Original Article

Journal of Child Neurology

2014, Vol. 29(2) 194–202
Behavior Problems in Children With ª The Author(s) 2013
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Specific Language Impairment DOI: 10.1177/0883073813509886
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Verónica Maggio, SLP, PhD1, Nora E. Grañana, MD, PhD1,2,

Alba Richaudeau, MD, PhD1, Silvio Torres, MD1,
Adrián Giannotti, MD1, and Angela M. Suburo, MD, PhD3

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 Withdrawn was the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

Keywords
language impairment, behavior problems, social behavior, communication, Child Behavior Checklist, Illinois Test of Psycholinguis-
tic Abilities

Received May 12, 2013. Received revised August 28, 2013; September 27, 2013. Accepted for publication September 30, 2013.

Specific language impairment is one of the most important com- rate being estimated at 50%-70%.11 Behavior problems can alert
munication problems affecting young children.1 Children having about the magnitude of the communication impairment, but they
this condition show ‘‘inadequate language acquisition at the can also confound the diagnosis with other conditions such as dis-
expected age with otherwise ostensibly normal development.’’2 orders of the autistic spectrum, pragmatic language impairment or
Thus, diagnosis is based on a mismatch between language and attention-deficit hyperactivity disorder (ADHD). As clearly
nonverbal abilities, which disturbs academic achievement or stated more than a decade ago, not every child with language
social communication.3,4 A similar definition is given by the impairment is a misdiagnosed case of autistic disorder.12
National Institute on Deafness and Other Communication Disor- Because knowledge about the burden of behavior problems
ders,5 which acknowledges developmental language disorder, could improve attention by primary care physicians, we evalu-
language delay, and developmental dysphasia as alternative ated these difficulties in a population of consecutive pediatric
names. Specific language impairment is clearly separated from patients with confirmed specific language impairment. We
the secondary language impairment that accompanies various applied the Child Behavior CheckList13,14 after careful exclu-
conditions displaying frank sensory, cognitive, or neurologic sion of any other neurologic, psychological, or social deprivation
deficits. condition. This well-known norm-referenced test assesses
Although exact numbers are lacking, specific language
impairment seems to be one of the most common childhood learn-
ing disabilities.5 In the 1990s, a prevalence of 7% was shown in 1
Clı́nica CLASE de Neuropsicologı́a, Hospital Universitario Austral, Pilar,
preschoolers,6 but a more recent review found a median for Argentina
prevalence of 5.95%.7 A similar figure has been described in 2
Neurologı́a Infantil, Servicio de Pediatrı́a, Hospital Carlos Durand, Buenos
Sweden.8 By contrast, a prevalence smaller than 1% for children Aires, Argentina
younger than 6 years has been recently reported in Finland.9 Clin-
3
MedicinaCelular y Molecular, Facultad de Ciencias Biomédicas, Universidad
ical populations of children with specific language impairment Austral, Pilar, Argentina
show high levels of comorbidity with literacy and behavior disor- Corresponding Author:
ders.10 The coexistence of language impairment and emotional Nora E. Grañana, MD, PhD, Juncal 2354-PB 3-(1125) Buenos Aires, Argentina.
and behavior problems has been recognized by several authors, its Email: ngranana@gmail.com
Maggio et al 195

Table 1. Illinois Test of Psycholinguistic Abilities (ITPA): Subtests medical, genetic, or neurologic disorder, such as sensory deafness,
Included in This Study. blindness, a definite diagnosis of autism or any autism spectrum disor-
der, pragmatic language impairment, or any other neurodevelopmental
Visual reception (VR): Measures ability to gain meaning from familiar
delay excluded the diagnosis of specific language impairment.
pictures.
Language evaluation was based on the Gardner’s Receptive One
Example: Match picture stimulus with picture from same category.
Auditory association (AA): Measures ability to relate concepts Word Picture Vocabulary Test, including 2 subtests: Gardner’s
presented orally. Comprehensive Vocabulary and Gardner’s Test for Expressive Vocabu-
Example: Verbal-analogies test (eg, ‘‘Grass is green, sugar is . . . "). lary.25,26 In addition, we used several subtests of the Illinois Test of
Visual association (VA): Measures ability to relate concepts presented Psycholinguistic Abilities, 3rd Ed (ITPA-3),27 to clarify the aspects of
visually. language that were difficult for a particular child. Examples of these subt-
Example: Relate a pictorial stimulus to its conceptual counterpart (eg, ests—visual comprehension, visual association, auditive association,
bone goes with dog). and grammatical closure—are shown in Table 1. Impairments were
Grammatical closure (GC): Measures ability to complete a phrase classified as expressive or mixed expressive-receptive.28 An expres-
grammatically correct in an automatic way. sive specific language impairment was diagnosed when children dis-
Example; the examiner shows 2 pictures and say: ‘‘There’s one bed here, played Gardner’s and/or Illinois expressive subtest scores 2 standard
there . . . here,’’ to which the child might respond, ‘‘There’re are two deviations or more below the population mean, that is, below the third
beds here.’’ 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
emotional (internalizing) and behavioral (externalizing) disor- mean.
ders.15 We also assessed sex ratios for each group, because a pre- Behavioral/Emotional problems and competencies were assessed
with the Child Behavior Checklist for preschoolers and for children
ponderance of boys or girls in any of the groups under study
(CBCL/1½-5, CBCL/6-18), with a questionnaire validated for Latin
might suggest a difference in the etiopathogenesis of the differ- American populations.29 The Preschool Age test for 1½-5-year-old chil-
ent conditions.16 Hand preference, which might be underdeve- dren uses the 7-syndrome model, including I, emotionally reactive; II,
loped in children with specific language impairment,17 was anxious/depressed; III, somatic complaints; IV, withdrawn; V, sleep
also examined. 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
Methods and Materials school-age children (6-18 years) includes I, anxious/depressed; II, with-
We analyzed the clinical histories of children consulting the Clı́nica de drawn/depressed; III, somatic complaints; IV, social problems; V,
trastornos de Atención, Lenguaje y del Seguimiento Escolar at Hospi- thought problems; VI, attention problems; VII, rule-breaking behavior;
tal Universitario Austral, and a speech pathologist private practice VIII, aggressive behavior and other problems. Internalizing syndromes
during the period 2008 to 2011. Both centers work with referrals of comprise groups I, II, and III, whereas VII and VIII represent the exter-
children with problems of attention, language, or school performance nalizing syndromes. For each problem class, children above the 93th
from the same community, a suburban area of medium-high socioeco- percentile were scored as positive.
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 Comité de Investigaciones de la Statistics
Facultad de Ciencias Biomédicas, Universidad Austral, 2009. Only
The hypothesis under evaluation was that a significant proportion of
native Spanish-speaking children with a confirmed specific language
children with specific language impairment presented behavior prob-
impairment were included.
lems. Therefore, we used simple descriptive statistics to evaluate their
Specific language impairment was diagnosed according to the
frequency. As a secondary hypothesis, we tested whether different
tenets of the International Classification of Diseases–10 (ICD-10).
types of language impairment correlated with different frequencies
This standard uses a statistical definition and requires an intelligence
or types of behavioral problem. Results were expressed as mean +
quotient within normal values, with at least a language test, either
standard error, or median (lower and upper 95% confidence interval).
expressive or receptive, scoring 2 standard deviations or more below
We used 2-tailed tests, and a 95% confidence interval was considered
the population mean, that is, below the third percentile. In addition, it
acceptable. Calculations were made with GraphPad Prism (GraphPad
stipulates that language skills should be at least 1 standard deviation
Software, San Diego, CA, www.graphpad.com).
below that measured for nonverbal skills.18
For evaluation of nonverbal intelligence quotient, we used the
Wechsler tests for Preschool and Primary Scale of Intelligence
(version III, WPPSI III), and the Intelligence Scale for Children (Ver-
Results
sion IV),19,20 the Leiter-R Brief nonverbal intelligence quotient,21 the Language Impairment Diagnosis
Beery Developmental Test of Visual-Motor Integration,22 the
Low scores in any one of the language tests would suffice to
McCarthy Scales of Children’s Abilities,23 and the Visual Construction
and Draw-a-Person.24 The diagnosis of a specific language impairment diagnose language impairment. However, most children
requires an intelligence quotient within normal values 100 + 15 (þ 1 showed 2 positive expressive tests. The agreement between the
and – 1 standard deviation). Children showing a developmental delay, Gardner’s test for expressive vocabulary and the Illinois Gram-
that is, nonverbal intelligence quotient below the third percentile, did matical Closure was 84% in the expressive group and 92% in
not receive this diagnosis. The presence of any other concomitant the mixed (expressive-receptive) Group (Table 2). In the mixed
196 Journal of Child Neurology 29(2)

Table 2. Children Failing the Different Expressive Tests. boys and girls displayed the same burden of problems: 2.25
Gardner’s Gardner’s
problems per girl and 2.48 for boys.
test for Gramm- Test and As shown in Table 7, 80% of the preschoolers with behavior
expressive atical grammatical problems showed internalizing syndromes. Withdrawn was the
vocabulary closure closure most frequently found syndrome, appearing in 65% of children
with problems. Syndromes of the externalizing domain only
Expressive impairment
Infant (n ¼ 11) 11 10 10
occurred in 57% of children with behavior problems. Children
Kindergarten age (n ¼ 2) 2 2 2 displaying more than 3 syndromes were often found. These
School age (n ¼ 6) 5 5 4 highly troubled children usually displayed withdrawn in
Mixed impairment various combinations with emotionally reactive, attention
Infant (n ¼ 32) 31 32 31 problems, or aggressive behavior.
Kindergarten age (n ¼ 43) 39 42 38 Internalizing problems were also the most frequently found
School age (n ¼ 20) 19 18 17 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-
group, most reception difficulties were identified by the Illinois breaking behavior were also present.
Auditive Association test, which was positive in 94% of the Complexity of the behavioral difficulties, as reflected by the
affected children. There was high agreement between the var- number of syndromes detected in each affected child, was
ious tests (Table 3), and most children scored positive in 2 to 3 higher in the mixed (2.67 + 0.28 syndromes/child) than in the
tests (42%), or in all 4 of them (46%). expressive group (1.50 + 0.38 syndromes/child, Mann-
Whitney test, P < .05).
Behavior problems could be a consequence of communica-
Characterization of the Population
tion difficulties. If this were the case, more behavior problems
We identified 114 children with a specific language impairment. should be found in those children that failed in a larger number
Their ages ranged from 2.1 to 7.9 years (4.7 + 0.1 years). Girls of language subtests. To test this hypothesis, we looked for
and Boys showed similar age distributions, 5.2 + 0.3 and associations between the number of behavior problems per
4.5 + 0.1 years, respectively. Taking into account developmental child and the number of failed receptive Illinois subtests in
milestones and the behavior checklists, we considered 3 age preschool children with a mixed language impairment. We did
groups: infant (2-3 years), Kindergarten (4-5 years), and school not observe any correlation between the number of failed Illi-
(6-7 years) (Table 4). Affected children of school age were less nois subtests and the number of behavioral syndromes. Many
numerous than preschool children. This was to be expected, children with difficulties in the 3 receptive subtests remained
because language impairment is usually diagnosed at an early age. free of behavior problems, whereas about 70% of the children
The sex ratio indicated a predominance of affected boys over showed deficits in 3 receptive tests, irrespective of their
affected girls (Table 4). Infant children showed a much higher sex behavioral burden (Figure 1).
ratio than Kindergarten and school-age children (w2 for trend,
P < .05). Right lateralization was absent in 47% of the children
included in this study. Differences of dexterity between age Discussion
groups were not statistically significant (Table 4). We have evaluated a sample of children with specific language
About 17% of the children had an expressive specific lan- impairment who attended our clinic for diagnostic purposes.
guage impairment. No significant differences in age or sex ratio Because disruptive or withdrawn manners frequently appeared
of children were detected between these children and those as an important or even the main reason for consultation, we
having a mixed impairment (Table 4). Most children with an evaluated the importance of behavior problems in this selected
expressive specific language impairment diagnosis appeared sample. In addition, we investigated possible associations
in the infant group, whereas the mixed cases clustered in the between the characteristics of the language impairment and the
Kindergarten group. This difference of proportions was statis- quality and load of these behavior problems. Our study, based
tically significant (w2, P < .02). on the Child Behavior Checklist (Achenbach’s test), showed
that these problems appeared in about half of the children with
specific language impairment.
Behavior Problems
About half of the children displayed behavior problems (Tables Prevalence of Behavioral Difficulties in Children With
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
Specific Language Impairment
impairment. No demographic differences could be detected It must be stressed that the importance of social withdrawal and
between children with and without problems (Table 6). other behavior problems has been well established for children
Moreover, both groups showed the same predominance of boys with language impairment associated to neurodevelopmental
over girls and similar proportions of nondexterity. Affected delay, such as low intelligence quotient or neurologic insult
Maggio et al 197

Table 3. Number of Children Failing the Different Receptive Tests.

Gardner’s Comprehensive Vocabulary Visual comprehension Visual association Auditive association All tests

Infant (n ¼ 32) 27 28 30 31 23
Kindergarten age (n ¼ 43) 30 23 29 41 18
School age (n ¼ 20) 12 4 6 17 3

Table 4. Characteristics of Children With Specific Language Table 5. Behavioral Problems in Children With Specific Language
Impairment. Impairment.
Age Age

Infant Kindergarten School Total Infant Kindergarten School All ages

N 43 45 26 114 Expressive impairment 11 2 6 19

Age With problems 5 0 3 42%
Range 2.1-3.9 4.0-5.8 6.0-7.9 2.1-7.9 Without problems 6 2 3 58%
Median 3.1 4.9 7.0 4.6 Mixed impairment 32 43 20 94
Mean 3.2 4.9 6.8 4.7 With problems 19 23 11 55%
Standard error 0.1 0.1 0.1 0.1 Without problems 13 20 9 45%
Dexterity
Yes 18 26 16 60
No 25 19 10 54
Sex ratio 6.7 3.8 1.9 3.8 Table 6. Characteristics of Language Impaired Children With and
Boys 37 36 17 90 Without Behavioral Problems.
Girls 6 9 9 24 Age
Specific language
impairment Group Problems n Range Median Mean Standard error
Expressive 11 2 6 19
Mixed 32 43 20 95 Infant
With 24 2.1-3.9 3.1 3.2 0.1
Without 19 2.6-3.9 3.2 3.3 0.1
Kindergarten
30 With 23 4.0-5.7 5.0 4.9 0.1
(reviewed by Rescorla et al ). However, the association of spe-
Without 22 4.0-5.8 4.9 4.8 0.1
cific language impairment with behavior difficulties has not yet With 14 6.2-7.1 6.9 6.8 0.1
been established, because available studies have diverse results. Without 12 6.0-7.9 6.9 6.8 0.2
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, Difficulties Questionnaire, which evaluates behavioral, emo-
they were significantly greater than those from age peers with tional and social difficulties. In the conduct subscale, fewer
typical language development.31 Authors suggested that these problems occurred at age 16 than at ages 7-8, whereas problems
behavior problems would most likely represent an emotional in the peers subscale increased over time.36 As in the previous
response. Behavior and social difficulties, though not necessarily studies, however, the mean scores did not reach clinical levels
within the clinical range, might be more evident in language- of difficulty. Nevertheless, substantial peer problems have been
impaired children from low-income families.32 found in a group of 16-year-old youngsters with specific
On the other hand, several studies carried out in children language impairment.37
attending schools for the language and hearing impaired Our figures for the coexistence of behavioral difficulties and
showed clinically significant behavior problems in children specific language impairment were, in average, larger than
with specific language impairment: 23% of a sample (n ¼ those in previous reports. Moreover, we found almost the same
56) of school-age children,33 30% of a large sample (n ¼ 71) proportion of children with and without problems in the differ-
of 5-year-old children,34 and 18% of a smaller sample (n ¼ ent age groups—infant, Kindergarten, and school—suggesting
38) of children between 2.5 and 5.5 years.35 Studies in toddlers that these problems would be intrinsic to the language impair-
(up to 30-35 months of age) did not show a strong relationship ment and not a reactive effect. Remarkably, the largest propor-
between language delays and behavioral/emotional problems, tion of behavior problems appeared in the infant group.
leading to the suggestion that these difficulties only affected Although these figures might not represent the prevalence of
older children.30 Remarkably, some of these studies concluded behavior problems in the general population of children with
that behavior problems were associated with the inclusion of specific language impairment, they certainly demonstrate the
children with neurodevelopmental delay or autism spectrum existence of this association and its relevance for diagnosis and
disorders.30,31 Other recent studies have used the Strengths and treatment.
198 Journal of Child Neurology 29(2)

Table 7. Behavioral Syndromesa Found in Children of Preschool Age.

Number of syndromes in the expressive Number of children with
and mixed subpopulations syndromes

Children with Emotionally Anxious/ Somatic Sleep Attention Aggressive Syndromes/

behavior problems reactive depressed complaints Withdrawn problems problems behavior Internalizing Externalizing child

Expressive (n ¼ 6) 0 3 1 2 1 2 2 5 2 1.8
Mixed (n ¼ 41) 15 9 9 28 7 15 17 35 25 2.4
All (n ¼ 47) 15 12 10 30 8 17 19 40 27 2.4
a
Columns showing internalizing and externalizing problems are painted in dark and pale gray, respectively.

Table 8. Behavioral Syndromesa Found in Children of School Age.

Number of children with
Number of syndromes in the population syndromes

Children with Rule-

behavior Anxious/ Withdrawn/ Somatic Social Thought Attention breaking Aggressive Syndromes/
Problems depressed depressed complaints problems problems problems behavior behavior Internalizing Externalizing child

Expressive (n ¼ 3) 1 0 1 0 0 0 1 0 2 1 1.0
Mixed (n ¼ 11) 6 3 2 5 1 2 3 2 8 4 2.2
All (n ¼ 13) 7 4 2 5 1 2 4 2 10 5 1.9
a
Columns showing internalizing and externalizing problems are painted in dark and pale gray, respectively.

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 disorders38 or attention-deficit hyperactivity disorder.39
Further studies are required to evaluate the stability of these
syndromes over time and their possible association to biologi-
cal markers that could indicate their etiology.
There is no consensus about the predominance of internaliz-
ing or externalizing syndromes in children with specific lan-
guage impairment. Some studies have found internalizing
syndromes as the most frequent problems,11,33 whereas others
have reported that the highest frequency corresponded to exter-
nalizing syndromes.40 At least one study reported that interna-
lizing syndromes had the same frequency as externalizing
ones.34 Internalizing syndromes (Teacher Behavior Rating
Scale; reticence and solitary-passive withdrawal) have also
been recorded as the most frequent problems in a school sample
(n ¼ 41). Comparison with studies based on other behavioral
Figure 1. Bars correspond to preschool children with a mixed scales41 is more difficult.
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 Behavior Problems and Neurodevelopmental Domains
graph illustrates the lack of correlation between the burden of beha-
vior problems and the extension of the language impairment. As previously acknowledged,33 not all children had behavioral
difficulties, suggesting that the relationship of these problems
The Nature of Behavior Problems Associated to Specific with language impairment is not linear and that behavior could
be influenced by other—still unknown—variables. Conceiva-
Language Impairment bly, specific language impairment with behavior problems
Internalizing problems almost duplicated externalizing prob- might represent a different condition from the impairment
lems in children of preschool age as well as in older children. without such problems. At the present time, however, there are
The most frequently found syndromes in preschool children no clues about the underlying neurobiological mechanisms.
were withdrawn and aggressive behavior. In children of school Hand preference was carefully evaluated because it might
age, the highest frequency corresponded to anxious/depressed be related to the asymmetric development of the brain
Maggio et al 199

hemispheres underlying language maturation.42-44 Moreover, A similar explanation has been given to account for the herit-
functional MRI has recently shown that children with specific ability of specific language impairment in different scenarios.50
language impairment exhibit a significant lack of left laterali- Behavior problems were found in 42% of children with an
zation in all core language regions.45 Handedness has been expressive impairment and in 55% of children with a mixed
associated to intellectual, motor, temperament, and behavioral impairment, a not statistically significant difference. However,
status, and moreover, evidence supports the existence of intrau- children with a mixed impairment displayed more clinical
terine and neonatal pathological mechanisms, other than brain syndromes, indicating a higher complexity of their behavioral
damage, leading to left hand preference.46 Likewise, several disorder. Several studies have indicated that children with
studies have reported higher rates of specific language impair- receptive difficulties are more likely to have social and
ment among males than among females.7,16 Recent measure- behavioral difficulties than those with only expressive prob-
ments of testosterone in cord blood show a correlation of lems.51,52 Within the receptive group, however, we could not
hormonal levels with increased risk of specific language find any correlation between behavior problems and specific
impairment in boys and decreased risk in girls.47 On the other language deficits. These associations, however, have been
hand, studies recruiting cases from the general population identified by other investigators. Girls with more severe recep-
reported similar proportions of boys and girls,6 and it has been tive problems appear with higher levels of solitary-passive
suggested that the increased male prevalence could reflect the withdrawal than girls with less severe language problems.41
fact that boys attract the attention of parents and teachers more By contrast, children with less severe receptive language
than girls.48 impairment exhibit more sociable behavior than their peers
In the children included in our study, hand preference and with more severe impairment.41
sex ratios were different from the standard patterns. Almost
half of our population lacked right hand preference. A large
Communication Problems as the Basis for
proportion of nondexterity (58%) appeared in infants, but it
was also found in 38% of the school-age children. Thus, it
Behavioral difficulties
cannot be attributed to lack of maturation. Remarkably, the sex Association of specific language impairment with behavior
ratio was 6.7 in infants and 1.9 in children of school age (boys problems has been explained in several ways. Classical
to girls). The higher sex ratio of infants compared to that of descriptions include limited information processing as a cause
older children probably implies that language impairment of difficulties in language learning and social communication;
became evident earlier in boys than in girls. rejection from others, including their peers, that might result in
We found the same burden of behavior problems in boys and limited opportunities for social learning; and primary deficits in
girls, suggesting that the male prevalence would not depend on the social cognition domain that would translate into oral
the different attention elicited by boys and girls.48 Because hand language.53
preference and sex ratios were similar in children with and with- Two frameworks (or models) have been proposed to under-
out behavior problems, the causes of these difficulties must be stand the relationship between the language impairment and the
sought in other, still unidentified developmental domains. behavioral comorbidities: the Social Adaptation Model consid-
ers that behavior problems of language-impaired children
reflect social adaptations to their language limitations. The
Behavior Problems in Expressive and Receptive/
second model, the Social Deviance Model, considers that
Expressive (Mixed) Specific Language Impairment differences between children with language impairment and
Only 17% of the children in our population displayed an nonaffected children reflect differences in the underlying traits
expressive language impairment. A similar proportion (20%) that guide children’s socioemotional development.11 These
was also found in a sample of ages 3.5-9.5 years (n ¼ 86).49 authors studied a small sample (n ¼ 17) and found a large pro-
A larger proportion (30%) was described in a school sample portion of children showing behavior problems at a clinical
(n ¼ 41, ages 6-13 years).41 Probably, much larger samples level. Because parents and teachers gave different behavioral
would be required to evaluate the prevalence in the general ratings, they favored the Social Adaptation Model.11 In our
population. In our study, most children with an expressive study, the lack of association between behavior and biological
impairment belonged to the infant age group. About 34% of the markers such as handedness and sex supports this hypothesis.
children in the infant group had an expressive impairment, as in Adolescents with an earlier story of specific language
another large sample (n ¼ 103) of children aged 18-35 impairment display receptive language problems together with
months.30 In all these groups, the predominance of children emotional health difficulties.54 Moreover, those with emotional
with a mixed impairment contrasts with the predominance of problems at 7 years of age also have increased anxiety at 16
expressive impairment described in the Diagnostic and Statis- years. Authors suggested, however, that behavior problems
tical Manual of Mental Disorders, Fourth Edition. To our would not be a direct result of impoverished communicative
knowledge, there is no justification for this phenomenon. How- experiences.54 In consonance with these findings, our observa-
ever, comparison of the available evidence and our own results tion of the same frequency of behavior problems in the infant
allows speculating that higher mixed/expressive ratios might age as in children of Kindergarten and school age suggests the
be found in the clinical setting than in the general population. involvement of developmental factors unrelated to social
200 Journal of Child Neurology 29(2)

environment. Because we can assume that rejection and The need for screening of speech and language delay in pri-
intolerance would increase in the Kindergarten and school mary care practice has already been emphasized.64 Our findings
years, and without denying the importance of the social envi- further stress that language impairments should be methodically
ronment, our data suggest that rejection would not be the sole explored to discriminate specific language impairment from
explanation of behavior problems. 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
Association and Differential Diagnosis With Other
assessment of children referred for language impairment and
Nosological Entities to advocate for appropriate early intervention.
A diagnosis of specific language impairment can be hindered
by other possibly related impairments. One of them is late lan- Author Contributions
guage emergence, a condition of significant delay in language VM assessed the language and wrote the manuscript. NEG developed
development that is observed in about 19% of 2-year-olds.55 the hypotheses, led the clinical team, and wrote the manuscript. AR
Many ‘‘late talkers’’ will normalize their language skills by performed neuropsychological assessment of patients. ST analyzed
3-4 years, although some might still show some language the data. AG performed clinical and behavioral assessment of patients.
impairment during adolescence.56 AMS analyzed data and wrote the manuscript.
Language impairment seems to be a key feature of autism
and, vice versa, autism has some remarkable similarities to lan- Declaration of Conflicting Interests
guage problems in specific language impairment. Previous The authors declared no potential conflicts of interest with respect to
studies have evidenced that autism-like symptoms, such as the research, authorship, and/or publication of this article.
poor social relations, aloofness, affectless behavior, and
unusual responses to stimuli, appear in about half of the Funding
children with persistent language difficulties.57-60 Moreover, The authors received no financial support for the research, authorship,
some studies suggest that children who present with autism and/or publication of this article.
spectrum disorders and attention-deficit hyperkinetic disorder
have a similar neuropsychological and early language develop- Ethical Approval
ment profile as children who present with a suspicion of early This work was approved by Comité de Investigaciones de la Facultad
preschool language delay and are shown at school age to have de Ciencias Biomédicas, Universidad Austral.
autism spectrum disorders or attention-deficit hyperactivity
disorder.61 Although similarities might suggest a common References
pathogenesis, these are different clinical entities. Children with 1. Rapin I. Preschool Children With Inadequate Communication.
an autistic spectrum disorder with language impairment display London: Mac Keith Press; 1996.
weaker functional communication and more severe receptive 2. Rapin I. Understanding childhood language disorders. Curr Opin
language difficulties than children with specific language Pediatr. 1998;10:561-566.
impairment.12,62 However, these conditions might recognize 3. Bishop DV. The underlying nature of specific language impair-
a common neural substrate.63 ment. J Child Psychol Psychiatry. 1992;33:3-66.
4. American Psychiatric Association. Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition (Text Revision).
Washington, DC: American Psychiatric Association; 2000.
Conclusions 5. National Institute on Deafness and Other Communication Disor-
Behavior problems were highly prevalent in specific language ders. Specific language impairment. 2013; http://www.nidcd.nih.
impairment–affected children; they were equally frequent in gov/health/voice/Pages/specific-language-impairment.aspx.
children of infant age as in older children. Moreover, children Accessed July 08, 2013.
with an expressive disorder displayed behavior problems as 6. Tomblin JB, Records NL, Buckwalter P, Zhang X, Smith E,
often as those children with a mixed impairment. Withdrawn O’Brien M. Prevalence of specific language impairment in Kin-
was the most frequently found behavior problem in younger dergarten children. J Speech Lang Hear Res. 1997;40:1245-1260.
children, whereas children of school age usually displayed anx- 7. Law J, Boyle J, Harris F, Harkness A, Nye C. Prevalence and nat-
ious/depressed and social problems. ural history of primary speech and language delay: findings from
Professionals and caregivers should be aware of these beha- a systematic review of the literature. Int J Lang Commun Disord.
vior problems: first, because they further reduce the quality of 2000;35:165-188.
life of more than half of children with specific language impair- 8. Miniscalco C, Westerlund M, Lohmander A. Language skills at
ment and their families; second, because in some children they age 6 years in Swedish children screened for language delay at
might serve as an alert for an early diagnosis; and third, because 2½ years of age. Acta Paediatr. 2005;94:1798-1806.
they might induce an autism spectrum disorders misdiagnosis, 9. Hannus S, Kauppila T, Launonen K. Increasing prevalence of spe-
as they often include isolation, social problems, and even cific language impairment (SLI) in primary healthcare of a Fin-
rule-breaking behavior. nish town, 1989-99. Int J Lang Commun Disord. 2009;44:79-97.
Maggio et al 201

10. Law J, Tomblin JB, Zhang X. Characterizing the growth trajec- 31. Benasich AA, Curtiss S, Tallal P. Language, learning, and beha-
tories of language-impaired children between 7 and 11 years of vioral disturbances in childhood: a longitudinal perspective. J Am
age. J Speech Lang Hear Res. 2008;51:739-749. Acad Child Adolesc Psychiatry. 1993;32:585-594.
11. Redmond SM, Rice ML. The socioemotional behaviors of chil- 32. Qi CH, Kaiser AP. Problem behaviors of low-income children
dren with SLI: social adaptation or social deviance? J Speech with language delays: an observation study. J Speech Lang Hear
Lang Hear Res. 1998;41:688-700. Res. 2004;47:595-609.
12. Bishop DV, Norbury CF. Exploring the borderlands of autistic 33. Coster FW, Goorhuis-Brouwer SM, Nakken H, Spelberg HC.
disorder and specific language impairment: a study using standar- Specific language impairments and behavioural problems. Folia
dised diagnostic instruments. J Child Psychol Psychiatry. 2002; Phoniatr Logop. 1999;51:99-107.
43:917-929. 34. van Daal J, Verhoeven L, van Balkom H. Behaviour problems in
13. Achenbach TM, Rescorla LA. Manual for the ASEBA Preschool children with language impairment. J Child Psychol Psychiatry.
Forms & Profiles. Burlington, VT: University of Vermont, 2007;48:1139-1147.
Research Center for Children, Youth, & Families; 2000. 35. Keegstra AL, Post WJ, Goorhuis-Brouwer SM. Behavioural prob-
14. Achenbach TM, Rescorla LA. Manual for the ASEBA School-Age lems in young children with language problems. Int J Pediatr
Forms & Profiles. Burlington, VT: University of Vermont, Otorhinolaryngol. 2010;74:637-641.
Research Center for Children, Youth & Families; 2001. 36. St Clair MC, Pickles A, Durkin K, Conti-Ramsden G. A longitu-
15. Pandolfi V, Magyar CI, Dill CA. Confirmatory factor analysis of dinal study of behavioral, emotional and social difficulties in indi-
the Child Behavior Checklist 1.5-5 in a sample of children with aut- viduals with a history of specific language impairment (SLI). J
ism spectrum disorders. J Autism Dev Disord. 2009;39:986-995. Commun Disord. 2011;44:186-199.
16. Whitehouse AJ. Is there a sex ratio difference in the familial 37. Lindsay G, Dockrell JE. Longitudinal patterns of behavioral,
aggregation of specific language impairment? A meta-analysis. emotional, and social difficulties and self-concepts in adolescents
J Speech Lang Hear Res. 2010;53:1015-1025. with a history of specific language impairment. Lang Speech Hear
17. Bishop DV. Handedness and specific language impairment: a Serv Sch. 2012;43:445-460.
study of 6-year-old twins. Dev Psychobiol. 2005;46:362-369. 38. Duarte CS, Bordin IA, de Oliveira A, Bird H. The CBCL and the
18. World Health Organization. The ICD-10 Classification for Men- identification of children with autism and related conditions in
tal and Behavioral Disorders: Diagnostic Criteria for Research. Brazil: pilot findings. J Autism Dev Disord. 2003;33:703-707.
Geneva: World Health Organization; 1992. 39. Biederman J, Petty CR, Day H, et al. Severity of the aggression/
19. Weschler D. Escala de Inteligencia infantil Weschler. WPPSI III: anxiety-depression/attention Child Behavior Checklist profile
Paidós; 2002. discriminates between different levels of deficits in emotional
20. Weschler D. Escala de inteligencia WISC IV. Buenos Aires: Pai- regulation in youth with attention-deficit hyperactivity disorder.
dós; 2010. J Dev Behav Pediatr. 2012;33:236-243.
21. Roid G, Miller L. Escala manipulativa internacional Leiter. 40. Tomblin JB, Zhang X, Buckwalter P, Catts H. The association of
Madrid: Editorial Psymtec; 2006. reading disability, behavioral disorders, and language impairment
22. Beery K. VMI, prueba Beery-Buktenica del desarrollo de la inte- among second-grade children. J Child Psychol Psychiatry. 2000;
gración visomotriz. México: Editorial Manual Moderno; 2000. 41:473-482.
23. Mc Carthy D. MSCA. Escalas Mc Carthy de aptitudes y psicomo- 41. Hart KI, Fujiki M, Brinton B, Hart CH. The relationship between
tricidad para niños. Madrid: TEA ediciones; 1972. social behavior and severity of language impairment. J Speech
24. Casullo M. El test gráfico del dibujo de la figura humana. Normas Lang Hear Res. 2004;47:647-662.
regionales. Buenos Aires: Editorial Guadalupe; 1998. 42. Corey DM, Hurley MM, Foundas AL. Right and left handedness
25. Gardner MF, Morrison F. Test Figura/Palabra de vocabulario defined: a multivariate approach using hand preference and hand
expresivo. Manual y láminas. Buenos Aires: Editorial Médica performance measures. Neuropsychiatry Neuropsychol Behav
Panamericana; 1987a. Neurol. 2001;14:144-152.
26. Gardner MF, Morrison F. Test Figura-palabra de vocabulario 43. Adamo DE, Taufiq A. Establishing hand preference: why does it
receptivo: manual y láminas. Buenos Aires: Editorial Médica matter? Hand (N Y). 2011;6:295-303.
Panamericana; 1987b. 44. Johnston RB, Stark RE, Mellits ED, Tallal P. Neurological status
27. Kirk S, Mc Carthy J, Kirk W. Test Illinois de aptitudes psicolin- of language-impaired and normal children. Ann Neurol. 1981;10:
guı´sticas ITPA. Madrid: Editorial TEA; 2004. 159-163.
28. López-Ibor Aliño JJ, Valdés Miyar M. Manual diagnóstico y esta- 45. de Guibert C, Maumet C, Jannin P, et al. Abnormal functional
dı´stico de los trastornos mentales. Texto revisado. Barcelona: lateralization and activity of language brain areas in typical
Masson; 2002. specific language impairment (developmental dysphasia). Brain.
29. Viola L, Garrido G, Rescorla L. Testing multicultural robustness 2011;134:3044-3058.
of the Child Behavior Checklist in a national epidemiological 46. O’Callaghan MJ, Burn YR, Mohay HA, Rogers Y, Tudehope DI.
sample in Uruguay. J Abnorm Child Psychol. 2011;39:897-908. The prevalence and origins of left hand preference in high risk
30. Rescorla L, Ross GS, McClure S. Language delay and behavioral/ infants, and its implications for intellectual, motor and beha-
emotional problems in toddlers: findings from two developmental vioural performance at four and six years. Cortex. 1993;29:
clinics. J Speech Lang Hear Res. 2007;50:1063-1078. 617-627.
202 Journal of Child Neurology 29(2)

47. Whitehouse AJ, Mattes E, Maybery MT, et al. Sex-specific asso- 56. Bishop DV, North T, Donlan C. Nonword repetition as a beha-
ciations between umbilical cord blood testosterone levels and lan- vioural marker for inherited language impairment: evidence from
guage delay in early childhood. J Child Psychol Psychiatry. 2012; a twin study. J Child Psychol Psychiatry. 1996;37:391-403.
53:726-734. 57. Conti-Ramsden G, Simkin Z, Botting N. The prevalence of autistic
48. Shaywitz SE, Shaywitz BA, Fletcher JM, Escobar MD. spectrum disorders in adolescents with a history of specific language
Prevalence of reading disability in boys and girls. Results of the impairment (SLI). J Child Psychol Psychiatry. 2006;47:621-628.
Connecticut Longitudinal Study. J Am Med Assoc. 1990;264: 58. Paul R, Cohen DJ. Outcomes of severe disorders of language
998-1002. acquisition. J Autism Dev Disord. 1984;14:405-421.
49. Crespo-Eguı́laz N, Narbona J. Subtipos de trastorno especı́fico del 59. Paul R, Cohen DJ, Caparulo BK. A longitudinal study of patients
desarrollo del lenguaje: perfiles clı́nicos en una muestra hispano- with severe developmental disorders of language learning. J Am
hablante. Rev Neurol. 2006;43: S193-S200. Acad Child Psychiatry. 1983;22:525-534.
50. Bishop DV, Hayiou-Thomas ME. Heritability of specific lan- 60. Reisinger LM, Cornish KM, Fombonne E. Diagnostic differentia-
guage impairment depends on diagnostic criteria. Genes Brain tion of autism spectrum disorders and pragmatic language impair-
Behav. 2008;7:365-372. ment. J Autism Dev Disord. 2011;41:1694-1704.
51. Beitchman JH, Brownlie EB, Inglis A, et al. Seven-year follow-up 61. Hagberg BS, Miniscalco C, Gillberg C. Clinic attenders with aut-
of speech/language impaired and control children: psychiatric ism or attention-deficit/hyperactivity disorder: cognitive profile at
outcome. J Child Psychol Psychiatry. 1996;37:961-970. school age and its relationship to preschool indicators of language
52. Lindsay G, Dockrell J. The behaviour and self-esteem of children delay. Res Dev Disabil. 2010;31:1-8.
with specific speech and language difficulties. Br J Educ Psychol. 62. Loucas T, Charman T, Pickles A, et al. Autistic symptomatology
2000;70(pt 4):583-601. and language ability in autism spectrum disorder and specific lan-
53. Bishop DV. Uncommon Understanding: Development and Disor- guage impairment. J Child Psychol Psychiatry. 2008;49:
ders of Language Comprehension in Children. East Sussex, UK: 1184-1192.
Psychology Press, Taylor & Francis Group; 1997. 63. Verhoeven JS, Rommel N, Prodi E, et al. Is there a common neu-
54. Conti-Ramsden G, Botting N. Emotional health in adolescents roanatomical substrate of language deficit between autism spec-
with and without a history of specific language impairment (SLI). trum disorder and specific language impairment? Cereb Cortex.
J Child Psychol Psychiatry. 2008;49:516-525. 2012;22:2263-2271.
55. Zubrick SR, Taylor CL, Rice ML, Slegers DW. Late language 64. Nelson HD, Nygren P, Walker M, Panoscha R. Screening for
emergence at 24 months: an epidemiological study of prevalence, speech and language delay in preschool children: systematic evi-
predictors, and covariates. J Speech Lang Hear Res. 2007;50: dence review for the US Preventive Services Task Force. Pedia-
1562-1592. trics. 2006;117: e298-e319.