
score was 76.33 [71, 82], which was significantly below average. Implications include the need to
(a) require language screening for all students with EBD, (b) clarify the relationship between lan-
guage and behavior, and (c) develop interventions to ameliorate the effects of these dual deficits.
Exceptional Children
by guest on January 14, 2016ecx.sagepub.comDownloaded from
170 Winter 2014
foundation of, and inexorably intertwined with,
adaptive academic, social, and behavioral perfor-
mance (Im-Bolter & Cohen, 2007; Toppelberg &
Shapiro, 2000).
An extensive body of literature has described
interrelations among language, learning, and be-
havioral problems in school-age children. Al-
though causal or directional mechanisms of these
relations have yet to be established, descriptive ev-
idence supports a strong association between lin-
guistic and behavioral competence (Hooper,
Roberts, Zeisel, & Poe, 2003; Zadeh, Im-Bolter,
& Cohen, 2007). That is, children who exhibit
problem behavior tend to have low language pro-
ficiency, and children with low language profi-
ciency tend to exhibit problem behavior (Benner,
Nelson, & Epstein, 2002). As many scholars have
noted, although children with a range of mal-
adaptive behavioral profiles are at risk for com-
munication disorders, low language proficiency is
often overlooked in children whose challenging
behavior is highly salient to adults (e.g., Cohen,
Davine, Horodezky, Lipsett & Isaacson, 1993;
Donahue, Cole, & Hartas, 1994).
Many researchers have documented the asso-
ciation between language and behavioral compe-
tence, but only one systematic review to date has
focused on children formally identified as EBD.
In 2002, Benner et al. conducted a comprehen-
sive search and narrative summary of the litera-
ture. They concluded that 71% of students with
EBD had concurrent language impairments.
Moreover, 64% were deficient in expressive lan-
guage, and 56% in receptive skills. The current
investigation also synthesized studies reporting
prevalence estimates of language impairment (LI)
in children with formally recognized EBD, but
adds to the literature in several ways. Most impor-
tantly, meta-analytic methods incorporated both
systematic review procedures and quantitative
synthesis of data reported in primary research
studies. Meta-analysis was used to compute not
only prevalence rates, but also a second depen-
dent variable: mean standard scores on compre-
hensive language assessments. The methodology
also permitted analysis of moderator variables for
both prevalence and means. Additionally, it has
been demonstrated that for many children with
psychiatric disorders, concurrent language deficits
often are undetected (e.g., Cohen et al., 1993). To
determine the extent of this problem, the popula-
tion of interest was children with EBD and
unidentified language deficits. Finally, stringent
inclusion criteria were employed to minimize al-
ternative explanations for high prevalence rates.
For children with EBD, undetected LI can
have serious consequences. Researchers have
noted that childrens language deficits often are
misperceived as low intelligence; inattention;
noncompliance; or deliberate dishonesty, disre-
spect, and defiance (Cohen et al., 1993; Donahue
et al., 1994). Such characterizations may add
stress, frustration, and blame to interactions that
already are likely to be challenging, and may con-
tr ibut e to negative or coercive interacti ons
(Sutherland & Morgan, 2003). Finally, problem
behavior may be exacerbated if adults’ verbal
input is too complex for students to comprehend
(Harrison, Gunter, Reed, & Lee, 1996). Instruc-
tion and interventions requiring intact language
skills therefore may be counterproductive.
Identifying prevalence and severity of lan-
gu age defic its, a s wel l as areas of l ingu istic
strengths and weaknesses, may provide a founda-
tion on which to build supports for children with
EBD. This information is vitally important to en-
sure that children receive appropriate assessments,
resources, and treatment. The purpose of the cur-
rent study was to provide a quantitative synthesis
of research examining unidentified language im-
pairment in school-age children with EBD. An
overview of issues surrounding identification of
language and behavioral disorders is provided, fol-
lowed by discussion of sources of heterogeneity
among primary studies highlighted in prior re-
search. Methods and procedures employed in the
meta-analyses designed to either minimize or ana-
lyze differences among studies also are presented.
Children may be identified as having emotional
and behavioral disorders through either educa-
tional or mental health channels; however, these
two pathways are independent and not mutually
exclusive. According to criteria outlined in the
Diagnostic and Statistical Manual of Mental Disor-
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ders (DSM-IV; American Psychiatric Association,
2000), children may receive diagnoses for affec-
tive (e.g., mood or anxiety), disruptive (e.g., at-
tention deficit/hyperactivity), or behavioral
disorders (e.g., oppositional defiant or conduct
disorders; ODD or CD respectively). Regardless
of the presence or absence of a psychiatric diag-
nosis (Della Toffalo & Pedersen, 2005), children
may receive educational services under the dis-
ability label emotional disturbance (ED), as de-
fined by the Individuals With Disabilities
Education Improvement Act (IDEA, 2006). Be-
cause the current definition of ED remains con-
troversial and may underrepresent the population
of interest (Gresham, 2005), the term EBD is
used here to include all children with either ED
labels or DSM diagnoses, regardless of the source
of identification or setting of services received.
Identifying prevalence and severity
of language deficits, as well as areas of
linguistic strengths and weaknesses, may
provide a foundation on which to build
supports for children with EBD.
Defining and diagnosing language disorders
also can be controversial, as can the terms used to
describe children with language disorders, deficits,
delays, or impairments. For example, specific lan-
guage impairment (SLI) has been defined as
expressive (production) or receptive (comprehen-
sion) delays in the absence of explanatory factors
such as neurological, sensory, motor, or environ-
mental deficits (Tomblin et al., 1997). Inclusion
criteria for specifying a delay, however, is less
straightforward. Some researchers and practition-
ers have used discrepancy criteria (e.g., between
verbal and nonverbal intelligence or achievement
and chronological age expectations), and others
have used various cutoff scores on diagnostic mea-
sures (Law, Boyle, Harris, Harkness, & Nye,
2000; Tomblin et al., 1997). Note that disorders
affecting the mechanics of speech (e.g., articula-
tion, fluency) are excluded from these definitions.
For the present discussion, language deficit or
impairment is abbreviated LI to avoid confusion
with terminology from other disciplines (e.g.,
LD, or learning disability). LI is used here to de-
note low language proficiency identified through
various assessment methods and defined by differ-
ent diagnostic criteria. The term may or may not
include children with a diagnosed disorder such as
SLI. The purpose of the current study was not to
diagnose children, but to synthesize descriptive
data as reported in primary studies. The data
most commonly reported related to expressive or
receptive deficits occurring in one or more areas
of language, including semantics (meaning) and
syntax (grammar). Deficits in each of these areas
commonly overlap, and all have been linked with
children’s problem behaviors (Beitchman et al.,
1996; Harrison et al., 1996).
In the primary research studies summarized by
Benner et al. (2002), prevalence estimates ranged
from 35% to 97%. Although unable to assess
potential moderator variables empirically, Benner
and colleagues suggested that between-studies
heterogeneity may be due to differences in mea-
surement variables, diagnostic standards, and
participant characteristics. Limitations and rec-
ommendations noted by those and other authors
are outlined, as are the strategies used to address
those concerns in the current study.
Measurement Variables. There are many ways
to determine the presence, type, and severity of
LI, and method of assessment is known to affect
those outcomes (Friberg, 2010; Law et al., 2000).
For example, the number and type of assessments
used to determine case status may vary according
to the purpose for the assessment (Law et al.,
2000). In research studies, a single diagnostic in-
strument often is used to determine case status or
presence/absence of LI. In practice, however,
speech-language pathologists (SLPs) are encour-
aged to use multiple assessments that include
standardized and naturalistic measures (e.g., spon-
taneous language samples) and use of clinical
judgment when determining eligibility for ser-
vices and developing treatment plans (Friberg,
2010). Potential moderators of prevalence out-
comes are, therefore, whether estimates were ob-
tained (a) via a single measure or an assessment
battery, and (b) for the purpose of informing re-
search (e.g., describing language performance) or
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practice (e.g., providing services). Benner et al.
(2002) also noted that test instruments may pro-
duce different estimates as a function of technical
adequacy. Although it was not possible to analyze
all differences (e.g., compare versions of the same
test), moderator analyses included whether differ-
ent measures produced significantly different
Diagnostic Standards. Determining preva-
lence of LI is complicated further by use of vary-
ing cutoff scores to determine case status (Law et
al., 2000; Tomblin et al., 1997). Benner et al.
(2002) noted that prevalence varied across stud-
ies according to cutoff criteria established by in-
dividual researchers: Studies with more stringent
criteria reported lower rates of LI and vice versa.
In studies using a single test to determine LI in
children with EBD, cut scores typically were 1,
1.5, or 2 standard deviations below standardized
norms. These roughly corresponded to mild,
moderate, and severe deficits; however, a child
with a score of 77 could be considered LI in one
study and not another. In the current study, dif-
ferences in diagnostic standards were minimized
by assigning a priori definitions and cutoffs. A
1–2 standard deviation cutoff on a single mea-
sure was considered less stringent, and scores re-
ported in this range were assigned to the mild
category. Scores 2 or more standard deviations
below the mean were assigned to the moder-
ate/severe category.
Reporting standards also varied across stud-
ies. Some authors reported test results as sample
means or as a prevalence estimate defined as pro-
portion of the sample with scores 1, 1.5, or 2
standard deviations below the mean. Others re-
ported only the number of children achieving
case status, or prevalence in the sample, without
reference to mean scores. Additionally, some stud-
ies reported case status for the entire sample, in-
cluding proportions of students with mild,
moderate, and severe LI as well as those without
deficits. Others reported only presence/absence of
language impairment, without indication of
severity. For studies with stringent cutoff criteria,
results for all children often were not reported
(thus omitting children with mild deficits and un-
derestimating the numerator in overall prevalence
rate). For studies that did not specify severity,
findings were included only in the moderate to
severe category. Although it is possible some chil-
dren may have received standard scores above 70
(2 SD), the authors’ use of stringent criteria to as-
sign LI diagnoses supported this decision. In the
current investigation, the below-average category
included only those studies reporting the full
range of language proficiency.
Participant Characteristics. Benner et al.
(2002) noted that studies conducted in schools
reported higher prevalence than studies con-
ducted in “more restrictive clinical settings” (p.
51), defined as treatment centers, speech, or psy-
chiatric clinics. Level of restriction (day or resi-
dential program) and setting (school or clinic)
were reported in several studies, and were as-
sessed as moderator variables. Researchers
(Cohen et al., 1993; Nelson, Benner, & Cheney,
2005) also have questioned whether form or
severity of problem behavior is related to linguis-
tic proficiency. That is, children may exhibit top-
ographies of behavior characterized as
internalizing (e.g., withdrawn, depressed, anx-
ious), externalizing (e.g., destructive, defiant, ag-
gressive), or combined, and behavioral subtypes
may be related to differences in language profiles.
Although assessing these associations may have
important implications for supporting children
with EBD, insufficient data were available to
conduct these analyses.
Meta-analysis is a quantitative method specifically
designed for synthesizing research studies (Boren-
stein, Hedges, Higgins, & Rothstein, 2009;
Lipsey & Wilson, 2001). An advantage of using
meta-analysis is that data used to calculate out-
comes are weighted to account for precision of
primary data. Larger sample sizes provide more
precise estimates and are assigned higher weights,
which is considered more accurate than simply
averaging across studies (Lipsey & Wilson, 2001).
It is also possible to analyze moderator variables
to explain between-group heterogeneity. Given
the data available in reports included in the cur-
rent study, however, it was not possible to follow
Benner et al.’s (2002) recommendation to analyze
moderator variables related to underlying cogni-
tive processes of language development such as at-
tention or intelligence. Instead, an attempt was
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made to control for those factors by employing
very conservative inclusion criteria.
Although presence of unidentified language
deficits in school-age children with EBD is a well-
documented phenomenon, and although uniden-
tified language deficits may contribute to poor
proximal and distal outcomes, questions remain
regarding the extent, severity, and types of deficits
these children are likely to experience. This infor-
mation is critically important to developing inter-
vent ions that have the potentia l to improve
childrens functioning across multiple areas. The
current investigation builds upon an earlier review
(Benner et al., 2002) by including additional
studies (conducted after 2001; published and un-
published) and specifying predetermined mea-
surement and diagnostic criteria. This study
extends the literature by including analyses of
mean standardized test scores in addition to
prevalence estimates, using conservative inclusion
criteria to minimize differences in participant
characteristics, and employing meta-analytic
methodology to answer the research questions.
This study was designed to answer research ques-
tions related to two primary outcomes for stu-
dents with EBD:
1. What is the prevalence and severity of
unidentified deficits in comprehensive, re-
ceptive, and expressive language proficiency?
Is prevalence moderated by differences in be-
havioral topography (internalizing or exter-
nalizing), program type (day or residential),
setting (school or clinic), number of mea-
sures (single or multiple), or purpose of as-
sessment (research or practice)?
2. Is mean performance on standardized mea-
sures of comprehensive language proficiency
significantly below average in specific lan-
guage components (comprehensive, expres-
sive, receptive, semantic, and syntactic)? Is
mean performance moderated by differences
in measures (specific comprehensive tests) or
participant characteristics (severity or topog-
raphy of problem behavior)?
Studies were selected according to eligibility crite-
ria for participant characteristics and for outcome
variables as outlined in this section. To avoid pos-
sible publication bias (Lipsey & Wilson, 2001),
no restrictions were in place regarding where
studies were conducted, language, date, or type of
publication (e.g., journal, dissertation, technical
report). All study designs were eligible for inclu-
sion (e.g., descriptive, group experimental or
quasiexperimental, single subject), providing
preintervention descriptive data were reported.
Participant Characteristics. As in the earlier
review (Benner et al., 2002), samples were chil-
dren with formal designations of EBD. To in-
crease the probability that samples were drawn
from a relatively homogeneous population, the
following criteria also were defined for participant
samples. First, all participants were in Grades K-8
(ages 5-13). Preschool-age children were excluded
because they are typically not identified as EBD
until kindergarten or later. Additionally, LI is as-
sessed differently in preschool-age children, and
may result in inflated prevalence rates relative to
those above kindergarten age (Law et al., 2000).
High school students were excluded because it
was unclear how delinquency, substance use,
school dropout, and retention may affect EBD
samples at that age (e.g., if students with LI were
more likely to be arrested or drop out of school,
prevalence estimates would be artificially low).
Second, participants with EBD had to be free of
conditions known to co-occur with LI. That is,
studies were excluded if study reports indicated
participants had below-average IQs (defined in
most of the primary studies as full scale IQ 80
or 85; a cutoff of 80 was adopted here), or any
neurological condition related to problems with
language or learning, including any intellectual or
developmental disability, schizophrenia, autism
spectrum, or attention deficit/hyperactivity disor-
ders. Finally, studies were excluded if participants
had pre-existing LI; were receiving speech, hear-
ing, or language-related services; or were sampled
because of suspected LI.
Outcome Variables. Studies contributed data
to prevalence estimates if they reported either (a)
number or proportion of the sample with clinical
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diagnoses of language delay, impairment, or
deficit; or (b) number of children scoring below 1
standard deviation, within 1-2 standard devia-
tions, or below 2 standard deviations on a com-
prehensive standardized language measure (i.e.,
composed of expressive and receptive language
tasks or composite scales). Studies contributed
data to mean outcomes if they reported sample
means and standard deviations on the same types
of standardized language measures. Because stan-
dard errors are not comparable across criterion-
referenced, informal, or naturalistic measures,
outcomes include only norm-referenced mea-
To locate studies reporting language outcomes in
children with EBD, keyword searches were con-
ducted in electronic databases (i.e., ERIC,
PsycINFO, PsycARTICLES, Linguistics & Lan-
guage Behavior Abstracts, PubMed, ProQuest
Dissertation Abstracts, OpenSigle, British Educa-
tion Index, ISI Web of Knowledge, and Google
Scholar). Searches were conducted in February
and August 2011, and included permutations of
the terms emotional disturbance, EBD, behav-
ior*disorder*, language, communicat*, psych*,
impair*, disorder, child*, and school. Forward
and backward searches of relevant reviews and fre-
quently cited studies also were conducted. Titles
and abstracts of identified articles then were
screened for broad inclusion criteria (i.e., presence
of EBD and any empirical data). Next, potentially
relevant studies were retrieved and full articles
were reviewed by two master’s-level research assis-
tants. Retained articles were read by the first and
third authors to determine whether data were re-
ported according to inclusion criteria. Finally, in-
cluded studies were coded by the first and third
Separate random effects meta-analyses were
planned to describe comprehensive, receptive, and
expressive language ability for two outcomes:
prevalence and means. Samples within meta-anal-
yses are comprised of research reports rather than
individual participants, and each report provides
one or more research findings (Lipsey & Wilson,
2001). In the current meta-analyses, findings
were prevalence estimates and mean scores on
standardized measures. These descriptive out-
comes each represent a single variable, unlike
more commonly reported effect sizes for between-
group or bivariate relationships such as Cohen’s d
or Fisher’s z. Means were point estimates of cen-
tral tendency, and prevalence was the proportion
of children in each sample with LI. For both out-
comes, represented the standard deviation and I2
represented the proportion of true heterogeneity
to random error, or the signal-to-noise ratio.
Additional analyses were conducted to assess pub-
lication bias, or “the file drawer problem” (Boren-
stein et al., 2009, p. 379), in which only
significant results from large studies are published.
To avoid violating the assumption of inde-
pendence, the following decision rules were im-
plemented to ensure each participant sample
within a primary research report was included
only one time in each meta-analysis. First, several
studies produced more than one report (e.g., a
longitudinal study, or dissertation later published
in a journal). If the same sample data were re-
ported in multiple articles, the earlier report was
cited. If the earlier report was a dissertation study,
the published version was cited (e.g., Griffith,
Rogers-Adkinson, & Cusick, 1997; Rogers-Ad-
kinson, 1995). If authors reported different data
in separate reports, the article providing data for
the largest number of participants per outcome
was selected to improve precision of the overall es-
timates (Lipsey & Wilson, 2001). Second, the
category boundaries for prevalence of mild and
moderate/severe LI were exhaustive and exclusive.
In two studies, however, cutoff scores were re-
ported as 1.5 standard deviations. In these cases,
half of the sample was counted in the mild cate-
gory, and half in moderate/severe.
Prevalence. To answer the first research ques-
tion regarding prevalence of LI in children with
EBD, individual meta-analyses were planned for
comprehensive, expressive, and receptive language
at two levels of severity: mild and moder-
ate/severe. For studies reporting results for the
total sample at all levels of severity, the two levels
were combined to represent all children in the
sample with below-average performance. Rather
than using authors’ varying definitions of LI, cat-
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egories were determined a priori. Children with
scores 1-2 standard deviations below the mean on
a comprehensive language measure (71–85 where
M= 100 and SD = 15) were classified as having
mild deficits. The moderate/severe category in-
cluded children with scores two or more standard
deviations below the mean (70). Children with
clinical diagnoses of language disorder also were
included in this category if severity was not other-
wise specified. The category of below average abil-
ity included all children with LI diagnoses or
scores below 85.
Prevalence was the proportion of participants
in a sample of children with EBD identified as
having low language ability. To calculate effect
sizes for proportions, Lipsey and Wilson (2001)
recommend transforming proportions and their
standard errors to a logarithmic scale using these
Whereas values for proportions are con-
strained between zero and one, logits have an infi-
nite range and, therefore, provide a more accurate
estimate of the distribution of proportions around
the mean (between-study variance). Logits were
then converted back to a scale of 0 to 1 to facili-
tate interpretation of prevalence rates and confi-
dence intervals. Statistical significance was
determined by examining 95% confidence inter-
vals for overlapping data points.
Mean Scores. To answer the second research
question—whether mean standard scores of chil-
dren with EBD are below average—means and
standard deviations were coded for studies report-
ing comprehensive, expressive, receptive, seman-
tic, or syntactic language scores from standardized
assessments. Standard errors were computed by
dividing the standard deviation by the square root
of N. To determine whether effect sizes were sta-
tistically different from 85 (the cutoff for average
language ability on standardized measures), zwas
calculated using the formula z= (mean ES –
85)/(SE of mean ES).
Moderator Analyses. Analyses of moderators
were planned for meta-analyses with sufficient
true heterogeneity as defined by I2> 75% (Lipsey
& Wilson, 2001). For prevalence, variables
included topography (internalizing or externaliz-
ing) and severity of problem behavior (defined as
more or less restrictive programs; i.e., day or resi-
dential), setting (school or clinic), purpose for
data collection (research or practice; e.g., data
were collected to determine eligibility for ser-
vices, often reported via chart review), and assess-
ment (single or multiple measures). The variable
assessed for mean scores was the measure used to
obtain outcome data. The only tests meeting in-
clusion criteria were various editions of the Clini-
cal Evaluation of Language Fundamentals
(CELF-R, Semel, Wiig, & Secord, 1987; CELF-
3, Semel, Wiig, & Secord, 1995) and the Test of
Language Development-Intermediate (TOLD-I,
Hamill & Newcomer, 1982; TOLD:I-2, Hamill
& Newcomer, 1988; or TOLD:I-3, Hamill &
Newcomer, 1997). Analyses therefore compared
means obtained from the CELF and the TOLD.
Search procedures identified 1,631 articles from
database searches and 98 from ancestral searches.
After screening titles and abstracts for those 1,729
articles, 194 articles were retrieved and screened.
In the first stage of screening, 103 articles were ex-
cluded: 74 did not include participants with EBD
(e.g., samples were characterized as at-risk, delin-
quent, ASD, or ADHD), 25 did not include em-
pirical data, and four were unavailable. Interrater
agreement for this stage of screening was 97%;
disagreements were included in the next round of
screening. For the remaining 91 studies, sample
age or IQ scores exceeded cutoff criteria in 31
cases, 25 had insufficient data, and 12 included
participants with previously identified or sus-
pected LI. These constraints resulted in rejection
of several well-known studies (e.g., Baltaxe & Sim-
mons, 1988; Gualtieri, Koriath, van Bourgondien,
& Saleby, 1983; McDonough, 1989) but were
considered necessary to avoid overestimating
prevalence of LI in students with EBD. Similarly,
some samples from the Benner et al. (2002) review
were rejected entirely or only a subset of the sam-
ple was retained (see Table 1). Interrater agreement
for screening was 89%; disagreements were re-
solved by discussion.
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The final number of articles meeting inclu-
sion criteria was 25; however, three included sam-
ples were described in multiple reports. After
applying the previously outlined decision rules,
22 studies were retained. No experimental studies
were identified (group or single subject designs).
In the two quasiexperimental studies (Heneker,
2005; Hyter, Rogers-Adkinson, Self, Simmons, &
Jantz, 2001), only preintervention data were used.
All other identified studies employed nonexperi-
mental (i.e., descriptive or comparative) group de-
signs. Of the studies identified in the earlier
review by Benner et al. (2002), 12 were included
in the current analyses (see Table 1). Of the 22
total studies, 12 studies contributed data to mean
outcomes, and 18 contained data used to com-
pute prevalence estimates (see Table 2). Data were
reported for two independent samples in three
176 Winter 2014
Participant Characteristics Reported for Samples Included in Meta-Analyses
Primary % Age M (SD) FSIQ M (SD),
First Author (Year) Ethnicity SES NMale or Range Range, or Other
Behar (1982) Low-mid 58 70 9.1 (3.0) 90.7 (12.0)
Benner (2005) EU 84 79 8.6 (1.7) 96.1 (14.8)
Camarata (1988)b—— 21 77 10.9 (1.2) Normal limits
Cohen (1989)a 5.5 37 78 6.9 (1.4) 95.4 (11.0)
Cohen (1993)b Low-mid 288 78 8.3 (2.2) 104 (15.2)
Cohen (1998)b Low-mid 97 66 10.0 (2.1) 98.0 (11.8)
Curtwright (2007) Mixed 63 86 8.6 (1.7) < 70 excluded
Giddan (1996)a Low-mid 55 72 9.5 (1.9)
Griffith (1997)a, c Mixed Mixed 21 81 8.95 (1.41) Average
20 85 10.7 (1.5) Average
Heneker (2005) —— 11 —511 —
Hyter (2001) —— 6100 8.5–12.9 85–115
Keefe (1992)a—— 19 84 9.67 105 (8.6)
Kotsopoulos (1987)a Lower 41 87 8.6 < 70 excluded
Lassman (2007) —— 27 —912 —
Mack (1992)aEU 20 100 11.8 (1.0) 96.9, 79–123
Miniutti (1991)aNon-EU Lower 27 85 7.8 (.79) < 70 excluded
Nelson (2005)cEU 65% FRL 57 82 7.75 (1.18) 93.79 (14.66)
39 84 10.97 (.86) 100.50 (13.77)
Novak (1992) Mixed 31 77 7–13 < 85 excluded
Rinaldi (2003) HS 92% FRL 61 84 10.83 89.83 (12.07)
Rogers-Adkinson 19 74 11.1 85–128
(2003)c19 79 11.0
Ruhl (1992)a—— 30 73 11.9 Normal range
Trautman (1990)bEU Lower 37 85 6–12 Median 91.5
Note. Hyphen indicates information was not specified in the original research report. EU = greater than 65%
European descent/White/Caucasian. Non-EU = sample described as “predominantly non-white.” HS = greater
than 65% Hispanic. Mixed = no single ethnicity or SES group constituted greater than 65% of the sample.
SES = Socioeconomic status. FRL = Free/reduced-price lunch. EU = European descent/White/Caucasian.
HS = Hispanic. FSIQ = Full Scale Intelligence Quotient.
aStudy was included in Benner et al. (2002) review; full sample was included in this study. bStudy was included
in Benner et al. (2002); only part of the sample was included in this study. cData reported for two independent
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Exceptional Children
T A B L E 2
Study Characteristics and Outcome Variables for Studies Included in Meta-Analyses
1st Author (Year) Program Setting Purpose Pub-Loc Measure Language Domain Mean (SD) % Mild % Mod/Severe
Behar (1982) Res Clinical Practice J-US Multiple Expressive 25.90
Receptive 12.10
Benner (2005) Day School Research J-US CELF-3 Comprehensive 70.24 15.47
Expressive 71.43 16.67
Receptive 52.38 10.71
Camarata (1988) Day School Research J-US TOLD-I Comprehensive 23.81 71.43
Cohen (1989) Day Clinic Practice J-CA Multiple Comprehensive 28.57
Cohen (1993) Day Clinic Practice J-CA Multiple Comprehensive 34.38
Cohen (1998) Day Clinic Practice J-CA Multiple Comprehensive 38.10 41.27
Curtwright (2007) Day School Practice D-US Multiple Comprehensive 65.39
Giddan (1996) Res Clinic Practice J-US Multiple Comprehensive 35.00
Griffith (1997) Res School Research J-US TOLD Comprehensive 77.30 (10.43)
Expressive 73.80 (11.71)
Receptive 84.35 (9.02)
Day Comprehensive 74.45 (11.43)
Expressive 70.05 (12.94)
Receptive 81.75 (12.87)
Mix Comprehensive 41.46 39.02
Expressive 39.02 46.34
Receptive 56.10 7.32
Heneker Day School Research J-UK Multiple Expressive 54.55 18.18
(2005) Receptive 36.36 27.27
Hyter (2001) Day School Research J-US TOLD-I:2 Comprehensive 72.00 (6.20) 66.67 0.00
Keefe (1992) Day School Research J-US TOLD-I:2 Comprehensive 92.53 (13.49)
Expressive 90.84 (18.03)
Receptive 91.05 (12.87)
Syntax 87.32 (18.13)
Semantics 94.42 (12.96)
Kotsopoulos Day Clinic Practice J-CA Multiple Comprehensive 19.51 53.66
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178 Winter 2014
T A B L E 2 . Continued
1st Author (Year) Program Setting Purpose Pub-Loc Measure Language Domain Mean (SD) % Mild % Mod/Severe
Lassman (2007) Day School Research D-US CELF-3 Receptive 71.48 (16.89) 25.93 48.15
Mack (1992) Res Clinic Research J-CA Multiple Comprehensive 15.00 60.00
Miniutti Day School Research J-US CELF-R Comprehensive 62.33 (13.20) 0.00 81.00
(1991) Expressive 63.26 (14.10)
Receptive 66.96 (12.10)
Nelson (2005) Day School Research J-US CELF-3 Comprehensive 84.95 (15.96)
Expressive 84.26 (16.47)
Receptive 87.67 (16.02)
Comprehensive 86.08 (16.24)
Expressive 81.59 (15.63)
Receptive 92.54 (17.91)
Novak (1992) Day School Research D-US CELF-R Comprehensive 65.50 (16.12) 13.33 73.33
Rinaldi (2003) Day School Research J-US TOLD-I:3 Syntax 83.51 (14.37)
Semantics 80.59 (13.98)
Rogers- Day School Research J-US TOLD-I:3 Comprehensive 67.26 (4.34)
Adkinson Expressive 62.52 (6.66)
(2003) Receptive 77.26 (7.46)
Syntax 65.42 (5.61)
Semantics 75.89 (11.19)
Comprehensive 85.26 (7.18)
Expressive 83.21 (9.89)
Receptive 90.21 (9.60)
Syntax 83.31 (11.84)
Semantics 89.57 (6.29)
Ruhl (1992) Day School Research J-US TOLD-I Comprehensive 72.70 (12.9)
Expressive 74.80 (16.70)
Receptive 80.50 (7.70)
Syntax 74.7 (14.4)
Semantics 79.90 (11.10)
Trautman (1990) Day Clinic Practice J-US Multiple Comprehensive 27.03
Note. Pub = Publication type. J = Journal. D = Dissertation. Loc = location. US = United States. UK = United Kingdom. CA = Canada. Res = Residential.
Mild = Standard scores 71–85. Moderate/severe = 70 or clinical LI diagnosis.
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studies (e.g., data for different age groups were re-
ported separately), so a total of 25 samples con-
tributed to outcomes. Reliability for coding was
90%; disagreements then were consensus coded.
The total number of participants with EBD in-
cluded in the sample of 22 primary research stud-
ies was 1,171 (range = 6–288; median = 27). The
mean age of the sample was 9.49 years (SD 1.6
years); however, several authors reported only
grade level or age range of the sample or means
without standard deviations (see Table 1). Because
this and other variables (e.g., IQ, race/ethnicity,
socioeconomic status, specific DSM diagnoses or
behavioral topographies) were not reported con-
sistently, their roles as moderators could not be
examined. The only moderator variable of interest
for subgroup analysis reported in every study was
measurement instrument (see Table 2). Nearly all
of the studies represented samples of convenience;
only one (reported in both Benner, 2005 and
Nelson et al., 2005) employed random selection
from a larger population of students with EBD.
Study settings and program types generally were
not well-described; thus, designations for pro-
gram type, setting, and purpose may reflect au-
thors’ professional affiliations as much as study or
participant characteristics.
Main Effects. Prevalence of below average,
mild, and moderate/severe language deficits was
computed for comprehensive, expressive, and re-
ceptive language ability (see Table 3). Results of a
meta-analysis including all children with LI re-
gardless of severity showed that the prevalence of
below-average comprehensive language ability was
distributed around a mean of 81%, with 34%
and 47% of deficits characterized as mild and
moderate/severe, respectively (see relevant tables
for confidence intervals). Note that summing the
point estimates of mild and moderate/severe
deficits does not equal the percentage of below
average deficits, due to differences in the number
of samples and participants contributing data to
each outcome.
The next meta-analyses examined expressive
and receptive components of language ability (see
Table 3); however, data were not available for
analysis of semantics or syntax. The prevalence
Exceptional Children
Prevalence (Proportion) of Students With EBD and Unidentified Language Deficits
Component Severity [95% CI] NsNpQtotal %I2
Comprehensive Below (1SD) 80.6% [76, 84] 9 367 7.07 00
Mild (1–2 SD) 33.8% [20, 50] 9 367 50.3*** 84.1 .89
Mod/sev (2SD) 46.5% [36, 57] 14 838 81.78*** 84.1 .68
Expressive Below (1SD) 85.7% [79, 91] 3 136 1.83 00
Mild (1–2 SD) 55.9% [32, 77] 3 136 11.69** 82.9 .77
Mod/sev (2SD) 26.5% [15, 43] 4 194 12.20** 75.4 .62
Receptive Below (1SD) 64.8% [57, 72] 4 163 1.15 00
Mild (1–2 SD) 45.0% [32, 59] 4 163 7.16 58.1 .42
Mod/sev (2SD) 17.8% [ 8, 36] 5 221 21.82*** 81.7 .95
Note. Random effects models. Prevalence = Proportion of children with EBD and language deficits. Ns= Number
of samples providing prevalence estimates from primary studies in each meta-analysis. Np= Total number of
participants in each meta-analysis. Degrees of freedom = Ns–1.Qt= Statistic of total heterogeneity across all
studies. I2= Ratio of true to random heterogeneity. = standard deviation. EBD = emotional and behavioral
** p< .01. *** p< .001.
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estimate for below-average expressive deficits was
86%. The proportions of children experiencing
mild and moderate/severe deficits in expressive
language were centered around means of 56%
and 27%, respectively. Prevalence of receptive
deficits was lower than expressive in the below av-
erage, mild, and moderate/severe categories (65%,
45%, and 18%, respectively).
Moderator Analyses. Before investigating
moderators, it was necessary to determine
whether there was sufficient heterogeneity in out-
come variables. Examination of heterogeneity
statistics in Table 3 reveals very little between-
study variance in outcomes in the category for
below-average comprehensive language (Qt=
7.07, p> .05). Although the Q statistic may be
unreliable when applied to small samples (Boren-
stein et al., 2009), this conclusion was supported
by I2= 0%, indicating that the ratio of true to
random heterogeneity was insufficient for exam-
ining moderator variables within that category.
However, heterogeneity was sufficient to examine
moderator variables in both the mild and moder-
ate/severe categories. Because (a) fewer studies re-
ported mild language deficits, and precision
increases with sample size and (b) conducting
tests in both categories would increase the likeli-
hood of Type I error, the decision was made to ex-
amine moderators within the moderate/severe
category only.
Separate meta-analyses were conducted for
three of the five proposed moderator variables:
setting, measures, and purpose for data collection
(see Table 4). The analyses for program type and
topography of behavior could not be conducted
as too few studies provided relevant data. In the
remaining moderator analyses, noticeable patterns
emerged. First, the number of samples in each
subgroup was equal or nearly equal; however, the
number of participants was two to three times
higher in clinical, multiple measures, and practice
subgroups (relative to school, single measure, and
research subgroups, respectively). Prevalence esti-
mates followed a reverse pattern: Moderate/severe
language deficits were 18% higher in schools than
clinical settings, 13% higher when obtained by
single measures, and 15% higher in studies con-
ducted for research purposes other than those in-
forming practice. Consequently, prevalence
estimates for the school, single measure, and re-
search subgroups ranged from 55% to 57%, and
estimates for the clinical, multiple measure, and
practice subgroups ranged from 39% to 43%.
None of these differences were statistically signifi-
Main Effects. Eleven samples contributed
data to the meta-analysis of mean comprehensive
language ability (see Table 5). The overall mean
language score was 76.33. Mean expressive and
receptive scores were 75.92 and 82.23, respec-
tively. Although each point estimate was below
180 Winter 2014
Moderator Analyses: Differences in Prevalence of Moderate/Severe Deficits by Study Characteristics
Variable Group Prevalence [95% CI] NsNpQw%I2
Setting School 56.9% [33, 78] 7 272 58*** 89.6 1.15
Clinic 38.7% [32, 46] 7 566 13* 53.8 0.28
Measures Single 55.2% [27, 80] 6 157 52*** 90.0 1.32
Multiple 42.6% [34, 52] 8 629 30*** 90.0 0.47
Purpose Research 55.9% [31, 78] 7 229 52*** 88.5 1.20
Practice 40.9% [32, 51] 7 609 27*** 77.7 0.46
Note. Random effects models. Ns= Number of samples providing prevalence estimates from primary studies in
each meta-analysis. Np= Total number of participants within samples. Degrees of freedom = Ns–1.Qw= The
statistic of within-group heterogeneity. I2= The ratio of true to random heterogeneity.
= The standard deviation.
*p< .05. *** p< .001.
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the cutoff score of 85, or 1 standard deviation
below average language ability, only mean com-
prehensive (z= –2.97; p= 0.002) scores reached
statistical significance. The analysis to determine
whether children had relative strengths or weak-
nesses in semantic or syntactic skills was a synthe-
sis of five studies, all of which reported results
obtained from TOLD composites. Participants
scored somewhat higher on semantic (84.03) than
syntactic composites (78.63) on this measure, but
neither were significantly below average.
Moderator Analyses. The only moderator anal-
ysis for mean standard scores was to determine
whether differences in comprehensive, expressive,
and receptive outcomes varied by test instruments
(CELF or TOLD). All of these scores represent
children with EBD in school settings only, as
mean scores for comprehensive standardized tests
were not reported in any of the clinical studies.
Generally, scores reported for each measure were
very similar, although scores on the CELF were
slightly lower and more variable (wider confi-
dence intervals; larger standard deviations), than
those obtained by the TOLD. In the moderator
analysis for comprehensive language, the CELF
was administered to 153 participants in four dif-
ferent samples. The weighted mean score for this
subgroup was 74.77. The TOLD was used more
often (7 samples), with fewer participants (n=
126), and the mean was 77.14. For expressive lan-
guage, scores from the CELF were 72.91, and
scores from the TOLD were 79.17. Scores for re-
ceptive language on the CELF were 79.68 and
83.82 on the TOLD. None of the differences in
scores obtained by different tests were statistically
Additional Analyses. Analyses were conducted
to identify “missing” studies due to publication
bias. That is, studies with significant positive re-
sults are more likely to be submitted and accepted
for publication, published in English, and cited in
other publications (Lipsey & Wilson, 2001). Re-
sults of Eggers statistical tests, the trim-and-fill
method, and an analysis of funnel plots all indi-
cated that small studies were not missing from the
analyses and presence of publication bias was un-
The purpose of the current study was to synthe-
size decades of research describing prevalence,
severity, and types of unidentified language
deficits in the population of students with EBD.
Research questions were answered using quantita-
tive methodology designed to synthesize out-
co mes ac ross prim ary research reports , and
stringent inclusion criteria to control for alterna-
tive explanations due to participant characteris-
tics. This study adds to the literature an analysis
of mean standardized test scores in several do-
mains of language performance.
The prevalence estimate of previously
unidentified language deficits in children with
EBD was distributed around a mean of 81%;
thus, in answer to the first research question, it is
likely that four out of five children with EBD had
at least mild LI that escaped the attention of rele-
Exceptional Children
Effect Sizes: Mean Performance on Standardized Language Assessments for Students With EBD
Mean [95% CI] NsNpzpQ
total %I2
Comprehensive 76.33 [71, 82] 11 279 –2.97 0.002** 208.9 95 9.38
Receptive 82.23 [77, 87] 10 270 –1.65 0.13 125.8 92 7.42
Expressive 75.92 [69, 83] 9 243 –1.48 0.004* 137.9 94 9.96
Semantic 84.03 [78, 90] 5 140 –0.31 0.377 43.24 91 6.54
Syntactic 78.63[70, 88] 5 140 –1.30 0.097 93.16 96 10.6
Note. Random effects models. Mean = Outcome point estimate, or weighted mean standard scores. Ns= Number
of samples providing mean scores from primary studies in each meta-analysis. Np= Total number of participants.
I2= The ratio of true to random heterogeneity. Ztests indicate whether means are statistically different from 85,
or 1 SD below norm means. EBD = emotional and behavioral disorders.
*p< .05 **p< .01.
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vant adults. Surprisingly, this estimate was even
higher than that reported in Benner et al. (2002),
which included a more broadly defined sample of
children with EBD. Although results are not di-
rectly comparable due to differences in methodol-
ogy and sampling procedures, the pattern of
results was repeated for prevalence of expressive
and receptive deficits: Both were higher than the
earlier estimate by 21% and 9%, respectively.
Regarding severity of those deficits, of the
838 participants in 14 studies, 47% had deficits
categorized as moderate to severe. That is, nearly
half the children across studies had either a diag-
nosis of LI or standard scores below the 3rd per-
centile in comprehensive language proficiency.
The majority of children evaluated in this study
had at least a mild language deficit or impair-
ment. This estimate is far higher than in the gen-
eral population of school-age children, in which
prevalence has been estimated at 3% to 14% de-
pending on criteria used to determine case status
(Law et al., 2000; Tomblin et al., 1997).
The results of the meta-analyses to determine
mean standardized test scores supported the above
findings and confirmed the second research ques-
tion: Language proficiency for students with EBD
was well below that of typical peers, even among
students without documented deficits. The sam-
ple mean comprehensive standard score was
76.33, or 1.5 standard deviation below normative
means, which is often cited as the cutoff criteria
for determining LI (Law et al., 2000).
Analyses regarding moderators did not reveal
variables predicting systematic differences in ei-
ther prevalence or mean outcomes, indicating
that these results may be consistent regardless of
how children are identified, where they are
served, or how they are assessed. Interestingly,
though, there were few differences in the samples
included in each subgroup analysis for prevalence.
That is, examination of Table 2 shows that three
of the subgroups overlapped considerably: studies
conducted in school settings also were conducted
primarily for research purposes and employed a
single measure. On average, prevalence was 15%
higher than in studies using multiple assessments
in clinical settings in which the purpose of assess-
ment was to inform practice. Clinical studies also
were more likely to use a retrospective design, in
which data were collected via chart review. Due to
lack of available data, the moderator analyses re-
garding form and severity of problem behavior
could not be performed.
The current study shares a limitation common to
all meta-analytic research: Results are dependent
on the quality and quantity of primary studies.
The greatest limitation regarding quality was that
participants and study characteristics seldom were
clearly described. For example, relevant studies
may have been excluded if not enough informa-
tion was provided to determine eligibility. Con-
versely, if samples were not well-defined, children
with overall cognitive, neurological, or attention
deficits may have been included inadvertently.
Imprecise descriptions may have led to incorrect
specification of childrens educational placements,
which would affect accuracy of the moderator
analyses. Inconsistent reporting standards also
may have contributed to improper specification
of severity categories. Furthermore, limited de-
scriptions of participants also limits external va-
lidity or the ability to generalize results.
Regarding quantity of primary studies used
to compute results, it was anticipated that there
would be more than 18 studies contributing to
the prevalence effect sizes, as Benner et al. (2002)
identified 18 studies a decade ago. The low num-
ber of identified studies was likely due to strict in-
clusion criteria: Six studies in the Benner et al.
review did not meet inclusion criteria for the cur-
rent analysis. Many more potentially relevant arti-
cles also were excluded on the basis of participant
age, IQ, or secondary conditions known to co-
occur with LI.
Sample size also may have played a role in
failure to reject the null hypotheses regarding dif-
ferences in mean expressive and receptive lan-
guage proficiency: Larger sample sizes may have
increased power to detect an effect. It is also pos-
sible, however, that conducting multiple meta-
analyses introduced family-wise error and
increased the probability of Type I error in analy-
ses of children’s comprehensive language abilities.
Finally, it is possible that outcomes were affected
by variations among test instruments. Although
every attempt was made to avoid comparing ap-
ples and oranges (Lipsey & Wilson, 2001) by re-
182 Winter 2014
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stricting the types of tests that were included in
analyses, even direct comparisons of instruments
included different versions of tests (and therefore
test items, subtests, normative groups, and sensi-
Results of all meta-analyses supported and ex-
tended conclusions drawn by Benner, Nelson,
an d Eps tein ove r a deca de ago. Des criptiv e
research has been instrumental in revealing that
co-occurrence of mild, moderate, and severe lan-
guage deficits is clearly widespread among chil-
dren with EBD. It is important to remember that
the children assessed in the primary research stud-
ies had no previous history of receiving language-
related services, or indeed of ever being previously
evaluated for LI. Additionally, it is unlikely that
results were attributable to developmental, neuro-
logical, or physical (e.g., hearing or speech) fac-
tors known to co-occur with both language and
behavioral problems. Although it is possible that
these results underestimate the problem due to
such conservative inclusion criteria, it must also
be noted that results may reflect children’s behav-
ioral performance during testing (e.g., lack of at-
tention, effort, or cooperation), thus inflating
estimates of deficits in language proficiency. Still,
the finding that so many children with EBD also
had previously unidentified LI echoes the refrain
that has been noted throughout the literature:
Children’s problem behaviors are so salient that
they effectively eclipse other intervention needs.
This study also confirms that all children
with EBD should be screened for language prob-
lems as early as possible. Even without resource-
intensive intervention, it is possible that simply
educating adults about the link between language
and behavior problems could affect some change.
Anecdotally, researchers have noted that simply
recognizing that problem behaviors such as non-
compliance could be in part due to deficits in
comprehension helps adults become “less likely to
fault the children for their misbehavior” (Cohen
et al., 1993, p. 600) and more likely to perceive
the child “in a more positive light” (Gallagher
1999, p. 7). Whether this phenomenon can be
replicated has yet to be demonstrated empirically.
Another promising area of research is clarify-
ing relationships among linguistic and behavioral
variables. For example, results of this and other
studies have yet to indicate directionality; that is,
whether LI contributes to development of EBD
or vice versa. In addition, fine-grained analyses of
patterns of language performance among children
with different behavioral profiles may be an im-
portant precursor to developing targeted interven-
tions. In the current study, some researchers did
report behavioral information; however, it was
not possible to calculate language performance by
behavioral topography given the available data.
There are conflicting results in the literature re-
garding type of problem behavior and compo-
nents of language (e.g., whether receptive or
expressive deficits are more prevalent or severe in
children with internalizing or externalizing behav-
ior; see Benner et al., 2002; Cohen et al., 1993;
Nelson et al., 2005). To answer these questions,
descriptive studies are warranted to investigate
how specific types of language and behavior are
associated and how those interactions affect chil-
dren’s academic, social, and behavioral develop-
Once specific relations among relevant vari-
ables are better understood, future research must
include interventions to address combined diffi-
culties in language and behavior. Language
deficits limit children’s ability to benefit from in-
struction, talk-based therapies, and complex be-
havior management plans. Interventions by
teachers, parents, and therapists must include
consideration of children’s linguistic needs. In ad-
dition, researchers must determine whether inter-
ventions to increase children’s communication
skills will decrease problem behavior.
Language deficits limit children’s
ability to benefit from instruction,
talk-based therapies, and complex
behavior management plans.
Another fruitful area for future research may
be examining adults’ use of language in interac-
tions with children with EBD. If adults use lan-
guage that is beyond students’ comprehension,
they may inadvertently increase the occurrence of
Exceptional Children by guest on January 14, 2016ecx.sagepub.comDownloaded from
problem behavior. Harrison et al. (1996) sug-
gested that verbal instruction may be aversive to
students due to a mismatch in the form, content,
or function of teacher talk and students’ ability to
reproduce or comprehend it. Ample evidence
supports the presence of coercive interactions and
decreased instruction in classrooms for students
with EBD, resulting in negative outcomes for
teachers and students alike (Sutherland & Mor-
gan, 2003). Determining the effects of teacher
talk on children’s problem behavior is an impor-
tant area of study, as is the ability of adults to
monitor and modify language use and the effect
of those adaptations on childrens behavior.
This synthesis of decades of descriptive re-
search confirms that children with E BD are
highly likely to have co-occurring language im-
pairment. It is now incumbent upon researchers
to identify important targets for change and de-
velop empirically grounded interventions to ame-
liorate the harmful effects of co-occurring LI and
EBD. Supporting language development and ef-
fective communication for these children may be
a critical step in interrupting the maladaptive aca-
demic, social, and behavioral outcomes so often
experienced by this population.
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toral Candidate; and JOSEPH H. WEHBY (Ten-
nessee CEC), Associate Professor, Department of
Special Education, Peabody College of Vanderbilt
University, Nashville, Tennessee. R EGI NA M .
OLIVER, Assistant Research Professor, Center for
Child and Family Well-Being, Department of
Special Education & Communication Disorders,
University of Nebraska-Lincoln.
Alexandra Hollo is now a Postdoctoral Fellow at
the University of Louisville.
Preparation of this article was funded in part by
the Office of Special Education Programs Leader-
ship Training Grant H325D020022. The opin-
ions expressed in this article are those of the
authors and do not necessarily reflect those of the
funding agency.
Address correspondence concerning this article to
Alexandra Hollo, College of Education and
Human Development, Department of Special Ed-
ucation, University of Louisville, Louisville, KY
40292 (e-mail:
Manuscript received February 2012; accepted
October 2012.
186 Winter 2014
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... DLD has repeatedly been associated with psychosocial and cognitive difficulties, which are likely to persist throughout adulthood (Conti-Ramsden et al., 2018;Parsons et al., 2011). Unfortunately, the lack of research attention and public health awareness about this phenomenon may have led to a high percentage of undetected cases of DLD among children consulting for emotional and behavioural problems (Hollo et al., 2014). This could in turn lead to an unfortunate cascade of developmental consequences for children with DLD. ...
... In addition, children who have a family history of language delay and who have an immigrant mother should be referred directly for a DLD assessment, instead of waiting for a potential recovery from their difficulties. This contribution is even more important considering that DLD is largely underidentified among clinical populations consulting for emotional and behavioral problems (Hollo et al., 2014). Adding these criteria to the decision-making process would make it easier to identify and allocate services to those children in need of early intervention. ...
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Many mental disorders (MD) share common etiology, fuelling debates about the specificity of clinical categories and whether the presence of specific risk factors (RF) can distinguish among them. The study of developmental language disorder (DLD), more specifically, has been further hindered by a lack of consensus regarding its definition. These limitations increase the risk of under-detection and lifelong consequences for affected children. This paper aims (1) to document which individual RF allow differentiating DLD from other MD and (2) to compare the cumulative RF between children with DLD versus other MD. This case-control design study used medical records of a psychiatric sample of 795 preschoolers (mean age 4:11, 75% boys). A logistic regression measured the predictive value of potential RF on DLD. Later first sentences, maternal immigration and family history of language delay were identified as significant in explaining 30% of the variance for DLD diagnosis. An ANCOVA revealed that children with DLD were exposed to a significantly higher number of RF than were children with other MD. Public health policies informed with the knowledge of specific RF associated with DLD, and their cumulative impact, could improve early detection and reduce the cascade of negative consequences associated with DLD.
... Further, students with lower reading skills are more likely to exhibit behavioral challenges than students without (Lin et al., 2013). In terms of L2, language difficulties have also been linked to behavior issues (Jansen et al., 2020), as poorer language skills are a risk factor for developing behavior difficulties (Chow & Wehby, 2018;Hollo et al., 2014). Petersen and LeBeau (2021) reported that social skills, language skills, and behavior difficulties are interrelated and that language ability plays a fundamental role in the development of externalizing behavior difficulties. ...
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Reading difficulties in German students are steadily increasing, while reading motivation is decreasing, yet reading is one of the most important aspects of literacy. Complicating matters , reading instruction is challenged by an enormous heterogeneity among the student body, which includes students learning German as a second language and students with behavioral problems. Thus, many teachers are faced with trying to narrow the large gap between strong and weak readers by providing reading support, which often has to start with basic skills, and at the same time meeting the individual students' needs. The present single-case study assessed the effects of a simple peer-tutored motivational reading racetrack intervention on word fluency within a short period of time for students with and without behavioral problems (N = 9) for whom German is an L2. The results are promising with high overlap indices and the followup data showing stable improvements. Limitations and implications are discussed.
... In contrast, 95% of participants worked with children who exhibited challenging behaviors, suggesting a mismatch between pre-service and in-service experiences related to behavior. This is a particular point of concern, as we know 81% of children with behavior disorders have clinically meaningful and unidentified language deficits (Hollo et al., 2014), and these deficits emerge across subdomains of language (Hollo et al., 2020). Further, children with language delay demonstrate more problem behaviors and are twice as likely to demonstrate behavior problems later on than their typical peers (Curtis et al., 2018;Yew & O'Kearney, 2013). ...
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The purpose of this study is to improve pre-service speech-language pathologists (SLPs) behavior management knowledge and self-efficacy via an adaptive intervention design. Using a sequential multiple-assignment randomized trial, we aim to identify the best pathways to knowledge that considers an individual's response to instruction. Given that school SLPs often experience challenging behavior but receive minimal training on behavior management and positive behavior supports in their preservice programs, identifying effective and efficient methods for providing this important content to SLPs during their training is important for SLP practice and their student outcomes. We will initially randomly-assign participants to either read a practitioner article or complete an online module on two evidence-based behavior management practices. Through a series of re-randomizations and intervention components, we will determine the best components and sequence that lead to improved outcomes. We will explore moderators of intervention efficacy (content engagement, self-efficacy) and assess social validity. We hypothesize that pathways in the design will lead to differential outcomes, and that the effects of the sequence of components may vary across the sample.
Background: The prevalence of language disorder in youth offenders far exceeds rates reported in community samples. Youth involved in the justice system are also at increased risk of a range of psychiatric disorders, including internalizing mental health problems (i.e., anxiety, depression). However, the frequency with which these co-occur in this population is not known. Understanding the co-occurrence of language disorder with anxiety and depression in youth offenders may contribute to more coordinated and targeted support for these vulnerable youth. Aims: To explore the co-occurrence of language disorder and anxiety and depression in youth offenders. Methods & procedures: A systematic literature search of six databases (CINAHL, ERIC, Medline, PyscINFO, PubMED, Scopus) was conducted (September 2021) using key search terms relevant to the systematic review question. Study inclusion criteria were: (1) original research published in English; (2) youth up to 21 years of age involved in the justice system; and (3) reported outcomes on language and anxiety and/or depression. All included studies were appraised using the Joanna Briggs Critical Appraisal tool checklist relevant to study design. Due to the heterogeneity of included studies, data synthesis was narrative. Main contribution: Eight studies met the eligibility criteria. A range of measures was used to assess language abilities across samples. Only two studies directly addressed the relationship between language disorder and internalizing mental health problems; both found no significant correlation. Conclusions & implications: Although the results did not support a significant relationship between language disorder and internalizing mental health problems in youth offenders, the two appear to occur comorbidly as evidenced by heightened rates of both in the included samples. This review highlights the need for more robust studies aimed to better understand this relationship. Stronger evidence may contribute to increased collaborative speech pathology and psychology services which might increase youth offenders' accessibility and engagement in intervention programmes (e.g., cognitive-behaviour therapy; interpersonal skills training; individual counselling). What this paper adds: What is already known on this subject The markedly high rates of language disorder in youth involved in the justice system have been widely reported. It is also known that externalizing mental health problems often bring youth in contact with the justice system. Though there is some information about the prevalence of internalizing mental health problems in this population, the co-occurrence of language disorder and internalizing mental health problems has not been examined as widely. What this study adds to existing knowledge This study aimed to identify the frequency of co-occurrence of language disorder and anxiety and/or depression in youth offenders. Although the results did not support a significant relationship between language disorder and internalizing mental health problems in this population, results of the review provide evidence of heightened rates of both. This study also provides a summary of the various measures used to assess language and internalizing mental health in youth offenders across the eight studies included in this review. What are the potential or actual clinical implications of this work? It is possible that the tests and sub-tests used to identify language disorders and internalizing mental health problems were not sensitive enough to identify the full extent of youth offenders' needs. Identifying the presence of language disorders and internalizing mental health problems and recognizing the impact these may have on the communication and behaviours of an individual can better inform staff and therapists as they engage and interact with youth in the justice system.
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This article argues for intentional collaboration between teachers of students with emotional and behavioral disorders and speech-language pathologists. After providing a rationale, we detail how special education teachers can leverage the expertise of speech-language pathologists during the individualized education program process. We provide actionable steps that special education teachers and speech-language pathologists can take together to improve the identification, assessment, and subsequent support of language difficulty in students with emotional and behavioral disorders.
A review of clinical records was conducted for children with developmental, emotional, and behavioral difficulties who were assessed with both the Wechsler preschool and primary scale of intelligence-third edition (WPPSI-III CDN ; Wechsler, 2004) and the Leiter international performance scale-revised (Leiter-R; Roid & Miller, 1997) within the same psychological evaluation. Forty children, ages 3–7, were included in this study. Pearson correlations showed that the IQ scores of the two instruments are strongly related ( r > .70; p < .001). However, paired t-tests showed that overall Leiter-R scores ( M = 99.03) were significantly higher than WPPSI-III CDN scores (PIQ; M = 82.28, FSIQ; M = 75.24) ( p < .001). The discrepancies between the instrument’s scores were clinically important as the use of only one of the two instruments could result in misclassification of child intellectual ability. These results should prompt professionals working with this clinical population to be cautious when using results from a single instrument in a child’s intellectual evaluation.
Background and aims A high rate of children in mental health services have poor language skills, but little evidence exists on how mental health support is delivered to and received by children with language needs. This study looked at parental experiences, asking parents of children with speech, language and communication needs (SLCN) about their experiences seeking help for their children's mental health. We were particularly interested on the experiences of parents of children with Developmental Language Disorder (DLD), a specific SLCN that remains relatively unknown to the general public. Methods We conducted an online survey of 74 parents of children with speech, language and communication needs (SLCN). Survey respondents included parents of children with a range of difficulties, including DLD, autism, verbal dyspraxia, global intellectual delay, a history of hearing problems, and SLCN without a primary diagnosis. Survey respondents were asked what sources of support they had accessed for their child's mental health and to provide comments on what was good and what was not good about this support. We then conducted 9 semi-structured interviews of parents of children with DLD about their experiences. These were parents of children with DLD aged 7 to 17 years, from across a range of educational settings, and with a range of present mental health concerns. Results Content analyses of the survey responses from parents of children with SLCN highlighted three broad factors of importance to parents’ experiences: relational aspects of care, organisational aspects of care, and professionals’ knowledge. Thematic analyses of the interviews of parents of children with DLD identified 5 themes: the effects of language problems on the presentation of distress; the role of the school environment; the role of key professionals; standard approaches to mental health support might not be appropriate; and the role and impact on parents. Parents expressed concerns that their children's mental health problems and need for support would not be recognised, and felt interventions were not accessible, or delivered in a manner that was not comfortable for their children due to high reliance on oral language skills. Some parents were left feeling that there was no provision suitable for their children. Conclusions Parents of children with SLCN face barriers accessing support for their children's mental health, including a lack of professional knowledge about their children's language needs. Parents argued that language and communication needs can significantly affect the delivery and success of psychological therapies and interventions. Systematic research is needed to understand how to successfully adapt services to make them accessible to children and young people with language needs, and to ensure that mental health problems are detected in children with language difficulties. Increased knowledge about language disorders such as DLD, and access to speech and language therapy expertise, is needed amongst professionals who work to support children's mental health.
Oral language skills are critical for psychosocial development and children with language difficulties are more likely than peers to experience behavioral problems. This study investigated the effects of an oral language intervention on behavioral adjustment. We collected teacher ratings of behavioral adjustment for 1173 children taking part in a cluster randomized trial of the Nuffield Early Language Intervention (NELI) program in 193 primary schools. Ratings were collected before and immediately after the 20-week intervention. Children receiving the language program showed significantly greater improvements than the untreated control group on a latent variable reflecting behavioral adjustment (d = 0.23). However, the improvements in behavioral adjustment for children receiving language intervention were not mediated by improvements in language. We suggest that the improvements in behavioral adjustment are a consequence of the small group and individual teaching sessions in the language intervention program, which emphasizes the need to pay attention and regulate behavior. This emphasis appears to produce generalized improvements in children's behavior regulation outside of the targeted language teaching sessions.
Most students with emotional and behavioral disorders (EBD) have significant reading difficulties, but educators have few in-service professional learning opportunities geared to reading instruction for these students. The Integrated Literacy Study Group was developed as an online professional development program to prepare elementary teachers to meet the literacy needs of students with or at risk of EBD. In this study, the authors use a within-subjects design to evaluate the feasibility of the 10-week digital program with 13 elementary teachers. From pretest to posttest, teachers made statistically and educationally significant gains in knowledge of evidence-based social and emotional learning and reading strategies for students with EBD, as well as significant improvements in general teacher self-efficacy, reading self-efficacy, and social and emotional self-efficacy. Pretest-to-posttest change in teacher burnout and classroom management was educationally significant, but statistically nonsignificant. Most teachers perceived the program content as relevant to their needs and those of their students.
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A cross-sectional design was used to assess the language skills and prevalence of language disorders among 84 randomly selected public school children (K-5) receiving special education services for emotional and behavioral disorders (EBD). The mean receptive language standard score fell in the nonclinical range, whereas the mean total and expressive standard scores fell in the clinical range. The prevalence rates of total, expressive, and receptive disorders among children with EBD were 54%, 55%, and 42%, respectively. Approximately two-thirds of children experienced a language disorder (i.e., total, expressive, and/or receptive). Half of those experiencing a language disorder met clinical criteria in all language areas (i.e., total, receptive, and expressive). Approximately 86% of children meeting clinical criteria for total, receptive, and/or expressive language disorder were not receiving formal language services (i.e., false negatives). The findings and future research needs are discussed. © Copyright by the Center for Great Plains Studies, University of Nebraska-Lincoln.
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This study was designed to explore a model of communicative competence (Abbeduto & Nuccio, 1989) and identify whether its components could (a) predict pragmatic language difficulties for children with emotional or behavioral disorders (E/BD) and (b) describe the semantic, syntactic, and pragmatic language ability as well as the social skills of these children. The Test of Language Development (Newcomer & Hammill, 1997), the Social Skills Rating System (Gresham & Elliot, 1990), and the Test of Pragmatic Language (Phelps-Terasaki & Phelps-Gunn, 1992) were used to assess 61 students. Results indicated that 93.5% of the students scored between one and two standard deviations below the mean in at least one area. Statistical analysis revealed that semantic language, syntactic language, IQ, and social skills - components of the model of communicative competence - predicted pragmatic language competence.
The purpose of the present investigation was to examine the language skills of a group of 38 mildly to moderately behavior-disordered students. At issue was whether such students suffer from language disorders as has been reported for Children with more severe behavior disorders such as autism. The results from the Test of Language Development-Intermediate (TOLD-I) (Hammill & Newcomer, 1982) revealed that 37 of the children (97%) fell a minimum of one standard deviation below the normative mean on one or more of the TOLD-I subtests. These findings are offered in support of the notion that the mildly to moderately behavior-disordered child is at risk for language disorders.
The authors examined (a) the extent to which kindergarten estimates of core language functions predicted teacher ratings of behavior problems in each of the child's first 4 years of elementary school and (b) the ability of core language measures to predict concurrent behavior problems at each of the early elementary school grades studied. Participants were 74 African American children who were recruited as infants into a longitudinal study of children's health and development. Sixty percent of the families were classified as low-income when the children entered kindergarten. Conduct problems and hyperactivity were assessed with the Conners' Teacher Rating Scale, core language functions with the Clinical Evaluation of Language Fundamentals-3 (CELF-3) and Peabody Picture Vocabulary Test-Revised (PPVT-R), and verbal working memory with the Competing Language Processing Task (CLPT). Results indicated that expressive and receptive language at kindergarten predicted teacher ratings of conduct problems, with increasing accuracy as children moved from kindergarten to third grade, particularly for receptive language. None of the early language measures predicted hyperactivity at any of the grades. Concurrent relationships, expressive language, conduct problems, and hyperactivity were stronger in second grade than in kindergarten, while lower scores in working memory predicted higher teacher-reported hyperactivity. These findings underscore the importance of core language functions in the prediction of behavior problems.
Children and youth exhibiting serious emotional, behavioral, and interpersonal problems create substantial challenges for schools, teachers, their parents, and other students. Students having these characteristics are often underserved or unserved by educational and mental health systems in the United States. Recent prevalence rates for children served as emotionally disturbed (ED) under the Individuals With Disabilities Education Act is less than 1 percent although over 20 percent of the school population could qualify for a psychiatric diagnosis. A major reason for the underservice of children as ED lies in the federal definition of emotional disturbance which is nebulous, often illogical, and self-contradictory. An alternative approach to ED identification based on a student's response to an evidence-based intervention is proposed in this article. Response to intervention is defined and described along with methods and procedures for quantifying whether or not a student shows an adequate or inadequate response to an evidence-based intervention implemented with integrity.
Oral language abilities in 20 boys with chronic behavior disorder (CBD) were investigated using 20 standardized language measures. As a group, boys with CBD performed significantly more poorly than the normative population, with 16 of the subjects scoring in the below-average range on at least four of the language measures. Compared to expected language levels based on IQ scores, 10 of the subjects presented inconsistent language skills. It appears that boys with CBD display a much higher prevalence of language disorders than the population at large. Overall, abstract language and concepts, as well as linguistically complex structures, were shown to be difficult for the boys with CBD.
The language skills of 27 learning disabled (LD), 27 behaviorally disordered (BD), and 26 normal achieving (NA) 6- to 9-year-old children were compared on the Clinical Evaluation of Language Fundamentals-Revised (CELF-R). A series of ANOVA procedures for the CELF-R standard scores revealed significant differences between the NA group and both special education groups on all subtests, clusters, and the total language score, but no significant differences were found between the LD and BD groups. The behavioral deviancy of a language-deficient special education subgroup, a language-competent special education subgroup, and the NA group was compared on the Behavioral Evaluation Scale (BES). Analysis of variance for the BES total standard scores showed significantly higher behavioral deviancy for the language-deficient subgroup than the NA group, but no significant difference between the language-competent subgroup and the NA group.
IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
The author explores the language processing ability of children with emotional disorders who have preexisting language delays (ED/LA) to determine whether language difficulties in this population are internal biological features rather than due to environmental variables such as lack of language stimulation in the home. A comparison group consisting of children with ED but without language delays was used to determine whether language processing may be a critical factor in the occurrence of language delays in children with ED. Language competence was determined using the Test of Language Development/Intermediate. Language processing skills were then compared in the typical versus delay language groups using the Language Processing Test-R. Children with ED and language delays presented concerns in areas of language processing difficulty suggestive of underlying neurological pathology.
This study investigated the language skills and behavior characteristic of 63 students with severe behavior disorders who were referred by a large, mostly urban school district for a neuropsychiatric evaluation between 2001 and 2005. Archival data were retrieved by chart review for this study and was used to answer the following questions: 1) What is the prevalence of language disorders in children referred for a psychiatric evaluation? 2) Do behavioral symptoms vary among children with and without a language disorder? and 3) What is the initial area of concern identified by the parents of children with language and behavior disorders? The study revealed: (1) prevalence rates of language disorders in children with severe behavior was 57%; (2) behavioral symptoms did not vary significantly among children with and without language disorders on the parent version of Child Behavior Check List; and (3) no relationship existed between parent initial area of concern about their child and communication. Study results support the need for teacher education about the high prevalence of language disorders in children with severe behavioral problems in school populations.